Hair Treatments

Minoksidil

Available topical formulations

Minoxidil is offered in 2% and 5% concentrations, applied to the scalp as a liquid or foam. Both concentrations are FDA approved for men and women. All topical forms are sold over-the-counter (OTC) and do not require a prescription. Many expensive “hair growth therapies” actually rely on topical minoxidil combined with other ingredients that are not FDA approved as hair loss treatments.

The foam preparation does not use propylene glycol as a solvent. Propylene glycol has a greasy feeling and is a common skin irritant, which makes the foam an attractive alternative to the solution for some patients. At present, the foam preparations are a 5% concentration- for both men and women.

Administration

Minoxidil is offered in 2% and 5% concentrations, applied to the scalp as a liquid or foam..  Both concentrations are FDA approved for men and women.  All topical forms are sold over-the-counter (OTC) and do not require a doctors prescription.  Many expensive “hair growth therapies” actually rely on topical minoxidil combined with other ingredients that are not FDA approved as hair loss treatments.

The foam preparation does not use propylene glycol as a solvent. Propylene glycol has a greasy feeling and is a common skin irritant, which makes the foam an attractive alternative to the solution for some patients.  At present the foam preparations are a 5% concentration- for both men and women.

Topical: applied to the scalp as a liquid or foam, ideally right after bathing so it is not washed away. Maximum efficacy requires application 2 times daily to the affected area for men; 1 time daily for women. The original minoxidil study results used to gain FDA approval were only performed on the vertex area, so they were only approved for this claim. However, minoxidil can stimulate hair growth wherever the active medication can reach. Most hair restoration doctors advise patients to use minoxidil on all thinning areas, both the vertex and frontal scalp. However, patients must be consistent and apply this therapy daily or risk causing shedding. If patients decide to discontinue topical minoxidil it is advisable to wean the dosing over several weeks rather than abrupt discontinuation, as the latter is more likely to provoke shedding in patients who are responders.

Mode of Action

How minoxidil acts to slow hair loss and stimulate hair regrowth is not well understood. It is believed that minoxidil sulfate acts by prolonging the anagen phase (growth phase) of the hair follicle, and increasing the size of the follicle. (9)

Effectiveness

Studies have shown that minoxidil slows or halts hair loss and promotes hair regrowth in both men and women, at both 2% and 5% formulations. The 5% formulation is generally more effective. Positive response to minoxidil therapy (reduced hair loss and/or hair regrowth) has been reported in various studies as less than 50% to more than 80% –possibly owing to genetic variation in study recipients. Any positive response is lost if minoxidil therapy is discontinued.

Side Effects

The most common reported side effects are scalp redness, Itchy scalp, dryness and flaking. Accidental application of minoxidil to the face can result in growth of unwanted facial hair, and the risk of facial hair growth from absorption is about 3% in most studies. Repeated, large applications of minoxidil have been associated with a drop in blood pressure in a few reported cases, presumably due to systemic absorption. There are also infrequent reports of heart palpitations, which require discontinuation of use.
Some patients may develop a true allergy with associated swelling and hives. In these cases, minoxidil can’t be used. The older pregnancy classification is a C. Newer classifications recommend not using minoxidil during pregnancy, with at least one case report of possible teratogenicity, though a causal relationship with minoxidil has not been shown.

Other

Minoxidil can stimulate all hair, and the topical formulation is currently the only drug approved for treatment of female pattern hair loss.

Minoxidil can be a valuable retardant to hair loss even in cases where it does not appear to regrow hair. Often patients discontinue minoxidil after several months if they haven’t noticed increased growth. However, for responders, the effect of retarding hair loss can be important compared to continued hair loss over the years. A patient who sheds after discontinuing this therapy is a likely responder, and may wish to reconsider resuming the medication if this occurs. Also, combined with oral finasteride, minoxidil appears to synergistically enhance hair regrowth effect of finasteride. Hair doctors commonly recommend the combination of these drugs, provided patients are committed to the daily regimen that topical minoxidil requires.

Finasterid

Administration

A 1mg dose daily is the suggested treatment for male-pattern hair loss. A 5 mg dose is given to treat benign prostatic hypertrophy (prostate enlargement) in men. Some patients quarter a 5 mg tablet with a pill cutter and then take ¼ of a tablet daily to save cost.

Finasteride is being used on postmenopausal women with greater frequency. The usual dose is 2.5 mg daily, but the results aren’t has dramatic as in men. Because it can feminize a male fetus, women in childbearing years cannot use finasteride.

Availability

By prescription. Finasteride comes in 2 strengths:
1mg- brand (Propecia) or generic
5mg- brand (Proscar) or generic

Generic versions are now available but beware that the price savings for a 1mg dose may not be as great as with most generics. Hopefully this may change with time. 5mg finasteride tablets are quite inexpensive.

Mode of Action

Finasteride inhibits the activity of Type II 5-alpha reductase, an enzyme that converts the male hormone testosterone into a more potent form called dihydrotestosterone (DHT). DHT is believed to act on scalp hair follicles to suppress them and gradually create weaker and smaller hair follicles. Finasteride will lower the tissue DHT levels by about 66%. It’s half-life in 6-8 hrs.

Scalp hair is rather unique in that it is nonpubertal hair that is not stimulated by testosterone and is thinned by the effect of DHT. Beard and chest hair are stimulated by testosterone and DHT. In these regions, finasteride reduces the density, but this effect is most often not noticed. Finasteride has been occasionally used to reduce body hair in women.

Effectiveness

Large, multi-year studies have shown finasteride to reduce hair loss and/or stimulate hair regrowth in a majority of men treated. In a 5-year study, 65% of men with mild to moderate male-pattern hair loss were found to have a positive result (hair loss reduced and/or hair regrowth stimulated). Finasteride therapy must be continued to maintain a positive result. Physician hair restoration specialists often combine minoxidil and finasteride therapy to achieve an optimal result in selected patients. Medical therapy may be combined with surgical hair restoration to achieve and maintain the best result.

Side Effects

Finasteride should not be used or handled by a woman who is pregnant or who may become pregnant. The drug can cause abnormal development in a fetus. Therefore, finasteride should not be used in women of childbearing years.

Reported side effects in men include decreased libido (sex drive), erectile dysfunction, male breast enlargement and psychological depression. To date no significant side effects have been noted in postmenopausal women.

Occasional patients may have side effects continue even after discontinuing finasteride. The frequency of this scenario is controversial with most hair surgeons finding it rare in their patients. Studies are on going to determine the true risk. See Post Finasteride Syndrome (below).

Note

Effects of finasteride can be enhanced by concomitant use of minoxidil. Abrupt stoppage of either drug is usually followed by significant shedding of gained and preserved hair.

PRP (Platelet Rich Plasma)

Platelet Rich Plasma, also known as PRP, is a relatively new addition to the list of hair loss treatments. The theory is this that platelets store growth factors to help stimulate wound healing and tissue growth where it is needed. Blood contains platelets in varying concentrations. If you take a patient’s own platelets and re-inject them into an area that needs healing and growth, the body’s own mechanisms will improve the regeneration of the tissue.

PRP injections have been verifiably used to help the growth and healing of slow growing tissues like bones and teeth. Early experiments in its use with hair have been mixed however. Most studies have concentrated on using PRP injections to possibly help the growth of the native hair (and possibly the grafts if surgery was done) in the areas of hair loss and thinning. What these studies have shown so far is that the treatments do not help hair to re-grow on a completely bald head, so the earlier a treatment is started the better. Higher concentrations of platelets, more frequent injections, and possibly activating the platelets or causing micro-injuries to the scalp may also provide better results. No study has been conclusive, however, and many variations within the research make it difficult to compare and draw conclusions.

The answer is, there is much we don’t know about the optimal wavelengths and dosing for PBM therapy to treat hair loss. Despite the studies that have been performed, important questions remain unanswered. For patients, it is advisable that prior to making the decision to purchase an OTC device to treat their hair loss all therapies and options should be reviewed with a hair loss specialist.

Since this use of PRP is not yet fully tested, it is impossible to know how much of an effect it would have in an individual case. That being said, it is a patient’s own “blood product,” and thus not likely to be detrimental. It is useful to remember that like most treatments, some patients have great results and others have results that are not as significant. A standard treatment regimen has not yet been developed with most practitioners advocating treatment schedules that range from monthly to every three months. Also, like all medical hair treatments it may require ongoing maintenance treatments. Whichever treatment frequency is used, at least 6 months are needed to see results.

Mikroneedling

Microneedling causes the body to go into wound healing mode and growth factors are released to repair the skin. In turn, these growth factors have an effect on hair follicles. Concentration of applications and frequency of applications will be discussed, as well as the type of results clinicians are seeing.

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