Hair loss is a common condition which may have a wide range of manifestations and causes. In this article I will talk about the best medications for people suffering from androgenetic alopecia (AGA) also known as male-pattern hair loss (MPHL).
Androgenetic alopecia (AGA)
Androgenetic alopecia is a condition estimated to affect about 85% of men during their lifetime.
Androgen hormones, testosterone and dihydrotestosterone (DHT) in particular, cause involution of the hair follicle in sensitive areas of the scalp, most commonly the frontal hairline and the vertex (crown). With the shrinking of the hair follicle, the hair become thinner turning into vellus hair. As the condition progresses, the hair follicle dies making the condition not reversible and no more hair is produced causing reduced hair density. Usually, patients notice hair loss only once they already lost around 50% of their hair density so for optimal cosmetic results they should seek a consultation as soon as possible to address the causes.
Best medications to treat hair loss according to a 2022 study
In February 2022, a meta-analysis was published in JAMA Dermatology, comparing data from 23 published studies and efficacy of three different agents taken over different routes: finasteride and dutasteride, two 5-alpha-reductase enzyme inhibitors, and minoxidil, a medication developed in the 1950s and originally approved to treat high blood pressure. According to their findings, here below you can see the ranking in decreasing order of efficacy for the treatment of hair loss in men:
- Dutasteride 0.5 mg per day via oral route
- Finasteride 5 mg per day via oral route
- Minoxidil 5 mg per day via oral route
- Finasteride 1 mg per day via oral route
- Minoxidil 5% topical solution
- Minoxidil 2% topical solution
- Minoxidil 0.25 mg per day via oral route
It is important to note that the choice of the agent to treat hair loss should not be solely based on its efficacy and on this ranking, but also on the risk profile of each medication as well as the subject’s medical history. 5-alpha-reductase inhibitors for example may cause decreased libido and sperm count and even erectile dysfunction while oral minoxidil especially in high doses may cause hypotension and hypertrichosis (excessive hair growth all over the body).
Most dermatologists and hair loss specialists tend to prescribe a combination therapy as this provides the best results.
Here below you can find more information on how these medications for hair loss work and on their possible side effects.
Topical Minoxidil for hair loss
Topical minoxidil is an FDA-Approved medication and the most studied therapy for hair loss in both male and female patients with both high efficacy and low rate and severity of side effects. It is available as 2% and 5% solution or as 5% foam to apply directly on the affected areas of the scalp. It is believed to work by prolonging the active growth phase (anagen) of the hair follicle. Moreover, as a vasodilator drug it increases blood flow and thus the amount of oxygen and nutrients delivered to the scalp; it also induces the production of the vascular endothelial growth factor (VEGF) which further increases vascularity.
Minoxidil for androgenetic alopecia is applied twice daily for as long as you want to stop the progression of hair loss.
Among the commonly experienced adverse events when using minoxidil are telogen effluvium, an increase in shedding during the first 2-8 weeks after starting the treatment, and scalp irritation, dermatitis, pruritus, and/or flaking. Excessive hair growth in other areas of the body is possible if the solution is applied inadvertently to them, such as the face or trunk: this can sometimes happen when the solution is applied right before bedtime. Other side effects can be avoided or minimized by using the foam formulation because it does not contain propylene glycol which is known to cause dermatitis and irritation of the skin in some individuals.
Oral Finasteride treatment for hair loss
Finasteride is another FDA-approved medication for hair loss. It works by inhibiting the 5-alpha-reductase type 2 enzyme which inhibits the conversion of testosterone to dihydrotestosterone (DHT) in the outer root sheaths of hair follicles. At this dose, it is capable of lowering serum and scalp DHT levels by 60-70%.
Finasteride for androgenetic alopecia is approved at a 1 mg per day dose and should be taken for as long as you want to stop the progression of hair loss.
Among the possible adverse events in men there are erectile dysfunction, decreased libido, decreased sperm count and production, and depression.
Dutasteride treatment for hair loss
Dutasteride is a non-FDA-approved treatment for androgenetic alopecia. It works by inhibiting 5-alpha-reductase type 1 and type 2; type 1 form of the enzyme is found also in the follicular keratinocytes. Serum DHT levels can be lowered by more than 90% at a daily dose of 0.5 mg per day.
Dutasteride is used off-label for the treatment of male androgenetic alopecia; due to the higher potency when compared to finasteride and the lower tolerability, it is sometimes anecdotally prescribed by doctors only once or twice a week; this is also because being a newer medication we know far less about possible long term complications of using this therapy and specialists may not be willing to prescribe it to younger individuals due to concerns about their hormone levels and fertility.
Among the possible side effects there are erectile dysfunction (ED), decreased libido, decreased sperm count, and depression.
Oral minoxidil for hair loss in males
Oral minoxidil is a non-FDA-approved treatment for male pattern hair loss commonly prescribed off-label in a wide range of dosages from 0.25 mg per day to 5 mg per day. The mechanism of action is believed to be the same as the topical formulations, although less data is available. At lower doses it is generally well tolerated by patients, but in 2.5 mg or higher doses it may cause hypotension, edema (swelling) of the lower extremities and hypertrichosis.
Other available treatments for hair loss
The hair loss market is estimated to be valued at least 10 billion USD, growing year by year. As for many other health-related conditions, companies try to profit from patients often marketing products with claims that have not been proved in rigorous scientific studies, and often with products that have been proved not to be effective in particular in the supplement and nutraceutical industry like the much-acclaimed biotin or vitamin B7.
Here below I’ll cite a few of the other available treatments for hair loss which work or at least have reasonable evidence to consider them promising.
- Low level laser therapy (LLLT), an FDA-Approved treatment for both male and female pattern hair loss
- Platelet-Rich Plasma (PRP)
- Ketoconazole 1-2% shampoo
- Microneedling of the scalp (also known as dermarolling from the device known as dermaroller)
- Hair transplantation (FUT, FUE, ARTAS)
- Relative Efficacy of Minoxidil and the 5-α Reductase Inhibitors in Androgenetic Alopecia Treatment of Male Patients – A Network Meta-analysis.
AK Gupta – JAMA Dermatology, Feb 2022
PM Zito – StatPearls, US National Library of Medicine, May 2022
- Microneedling for Hair Loss.
AK Gupta – Journal of Cosmetic Dermatology, Jan 2022
- Hair Transplant Surgery and Platelet Rich Plasma – Evidence-Based Essentials
LN Lee – Springer, 2020