When to Use Propecia and When to Have a Hair Transplant

Attendee: I know Propecia is good in keeping hair, but once you start it how do you know if it is working?

Dr. Bernstein: That’s a great question! There is a dilemma in going on Propecia, because once you go on Finasteride, there is no way to judge if it’s working unless you stop using it. And if you stop the medication, you’ll lose the hair that you gained or at least the hair that you held onto with the medication. If you stop the medication and lose this hair, when you restart Propecia the hair will usually not return to the level of fullness you had before you stopped. You will be at a new, lower baseline. So you really don’t want to stop the medication once you start. What you have to do is make sure you have a doctor make a correct diagnosis of androgenetic hair loss and then just continue to take it – as long as you want to have its benefits.

Attendee: So when should you have the hair transplant surgery?

Dr. Bernstein: When I used to do general dermatology, I used to give collagen injections. And women used to come in and say when should I schedule my next appointment? They wanted to be in the book for their next visit, before they even needed more collagen. I used to say “just call me when the wrinkles are beginning to come back – don’t’ worry about it until then.”

And it’s kind of the same thing with hair transplantation. The idea is not to come back every year hoping that you will have more hair loss just so that you can have the hair restoration surgery. When you go on Propecia you should just forget about it. You’ll know when you need a hair transplant. You’ll look in the mirror at some point and say I am just not happy with the way my hair looks anymore. And really the indication for a procedure for surgery is when you don’t like the way you look now, not because you’re concerned about future hair loss. Medication is the best treatment for future hair loss.


How Propecia Works

Attendee: What does Propecia do as far as preventing hair loss via growing hair back and what part of the scalp does it work on?

Dr. Bernstein: One of the problems with Propecia is that when the studies were first done, they were done on the crown. It was the same with Rogaine. And the reason why the studies were done on the crown is because it’s the easiest area to show results. And the reason is both Propecia and Rogaine work by increasing the diameter of thinning hair. They reverse the process of miniaturization.

DHT, a byproduct of Testosterone, acts on the hair follicle to cause it to shrivel up, miniaturize and eventually disappear. While the hair is undergoing this process, the process can be reversed. Once the hair is totally gone, neither Propecia nor Rogaine are going to work.

Propecia works much better than Rogaine, but they both work on the miniaturized follicle – on reversing the process so the hair becomes thicker again. Propecia is more effective in doing this.

In the crown, there’s a very long period where hair is miniaturized, so there’s a big window for medication to work. In the front, the area usually goes from being hairy to being bald very quickly - so there is little opportunity for finasteride to work. But in the crown, there’s that long period where it’s miniaturized.

So that’s the reason why it seems like the medicines are working better on the crown. However, it’s just common sense that if the medicines didn’t work in the front at all, eventually the front will become the back and they would be useless. They have to work in the front to some degree - at least in prevention.

If you take a young hair loss patient who’s really just starting to miniaturize in the front - where they are just first showing thinning at the hairline – the Propecia can work dramatically.

I did a study a number of years ago that showed that the diameter of the hair shaft contributes over two and a half times as much to the volume of a person’s hair as the absolute number of hairs on ones head. This is why reversing miniaturization can be so effective in some people in giving a fuller look even if it does not actually grow any new hair.

We have seen patients with early hair loss pushing for hair restoration surgery and we tell them to go on Propecia for a year, and then we’ll schedule a surgery. And we have them come back for their follow-up and they don’t need a hair transplant at all. So it can really work dramatically in front, too, on a younger person if there’s early balding and a lot of miniaturization.

Statistically 83 percent of people on Propecia will maintain the hair for a period of about five years and then it becomes less effective. It actually grows a visible amount of hair back in a much smaller number of patients. It’s probably about 40 percent in younger patients. In older patients, it’s much less than that.


When does Propecia Start to Work?

Attendee: I had seen you about a year ago and we talked about Propecia. And I started taking it. According to the guy who cuts my hair, it’s working really well and it has grown some hair in back of my head. I’ve just been on it for about ten months and every time I go to the barber to get my hair cut, he says, oh, you know, it’s coming in thicker. How long can I expect this to go on?

Dr. Bernstein: So the question is “how long does it take to get the full benefit of Propecia?” You get most of the benefit in the first year. And you may get some additional benefit with respect to improvement of hair volume up to two years. After two years, there’s no additional benefit. It continues to work, but you’ll no longer get more fullness. So the majority of visible benefit is in the first year with some additional benefit in the second.

The important thing for patients to remember is that Propecia doesn’t start to work until about three to six months. So over the first three to six months you should expect no improvement. In fact, some people can actually thin in the first few months as Propecia starts a new hair growth cycle and the old hair is pushed out, so people can sometimes experience shedding during this time. That indicates that the medicine is working if you’re losing hair with the medicine. Propecia is not known to cause hair loss, but it can cause some initial shedding.

The problem is that, for some reason, people’s attention spans are about six months, so unless we really emphasize that they have to wait a full year, after six months they throw up their hands and stop the drug. They come in for their one-year follow-up and they complain that the medication didn’t work. Well, I tell them that we just have to start again.
So the bottom line is that, barring the uncommon situation that you have side effects, you’re going to wait the year for the Propecia to work.

On the other hand, if you’re going to go on Propecia as a preparation for hair transplant surgery, you’ll probably only need to be on the medication one to three months. So if you prep the patient with Propecia before hair restoration – one to three months before – the surgery can be a little more effective, since shedding of miniaturized hair may be avoided or reduced. Obviously, you need to continue to stay on the Propecia. You don’t just do it for the surgery.

The thing that really makes me upset is when a patient goes to a doctor that specializes in hair transplantation and the doctor says, let’s see if Propeica will work. Come back in six months and if doesn’t work we’ll do a hair transplant.

So what happens is obviously it’s not going to work in six months. And they come back, they do the hair transplant and then they get the benefit of the Propecia and they think it’s the transplant, they think it’s the surgery, because the Propecia then kicks in at the same time as the hair transplantation, which is kind of dirty pool. So if your hair transplant surgeon says come back in six months to be evaluated for surgery, I suggest that you run.


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