Q: After achieving results with 5% Minoxidil is it possible to the switch to the 2% version to maintain those results without any adverse hair loss? — I.I., Winnetka, Illinois
A: It will be less effective. The dosing should not be decreased.
Posted byQ: I heard that Propecia stops working after five years. Is this true and why in five years? — B.P., Stamford, CT
A: That is not correct. Although the effects of Propecia (finasteride 1mg) will diminish over time, it does continue to work. Using finasteride long-term will still be better than stopping it at some arbitrary interval. In clinical practice, I often increase the dose of finasteride, after someone had been on the medication 3 to 5 years, to help maintain its effectiveness.
Posted byQ: I have been taking one tablet of Propecia daily for the past 5 years, with good results, until May of this year. At that point I started to experience some hair loss and so you recommended that I switch from Propecia to generic finasteride and increase the dose to 1/2 of a 5 mg pill per day. I started taking the 1/2 tablet of finasteride daily one month ago, and for the past 2 weeks I have seen a lot of hair in the bathtub and on the towel after taking a shower. I have not made any other changes in my diet or my shampoo, and I do not have any conditions on my scalp. Please advise me on what needs to be done. — C.C., Floral Park, New York
A: Just continue the medication at the higher dose. Either the finasteride hasn’t started working yet or you are getting temporary shedding from the medication (which means that it is working).
Posted byQ: I heard that there is a new drug on the market called Avodart for prostate enlargement which might help with hair loss as it blocks the conversion of testosterone to DHT better than Finasteride and is more effective than Propecia. Do you recommend taking it and if so what is the dose? — Y.B., Orlando, Florida
A: I am currently not recommending that patients take Dutasteride for hair loss, although it is more effective than Propecia, finasteride 1mg. (Dutasteride 0.5, the dose generally used for hair loss, seems to be slightly more effective than finasteride 5m in reversing miniaturization.)
The reasons that I am hesitant to prescribe it at present are outlined in the Hair Restoration Answers question, “Is Avodart Safe?”
In addition to the reasons that I listed in that response, I would also consider that: Dutasteride, unlike finasteride, decreases sperm counts, it can result in persistent decreased sex drive and the incidence is greater than with finasteride. Finally there are a significant number of alpha-type 1 receptors in brain, those affected by dutasteride, but not finasteride.
However, since Dutasteride is approved for older men with prostatic disease, using it for hair loss in this age group (usually in a lower dose) is reasonable.
Posted byQ: I have been using Propecia since it was released to the public in 1998 and have found it to work very well. Recently, its effectiveness has stopped and my hairs are miniaturizing again. I am going to increase the dosage to 1/2 a pill Proscar every day. How long will the increased dosage take to stop the miniaturizing process? — T.U., Chappaqua, N.Y.
A: It seems to take the same time to work as when you initially started Propecia.
When patients increase their dose, I rarely see re-growth, but rather the expectation is that further hair loss will be decreased. When it does work to actually re-grow hair, we sometimes see an initial period of shedding, similar to when finasteride was first started.
Posted byQ: I’m 52 years old and have been taking Propecia (finasteride) for two years. It seems to maintain the status quo with no apparent regrowth. I am considering adding a dose of Avodart (dutasteride) once a week in conjunction with the daily Propecia. My question is twofold: (1) Since dutasteride blocks production of both enzymes (type I and II) that produce DHT from testosterone, is it redundant to take the finasteride that only blocks the type I enzyme? — Y.B., Orlando, Florida
A: It is redundant to take both.
However, you may not be taking the optimal dose of dutasteride which seems to be at least 0.5mg a day for hair loss.
Posted byQ: First off thank you for providing this Blog, it is extremely informative and gives people the opportunity to ask questions of one of the most knowledgeable hair transplant surgeons in the world. You are considered the consummate researcher in the field of hair loss, so I ask this question of you. It appears that all the current hair loss drugs, at one point or another, begin to lose their effectiveness. Have you ever entertained the idea of cycling these drugs, or reducing the dosage for a period of time, to prevent the body from becoming acclimated to these drugs and subsequently making adjustments to receptors causing this? This method is commonly used by bodybuilders and others in the sports profession to elicit the maximum effect from the drugs they employ. Though I have not found any studies along these lines, I believe there are valid reasons why this may work. I hope you may be able to share any information on this subject. — Z.Z., Chicago, I.L.
A: Excellent question. I can answer it only indirectly.
It has been our experience that when you discontinue finasteride (Propecia), or decrease the dose to a degree that it no longer works, the patient will begin to shed hair. When the drug is re-started or the dose increased again, the medications will begin working, but the patient now maintains his hair at a lower baseline. He doesn’t seem to regain the amount of hair he has before the medication was stopped. For this reason, we don’t stop and start finasteride. The same argument applies to dutasteride, although we have less experience with this medication. This experience would speak against using pulse therapy for hair loss.
On the other hand, the hair loss medications finasteride and dutasteride do not necessarily need to be used once a day. Although the serum half-life of finasteride is around 6 hours, the tissue half-life is felt to be around two days. Therefore, alternate day dosing with 2 mg of finasteride (or approx. 1/2 of a 5mg tablet) should work just as well as 1mg a day. An average daily dose of less than 1mg, however, does not seem to be as effective. Dutasteride has a half-life of 5 weeks and is found to bind to scalp tissue for many months, so with dutasteride, a dosing of even once a week will most likely be just as effective as once a day.
Note that this regular alternate day dosing is different than pulse dosing. In pulse therapy, the body is given a chance to recover. The principle here is to take advantage of the persistence of the drug in the scalp even after blood levels drop and not to let the scalp recover (which we have found to result in a net loss of hair (as discussed above).
When patients do become acclimated to these drugs (which seem to be common after 3 to 5 years) we increase the daily dose of finasteride gradually up to 5mg and then consider switching to dutasteride 0.5mg a day.
Posted byQ: I am not yet ready for a hair transplant but am considering Propecia. What is your opinion on the “optimal dose”? I know Merck recommends 1 mg, but could I get away with taking less? Or would I get a better result by taking more (2-3 mgs)? — V.B, Darien, CT
A: You may get away with 0.5 mg a day. However, there are published data by Roberts et. Al. in the JAAD in 1999 showing a dose-response between 0.2 and 1 mg/day, with the lower dose showing reduced efficacy, from controlled clinical trials.
There is little evidence that a higher dose helps, but I often double the dose if a patient has been on 1mg a day for 3-5 years and then stops responding. The hope is that this can postpone the need for surgical hair restoration, but there is no scientific data to support that it will.
Posted byQ: I have been taking Propecia for three months. Would it help to up my dose? — F.J., Red Hook, Brooklyn, NYC
A: For most people (of average body weight of approximately 150 pounds) 1 mg is the ideal dose of finasteride (Propecia).
This is a statistical statement, however. There are some people who fall outside the bell curve. As we don’t know who these people are, we occasionally increase the dose on non-responders after 1-2 years, particularly for those who weigh significantly more than 150 pounds.
Remember, an increased dose also results in an increased risk of side effects and most people experience no additional benefit. There have been no scientific studies to support this regimen.
Read more answers to questions on Propecia Dosage
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