Answers to frequently asked questions about medical treatment for hair loss.
Q: Dr. Bernstein, I am experiencing side effects on Propecia, are there alternative treatments?
Q: What do I do if I start experiencing side effects on finasteride?
A: Don’t panic, just stop the medication and let your doctor know. He or she will give you guidance based on your symptoms.
Q: I had a good friend get a transplant at your practice and it seems that your practice is the industry leader in hair transplantation. I may one day be looking for one. That being said, my friend said I shouldn’t trust anyone else. I wanted to know if you may be able to tell me what tests/specific labs you have your patients do prior to starting Propecia. I am having my doctor put me on it but he does not recommend any labs but I don’t trust this. So I’m not looking for medical advice, just what your practice may advise a patient to get (in terms of labs/blood tests) prior to starting Propecia. I’m really hoping you can help as I have already contacted a number of other sources and can’t seem to get an answer.
A: Blood tests are not required before starting finasteride and we do not routinely perform them. If a patient requests test then Total and Free Testosterone, DHT, and Prolactin are reasonable to obtain, but there is no consensus on what the appropriate tests might be. If a patient requests tests because he has symptoms (i.e. such as lack of energy associated with low T), he should see his internist, urologist, or GP. That said, patients 50 and over (40 and over in patients with a high risk of developing prostate cancer) should have a PSA before starting finasteride.
Q: Does a man’s height and weight affect the dose of finasteride or Propecia he should take? i.e. will a 6’4″ man need a higher dose than a 5’7″ man. ~ T.B. — Rye Brook, NY
A: The dose of finasteride is the same (i.e. 1mg) regardless of a person’s height or weight. The reason is that one needs only 0.5mg a day for it to be effective, so there is much leeway built into the dose (but the rate of non-responders is slightly higher at the 0.5mg/day dose). That said, after 5 years or so, finasteride seems to be less effective and doctors often increase the dose a bit. The next step-up is generally to take 1/3 of a 5mg pill each day. Keep in mind that the dosing we are speaking about is for hair loss (androgenetic alopecia). When finasteride is used for prostate enlargement, the dose is 5mg a day.
Q: Hi. I am 52 years old and wish to know if Propecia will work for my age. I have started losing some hair a couple of years ago and it’s thinning out. Thank you very much for your help.
A: Propecia (Finasteride 1 mg) can hold on to hair at any age, but works best to re-grow hair in those who are younger. Occasionally we see patients in their 50s re-grow some hair with Propecia, but this is the exception rather than the rule.
Q: Can Propecia (finasteride) completely halt androgenic alopecia for the duration of your lifetime, or does it just slow down the progression of androgenic alopecia?
A: In many patients we have found finasteride to hold on to a patient’s hair for at least 15 years. We don’t have much longer data than that since it was approved for hair loss in 1998. Although finasteride will usually continue to work as long as you take it, it may lose some of its efficacy over time. Generally after about 5 years we may notice that the patient’s hair is starting to thin again and we will increase the dose slightly. It is important to understand that even if someone thins on finasteride it doesn’t mean the medicine is not working, because they might have thinned much more without it. To my knowledge, there are no studies that have looked at the effects of finasteride for such an extended period of time.
Q: I’ve heard that using Propecia and/or Rogaine is a good idea after having a hair transplant, but are they mandatory?
A: Neither finasteride (brand name: Propecia) nor minoxidil (brand name: Rogaine) will have any effect on transplanted hair. That said, while you don’t need them to protect your transplanted hair, you will likely have original hair interspersed among your transplanted hair that will continue to thin and fall out over time. This vulnerable hair can be protected by finasteride which has been shown to reduce future hair loss significantly; additionally, you can add Rogaine for extra benefit.
However, with Propecia, you should only use it if you can commit to it long-term because it takes up to a full year to see any effect. With Rogaine, you should only use it if you can commit to using it continually and regularly – you should not stop and start it.
Q: Both Propecia and Minoxidil definitely can work in the front of the scalp as long as there is some hair in the area. Although their mechanisms of action are different, both Propecia (finasteride) and Rogaine (minoxidil) act to thicken miniaturized hair regardless of where it is on the scalp. In fact, there are published data (Leyden et. al., JAAD, 1999) demonstrating this improvement in a controlled clinical trial of men with frontal hair loss.
A: Both Propecia and Minoxidil definitely can work in the front of the scalp as long as there is some hair in the area. Although their mechanisms of action are different, both Propecia (finasteride) and Rogaine (minoxidil) act to thicken miniaturized hair regardless of where it is on the scalp. In fact, there are published data (Leyden et. al., JAAD, 1999) demonstrating this improvement with finasteride in a controlled clinical trial of men with frontal hair loss.
The source of the confusion on this topic is the fact that the FDA limited the application of the drugs to the crown on the package inserts for both Propecia and Rogaine. The FDA did this because Upjohn (the company that introduced Rogaine) and Merck (Propecia) only tested the medications on the crown in the clinical trials. Logically, the fact that DHT causes frontal hair loss and Propecia works by blocking DHT gives a reasonable explanation for the efficacy of the drug on the front of the scalp. Also, a side effect of the use of minoxidil is facial hair, so how could it not also work on the front of the scalp? It is regrettable that some doctors and many patients think that these medications won’t work on the front of the scalp. Unfortunately, many hair restoration surgeons have done little to educate the public and dispel this myth.
To reiterate, yes, both of these medications can work on the front of the scalp to prevent hair loss and thicken a thinning hairline. However, it is important to note that neither of these medications can grow hair on a totally bald scalp or lower an existing hairline. Hair follicles must exist for the medications to work. It is also important to stress that the best results come from using both finasteride and minoxidil together.
Q: I’ve heard that FDA added a description of reports of male infertility to the side effect labels of both Propecia and Proscar (finasteride). Is this a likely side effect in your experience?
A: Propecia (finasteride 1mg) may, uncommonly, lead to male infertility by changing the consistency of the male ejaculate as well as decreasing the sperm count.
Ejaculate is a combination of sperm produced by the testes and a viscous fluid made by the prostate. Since finasteride shrinks the prostate it make the ejaculate less viscous (more watery).
Most patients taking Propecia and trying to conceive have no issues.
If one is trying to conceive for 4-6 months and having difficulty, then it is reasonable to stop taking Propecia.
It is important to know that taking Propecia while trying to conceive will not lead to congenital deformities or issues with the fetus as long as the women does not come in direct contact with the medication.
Q: I have been using an increased dosage of Propecia now for around 8 months and Rogaine for about 6 months. I know that shedding can be expected for the first 3-6 months, but I believe I am now beyond that timeframe. Have you seen cases in which these products merely exacerbate hair loss without the expected regrowth?
A: It is a bit long to still see shedding, but from my experience, either the medications are working (and you are still in the shedding phase) or you are not responding to them. I have not seen minoxidil or finasteride worsen hair loss. My advice would be to continue the same course for at least a year before re-evaluating their use.
Q: I read your 20 pages of FAQs but could not find this question addressed. I’m currently taking Finasteride 5 mg (one-fourth tablet per day) but since some drug companies make an oblong tablet that is hard to cut into four pieces, I found a plastic bottle with four equal measurements and I dissolve the tablet in water, shake it up and drink one-fourth of the liquid each day. I read somewhere that you’re not really supposed to dissolve the pill in water. Is that correct or is it OK to keep doing it the way I’m doing?
A: I would cut up the pills with a pill-cutter – they do not need to be in equal parts. Just finish a whole pill every four days. You can also take ½ pill every other day and achieve the same effect. I am not sure of the stability of the medication in water over several days. It is probably OK, but why take the chance?
Q: As a Propecia user, I was alarmed when I read headlines last year about about a new study indicating very high rates of depression and erectile dysfunction caused by Propecia, with symptoms persisting even after the drug was stopped. However, when I read the articles, this “study” appeared to be survey of 61 men who had taken Propecia and already reported sexual problems who were then asked about symptoms of depression. These rates of depression were compared to a small survey of men who had hair loss but had never taken Propecia.
Anyone with a basic understanding of statistics would know such a survey was deeply flawed. First, it is a textbook example of a bad data sample — to get sound results you have to start with an unbiased and random group of people who took the drug, not a self-selected group of men already suffering symptoms. The study also confuses correlation with causation — because these men are suffering from ED or depression does not necessarily mean it was caused by the drug. Am I missing something here, or did the media just report these “findings” with no scrutiny on what was actually studied? — Jonathan, Brooklyn, NY
A: Jonathan, I think you’re right on the mark. The way the study was conducted raises a lot of concern about the accuracy of the findings. It is really important that additional data is obtained in a controlled way, as this will be most useful for physicians in advising patients. I addressed concern on these reports on the Hair Transplant Blog last year. The issue of persistent sexual dysfunction as a side-effect of finasteride is an on-going issue that we take very seriously. I sit on the International Society of Hair Restoration Surgery (ISHRS) Task Force on Finasteride Adverse Events, so this is an issue that we watch very closely.
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?
A: It will be less effective. The dosing should not be decreased.
Q: Have you any experience with Azelaic Acid as a hair loss treatment — is this something you would recommend using with Rogaine (minoxidil) 2% or 5% solutions?
A: Azeleic acid has no direct benefit in promoting hair growth. Azelaic acid (like retinoic acid) increases the absorption of minoxidil, but also the side effects, so I would especially not recommend it in your case.
Q: Is it possible that side effects attributed to the use of Minoxidil 5% lotion can reduce over time or disappear altogether? Specifically I experienced a heightened sense of heart activity (palpitations).
A: Yes, the side effects may diminish over time.
Q: I have heard that side effects from finasteride can persist even after stopping the medication. What is the most current information on this issue?
A: For the past two years I have been on the ISHRS’s Task Force on Finasteride Adverse Events and struggling to make sense of this issue. There seems to be a disconnect between the relatively low incidence of side effects that we, as physicians, see in our practices, what published controlled studies have shown, and what is now being reported on the internet. For example, a 2012 study by Sato of 3,177 Japanese men published the Journal of Dermatology, showed a 0.7% incidence of adverse reactions to finasteride 1% and no persistent side effects after stopping the medication.
That said, there has been a recent increase in anecdotal reports of side effects from finasteride as well as reports of persistent side effects after the medication has been discontinued (referred to as “Post-finasteride Syndrome”).
Q: I have been taking finasteride for several years and I seem to be doing well. Does finasteride generally work long-term?
A: With regard to efficacy, a recent long-term, uncontrolled study by Rossi et al. reported that the effects of finasteride were not reduced as time goes on and that a significant proportion of patients, unchanged after 1 year, improved later on. In addition these patients maintained a positive trend over time -– up to ten years. When comparing different age groups, they found that subjects older than 30 years showed a better hair growth in the long term than those who were younger. Of the 113 patients in the study followed for 10 years, only 14% worsened, whereas the remaining 86% had benefits.
Q: Dr. Bernstein, I am an attending at Mass General Hospital in Boston and would like to ask you regarding your experiences using finasteride for male androgenetic alopecia. While I have not noticed any side effects in the patients that I have been treating, I increasingly get questions regarding side effects based on the recent media attention to reports of potentially permanent problems regarding libido or erectile dysfunction. I know that in the literature there is a slight increase of reversible sexual dysfunction (~4% vs. ~2% in placebo) with Propecia, and no convincing evidence to date in the medical literature that have used controlled studies regarding permanent problems even after discontinuing Propecia.
A: That is correct.
Q: I know that you have treated many patients over a long period of time, and I was thus wondering what your take is on potentially permanent sexual dysfunction after taking finasteride. Have you seen any convincing reports/patients or do you have any concerns regarding irreversible side effects?
A: I have seen 5 cases in over 10,000 patients on finasteride that complained of this but, of course, there is no way to know for sure if there is a cause and effect relationship. As you know, real side effects may be followed by psychological ones and if the sexual dysfunction has another cause, then stopping finasteride would have no effect on the symptoms. The incidence of sexual dysfunction in the population of men on finasteride is about 30%, so one would expect these numbers to be much higher just due to the normal incidence. It is really a difficult situation to understand. The experience that my colleagues and I have in our practices is much different than one would expect after reading the numerous anecdotal reports on the internet.
Q: Would you think it is safe to say that any potential sexual dysfunction is reversible after discontinuing the use of finasteride?
A: I don’t think that anyone knows at this point. The FDA is coming down on the side of caution and saying that it is possible, although it is not based on any new studies. If the phenomenon is real, the possible mechanism is not yet known.
Q: In the relatively few patients that I have treated with Propecia, they did not even report temporary problems regarding libido or erectile dysfunction. Do you think they are real or rather attributed to Propecia simply because the patient is made aware of these potential side effects?
A: I think that psychological effects may account for many cases. At this time, it is still not clear if a physiologic “post-finasteride syndrome” is real. A lot more work needs to be done before we have a definitive answer to this question.
Q: I recently visited my dermatologist regarding my hair loss, and after checking my hair he said I am showing signs of [Androgenetic Alopecia (AGA)], and said if I don’t treat it, it will progress. From my research on the net, I figured he will put me on Propecia. In fact he put me on Avodart. When I told him it is not FDA-approved for hair loss, and Propecia is, he said Avodart is better and brings DHT down more, and Propecia is nothing next to Avodart. He told me to take it every day for 2 weeks, then every other day from then on as it has a long half life. From researching on the net, many hair restoration doctors, rarely prescribe Avodart for hair loss due to some dangers. What is your opinion on this?
A: Although dutasteride (Avodart) can be more effective for male pattern hair loss, I would start with finasteride (Propecia) as many patients do great with it and the safety profile is better. The following are things I would consider before starting dutasteride:
- As you point out, dutasteride is not FDA-approved for hair loss.
- There is no data on its safety when used for hair loss. This is important since dutasteride has been only tested on an older population of patients (with prostate disease) rather than a younger population of patients needing medical treatment for androgenetic alopecia.
- These is no natural model for dutasteride’s combined blockage of both type 1 and 2 5-alpha reductase (finasteride blocks only type 2 5-AR and there are families that have this deficiency and have no long-term problems. This, by the way, is how the drug was discovered).
- The type 1 enzyme which dutasteride blocks is present in many more tissues of the body (including the brain) compared to type 2 (which is more localized to the skin).
- Although so far unproven, there is a concern that finasteride may produce side effects than can be persistent after stopping the medication (post-finasteride syndrome). It this does turn out to be true, the effects from dutasteride would most likely be significantly more persistent.
- If you start with finasteride and do have side effects, you will most surely have side effects from dutasteride; therefore, by taking finasteride first you will have avoided the potentially more problematic side effects from dutasteride
- You may respond well to finasteride, and so do not need to consider dutasteride
Q: I have been finasteride for several years. My wife and I are currently trying to conceive our first child and it is unclear to me if it is safe to continue taking finasteride during this period. Unfortunately, I have not been able to get a clear position via the Internet. Most people commenting on it are on blogs and the response goes both ways – some say it’s ok, others say stop. While I know that it’s imperative that a pregnant woman not touch the medicine, can you please let me know if I can continue taking the medicine while trying to conceive?
A: It is OK for you to continue finasteride while your wife is trying to conceive. However, there is some data to suggest that it may slightly decrease fertility since, by shrinking the prostate (the prostate produces 25-30% of semen volume) it slightly changes the overall composition of semen. These effects appear to be temporary and finasteride has no direct effect on sperm. If you and your wife were to have difficulty conceiving, at that point is might be reasonable to temporarily discontinue the medication.
Q: Doctor Bernstein, I was looking at your website and saw the photos of medical hair loss treatments only, with Rogaine and Propecia. Doctor, are all those pictures just with medical treatments or is there concealers as well? I don’t mean to sound rude or disrespectful, but are the pics all real and genuine? Those are some impressive responses to medical treatment.
A: The photos are un-retouched and without concealers. These are responses to medical treatment alone. Yes, medications (finasteride and minoxidil) can work really well in select patients. Patients with early stages of thinning usually respond the best. Contrary to popular belief, the medications can work in the front part of the scalp, as long as the area is not shiny bald.
Perhaps about 1/3 of patients respond well enough to be put on the site. Most others have a good response, but not necessarily improvement significant enough to be easily noticeable in photos.
Q: Are the “result” photos from taking Propecia and using Rogaine legitimate? Some of the after photos look too good to be real and a few patients looked like they combed their hair to look like they had more coverage.
A: The before and after photos of patients using Propecia and Rogaine are my patients. All photos on our website are un-retouched. Often, when patients have a good response to medical therapy, they have more flexibility in how they can groom and style their hair. This is reflected in the photos.
Q: You prescribed Propecia for my hair loss. I was wondering if the new news report on Propecia side effects has altered your opinion regarding the safety of this drug?
A: It has not changed. I believe you are referring to Dr. Michael Irwig’s study at George Washington University published in the Journal of Sexual Medicine. I was already aware of the study when I prescribed the medication for you and we discussed the risk of persistent side effects at your consult.
Although all types of data should be considered, it is important to realize that this was not a scientific study, but a survey. It had very significant selection bias. From this type of study, one can’t prove cause and effect relationships or even get a sense of actual incidences. These were patients who were recruited because they already had persistent sexual dysfunction. Since it is not clear if their persistent problems were directly due to the medication or from other factors, and since these patients were selected, rather than randomly assigned, the additional information can be gained from the report is very limited.
That said, the reporting of persistent side effects should not be taken lightly, but should be viewed in the context of all available data. It is extremely important for us to continue to be vigilant, as this is a very significant issue, but it is equally important not to make decisions on data sensationalized in the media. As a result of the finasteride data, some are presenting surgery as a more reasonable alternative than medication. For a young person, that is usually not the case.
Q: I am 27 years old and I have been on Propecia for 12 months now. Honestly, I have seen no response from it. In my dermatologist’s opinion I am a non-responder. I asked about Avodart and he said, since Propecia didn’t help then Avodart won’t help as well since both are DHT blockers, and if one didn’t work the other won’t either. In your opinion do you think Avodart is better? I have read that it blocks more DHT than Propecia. What is the dosing for Avodart? If someone does not respond to Propecia will they also not respond to Avodart?
A: Avodart (dutasteride) is more effective than Propecia (finasteride) and some patients will respond to dutasteride who do not respond to finasteride. Dutasteride decreases serum DHT about 90% compared to 70% for finasteride. The usual starting dose of Avodart is 0.5mg a day. That said, it is not FDA approved for use in hair loss and if a person has sexual side effects, the side effects are more likely to be persistent after stopping the medication compared to finasteride.
Q: Is taking Propecia absolutely essential to retain the transplanted hair after a hair transplant? — D.W., Toronto, Canada
A: Propecia (Finasteride 1mg) does not affect transplanted hair. The purpose of taking finasteride is to prevent further loss of the non-transplanted hair after the hair restoration procedure.
Q: I want to save money on Propecia (finasteride 1mg), so I have been using generic Proscar (finasteride 5mg) and cutting it into four pieces, but it is becoming a nuisance. I heard that Propecia will be generic soon. Do you know when this will happen? — P.R., Queens, NY
A: It is anticipated that Propecia will be available in a generic form in the Fall of 2013.
Q: I am taking finasteride as you prescribed. You also suggested using minoxidil liberally over the entire front and top of my scalp once a day. During our meeting I think that you said that once I start using this I would not be able to stop it, and, if I did, it might lead to further hair loss. Hence, I decided to use the laser comb three times a week in addition to the finasteride. Having said that, if you still feel I should start using minoxidil daily, I will start doing so.
A: Stopping therapy doesn’t lead to further hair loss in that it doesn’t accelerate it; you just continue on the path that you would have been without the treatment. When you stop, there may be an initial shedding as you quickly lose any benefits that you had from the treatment.
Q: I heard that Propecia stops working after five years. Is this true and why in five years?
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.
Q: Although I was prescribed Propecia, I have not yet started to take it. I would like to take it now, but my wife wants me to wait until after we have our second baby so as to avoid having the drug in my system when we conceive. She’s concerned that if it’s so harmful to pregnant women, that having it in my sperm is an issue.
A: There is no evidence that if you take the medication it will affect the fetus. However, your wife should not ingest the drug or handle broken pills during pregnancy.
Q: Can dandruff cause hair loss? I have a lot of dandruff and use the Nizoral Shampoo for it. And can the Nizoral be a reason I am losing my hair? — K.P., Suffern, NY
A: Dandruff (the medical term is seborrhea) does not cause hair loss as it is a condition that involves scaling and redness on the surface of the scalp and does not involve the growth parts of the hair follicle that lie deeper in the skin. Although Nizoral is an ineffective treatment for hair loss (it is sometimes prescribed for this) it will not cause hair loss.
Q: Should I use Nizoral every day? — L.S., Houston, TX
A: The product recommendation is to use Nizoral shampoo twice per week for dandruff, but many patients prefer to use it daily. Other than drying out the scalp, it is safe to use daily. The 1% formulation is over the counter. The 2% requires a prescription.
Q: I use Nizoral for my dandruff. Does it work for hair loss too? — M.D., Danbury, CT
A: The active ingredient in Nizoral is Ketoconazole. This medication, originally developed to treat fungus infections, has slight anti-androgen action. It is supposed to work in hair loss by inhibiting the action of DHT on hair follicles. Although, in theory, it should be useful for androgenetic hair loss, there have not been conclusive scientific studies to show that it works to treat balding when used as a topical application for balding.
Q: I heard that the sexual side effects of Propecia are irreversible. Is this true?
A: The sexual side effects of finasteride (Propecia) begin to subside soon after the medication is discontinued. This would make sense since the drug finasteride is a reversible inhibitor of DHT. Although it is possible for side effects to be persistent after stopping the medication, this situation seems to be very uncommon and a cause and effect relationship is still in question.
Q: I saw your post on the clinical trials of Latisse (bimatoprost) for hair loss on the scalp. What is the status of the study? — B.V., New Providence, NJ
After trading anecdotes with fellow hair loss physicians about how finasteride can reduce body hair in some patients, Dr. Sharon A. Keene asked whether finasteride might have a negative effect on patients who have body hair transplant (BHT) procedures. While the current research is inconclusive, her review sheds light on how to avoid any possible negative impact that finasteride might have on patients who have body hair transplant procedures.
Q: I started using both Propecia (finasteride) and Rogaine for roughly the past 15 weeks. In the last month I’ve been experiencing pain in my left testicle area. At first I thought this may be due to Varicocele; however, after some quick internet searches I thought it may also be the Propecia. The pain doesn’t seem to be in the testicle itself as much as the surrounding veins on the left side. What should I do? — B.L., Houston, TX
A: Your symptoms are the classic ones of a varicocele, namely pain on the left side that is adjacent to the testicle. Symptoms of finasteride would more likely be bilateral, although the discomfort does not need to be in the testicle itself. If your symptoms are worse at the end of the day when you have been standing, and less in the AM when you first arise, these suggest a varicocele.
In your pain is consistently worse towards the end of the day, I would see a urologist, as surgical intervention might be warranted, particularly if it is affecting sperm counts – which should be checked as part of the evaluation.
If this is not the case, then stop finasteride for a least a month and see if the symptoms subside. If they do go away off finasteride, I would not take the medication again. If the symptoms persist off finasteride, I would still see a urologist.
A: In theory, yes!
Q: I am currently taking Avodart and have done so for around 8 months. Last night I had a significant loss of hair after taking a shower, nothing like I have ever seen before and found it very distressing. Can you tell me if this is hair loss or could it be something known as shedding and could you please tell me what is the difference between hair loss and hair shedding?
A: Hair loss is a very general term that can refer loss of hair for any reason. Genetic hair loss is caused by the effects of DHT on hair follicles that result in miniaturization -– i.e. a slowly progressive change in hair diameter that starts with visible thinning and that may gradually end in complete baldness. Hair shedding is more sudden where hair falls out due to a rapid shift of hair from its growth phase into the resting phase. The medical term for this is telogen effluvium. This process is usually reversible when the offending problem is stopped. It can be due to stress, medication, or other issues. You should see a dermatologist to figure out which process is going on. Dutasteride can cause some shedding when it first starts to work, but it would be unusual to do this after being on treatment for eight months.
Q: I am a 34 year old male and my dermatologist prescribed Propecia for me today. Most of my hair loss is at the hairline, but there is some loss on top as well. It’s not bad, I just want to stay ahead of it. If I get a transplant I want to get it at your clinic, but I will give the Propecia a try first. I am going to be overseas for a couple of months starting this Sunday and I was wondering about the necessity or desirability of having someone measure my hair density prior to starting the Propecia. Would you advise waiting to start the Propecia until I come back in two months and having my density examined at your clinic?
A: I would start Propecia as soon as possible. What is important for a hair transplant is the density in the donor area and this is not affected by Propecia (or minoxidil). Your donor density can be measured anytime at an evaluation prior to surgery. If you want to wait to see the effects of Propecia prior to the hair transplant, you really should wait a year; since growth, if any, can take this long. If you just want to have Propecia on board for the hair restoration procedure, or to make sure you don’t have side effects, then generally a month will do. If you would like to do a photo consult through our website to get some preliminary information about how many grafts you might need, you can do that at your leisure, but start Propecia now since the longer you wait the less effective it will be at regrowing hair.
Q: 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.
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).
Q: I’m concerned that finasteride might result in unwanted body hair on the arms, back, etc. Is there any truth to this? My thinking is that since finasteride blocks the enzyme 5 alpha-reductase which converts testosterone to its more active form, DHT (dihydrotestosterone), is it possible that it might actually have some effectiveness in ameliorating unwanted hair?
A: Yes, finasteride does have some ability to decrease body hair, since growth of body hair is stimulated by DHT. However, the effects of finasteride are mild and not observed by everyone, so if you have unwanted body hair you will probably need some other means to remove it such as waxing, laser hair removal or electrolysis. The important thing is that finasteride doesn’t increase body hair.
Q: You mentioned that the hair at my crown and other areas where I now have baldness hasn’t really fallen off but has thinned to a great extent and that taking Rogaine and Propecia might help increase their thickness. If the medications do restore the hair thickness, I’m curious why you said that I could look like how I was 1 to 2 years ago. Technically, shouldn’t I be able to regain much more of my hair (and look like how I was longer than before that) since the follicles are all still there?
A: Although Propecia is much more effective than Rogaine, even when used together, the medications are just not that effective in reversing the miniaturization process. They may bring you back to the way you were a few years ago, but will not restore your adolescent density.
Q: Is it recommended to wait for 1 year after starting Propecia, when the effect of the medication kicks in and improves density of donor area, and then perform the surgery?
A: Propecia will not affect the donor area, as this area is generally not impacted by the miniaturizing (thinning) effects of DHT –- the hormone that Propecia blocks. The purpose of waiting the year is to possibly regrow hair in the recipient area. If regrowth is significant, a hair transplant may not be necessary. If a person’s hair loss is extensive and there is little chance that Propecia will grow a significant amount of hair back to give a satisfactory improvement, then waiting the year is unnecessary.
Q: I have read that a lot of doctors today administer Midazolam (Versed) to sedate the patient. I have two questions in reference to this drug: 1) How does the doctor determine how much of a dose to administer to the patient and 2) is the drug administered all at once, or intermittently throughout the procedure?
A: Each doctor has a different protocol, so it is hard to generalize. At Bernstein Medical we usually use Versed 2 to 4 mg IM one time 10 minutes prior to giving the local anesthesia. The dose is not repeated.
We also use Valium 5-15mg by mouth. I determine the dose of each based on body weight and history of sensitivity to sedatives.
Q: I am currently 28. I have been taking Propecia for 6 years and recently began to grow sparse chest hair for the first time in my life. Is the Propecia causing these effects?
A: DHT causes male pattern baldness and stimulates the growth of body hair. The use of Finasteride, a DHT blocker, will permit scalp hair to grown and inhibit the growth of body hair, not stimulate it.
However, the effects on body hair are quite small, so your natural tendency to grow chest hair over time is probably not being blocked by the treatment.
Q: Hey doc, you told me to cut up 5mg finasteride into four parts. Why not five, so that it will be equal to Propecia which is 1mg?
A: For several reasons; 1) you will lose some in the cutting process, 2) the generic dose can be slightly less than the brand, and 3) it is too difficult to cut into five parts – four is hard enough. Note that due to the fact that finasteride stays in the hair follicle for a long time, the pieces do not have to be in four equal parts.
Q: I have a friend who has been using Propecia 1mg a day for twelve months without having any regrowth. Is he likely to experience regrowth at this stage?
A: Your friend is unlikely to get any significant regrowth after one year, but that doesn’t mean that the medication is not working. He may have had even more hair loss without the medication.
Q: I know that Propecia works in only about half of patients. Are younger people more likely to be helped by this medication?
A: The main studies by Merck looked at men between the ages of 18 and 41. The five year data (which, in my view, is most important) showed that 48% of men had an increase in hair growth and 42% had no change over baseline. Thus a full 90% held on to their hair or had more over a 5-year period. This compares very favorably to the placebo group where 75% lost hair over the 5-year period.
Q: Is using Minoxidil combined with Retin-A better than regular Minoxidil for Hair Loss?
A: Minoxidil has been prescribed (off-label) in combination with other medications, such as topical retinoic acid (Retin-A), to enhance its penetration into the skin and thus increase its effectiveness. This combination of medications can increase the absorption of minoxidil into the bloodstream and may increase the risk of potential side effects, including changes in blood pressure and scalp irritation. It is important to use combination therapy under the supervision of a physician.
Q: I’ve now been taking finasteride for just over 5 months. I have noticed that my semen quality has changed just in the last 3 months, and it seems now much less in quantity and is quite watery and clear in color. I think the current problems are due to the finasteride, what do you think?
A: Finasteride, the active drug in Propecia, can change the quality of the semen, since it is decreasing the component of seminal fluid that is secreted by the prostate. You may want to consider having your sperm counts checked, as finasteride can lower this. If the symptoms are not bothering you, and your sperm counts are normal, it should be OK to continue the medication. If you were having difficulty conceiving, then I would stop the medication.
Q: What time should I take the Propecia? Does it work better if I take it at night as opposed to the morning and should I take it with meals?
A: It doesn’t matter what time of day you take Propecia and the time can very each day.
The absorption of Propecia (finasteride) is not affected by food, so it can be taken without regard to meals.
Q: I started thinning and saw more hair in the tub. I began Rogaine and stopped shampooing every night and is seems that there is now more coming out every time I shower. What is going on?
A: Rogaine can cause shedding at the beginning of treatment (i.e. in the first 3 months) but this is expected as it causes some hair to begin a new cycle of shedding and re-growth. This means the medication is working.
Another reason for your apparent shedding is that the less you wash your hair, the more will be lost each time. Go back to shampooing every day and see what happens.
Q: If I get transplants, do I still have to continue taking Propecia?
A: Yes, you should.
You do not need finasteride (Propecia) for the hair transplant to work, or the transplanted hair to continue to grow, but finasteride can decrease further hair loss.
Q: Do you think there is a difference in the efficacy between the 5% Rogaine foam or liquid formula?
A: In theory, the foam should be as effective as the original solution (liquid). However, an important part of the efficacy is getting the medication directly onto the scalp – rather than just on the hair.
For patients who are applying the medication to areas with a significant amount of hair, using the solution with a dropper applicator enables the medication to best reach the scalp. Because of this, I prefer that patients use the solution with a dropper applicator if they are using the medications in areas with a significant amount of hair. If patients find the solution irritating to the scalp (or too messy) and the foam less so, then using the foam is better than nothing.
Q: Medical information suggests that Rogaine works for about 50% of the men who try it. Does Rogaine actually worsen hair loss in some men? The Rogaine website states that during the first three weeks of use Rogaine causes increased shedding. If true, would intermittent use of Rogaine make hair loss worse even in men for whom Rogaine would work if applied daily as directed?
A: Rogaine, the brand name for the drug Minoxidil, does not worsen hair loss, but can cause initial shedding (which actually shows that the drug is working).
The medication should be used on a continuous basis for the long-haul. Intermittent use of the drug, or pulsing, makes no medical sense.
Q: I recently had a hair transplant about a month ago. Currently I’m on Propecia and I am a stickler to taking it at the same time every day. I don’t, however, use Rogaine namely because I fear the irritation it can possibly cause will halt graft growth and because I’ve heard that the grafts and post-surgical shock loss hair will return without its use. Is it ok to use only Propecia post-surgically? Or would adding Rogaine be of any significant benefit?
A: I would definitely stay on Propecia and, if you like, you can add Rogaine – it may have a little additional benefit. The 5% foam formulation is less irritating and can be started a week after the hair transplant.
Q: Are there DHT blockers that are sold in the pharmacy over the counter?
A: The only effective DHT blockers are finasteride (Propecia, Proscar) and dutasteride (Avodart).
These medications require a doctor’s prescription and are not sold OTC. Nizoral is a topical shampoo for seborrhea (a type of dandruff) that is sold over the counter, but it is not effective in treating hair loss.
Q: I have hair loss due to a treatment of Accutane. I have been off this medication for about a year and a half now, yet my hair has not recovered. The texture of my hair has completely changed. Given the fact that there is no family history linking me to male pattern baldness, I attribute my hair loss exclusively to Accutane. What should I do?
A: If the texture alone has changed there is nothing you can do except to wait. The texture should improve over time even though it has already been 18 months.
Q: 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?
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?“
Q: Our dermatologist originally suggested our son use the 5% Rogaine and he developed an allergic reaction to it. Allergy tests confirmed it was the propylene glycol causing the reaction. I understand that Rogaine foam has 5% minoxidil in it but no propylene glycol. Is that correct?
A: In addition to minoxidil 5%, Rogaine Foam contains: butane, butylated hydroxytoluene, cetyl alcohol, citric acid, fragrance, glycerin, isobutane, lactic acid, polysorbate 60, propane, purified water, SD alcohol 40-B, stearyl alcohol — but no propylene glycol.
Q: I am a 21 yrs old male having serious hair loss over the last few years. I also have very little facial hair. Since Propecia is a DHT blocker can it inhibit beard growth?
A: As you suggest, it would be reasonable to assume that since DHT stimulates beard growth, blocking DHT (with finasteride) would tend to inhibit its growth. In practice, this does not seem to be the case, i.e. we don’t find that Propecia has any effect on facial hair. The reason is not clear.
Q: 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?
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.
Q: I’m male, early thirties and in the early stages of hair loss, too early for hair transplants. I am experiencing extreme shedding. I took Avodart for 6 weeks, but because of the shedding I stopped. Now, it still continues as strong as ever. I’ve been losing about 200 hairs every day in the shower. 3 months ago I had so much more hair, what is going on? I heard that shedding can happen, but not like this. Could this have caused telogen effluvium, or something else?
A: Since Avodart (dutasteride) is a more potent medication than Propecia (finasteride), the shedding (telogen effluvium) may be more dramatic. If you have made a decision to use Avodart, then you need to tolerate this short-term effect. It should subside within the first 6 months on the drug.
Q: I stopped using Rogaine for my hair transplant, when can I start using it again? And would it be any different with the new Rogaine foam.
A: I would wait at least 7 days to use Rogaine (minoxidil) in either liquid or foam.
The foam has less alcohol and can be irritating when applied to open wounds, but should be fine one week post-op.
Q: I heard that Rogaine only works on the crown and not on the front or top of the scalp. Is this true?
A: Rogaine (Minoxidil) has the potential to work where ever there is miniaturized hair, either the front, top or crown (however, it will not work in areas that are completely devoid of hair).
Q: I am 22 yrs old and I started shedding hair in a very limited form since I was 20. I have now been on Propecia for nearly 8 months. To date I have not experienced any benefit. In fact, I have seen my hair continue to thin. Is it possible that this thinning is a result of Propecia?
A: Usually the shedding associated with finasteride will subside by 6 months.
If you are still losing hair at 8 months, most likely the medication is not working. Unfortunately, it is not effective in about 15% of patients.
Q: I am 26 and I have been diagnosed with Diffuse Unpatterned Alopecia (DUPA) and realize I am not a candidate for hair transplants. I have been on Propecia for about 9 months. There have been periods of increased shedding throughout and I am still shedding what seem to be mostly very fine, miniaturized hairs. Do you think this is the Propecia speeding up the hair cycle and pushing out the old fine hairs, or do you think this is an increase in the pace of my genetic balding? I know that your post states that the accelerated hair loss generally stops by the 6th month. Does DUPA have any effect on the timeframe? Also, I have read that Propecia is only effective for about 50% of patients with DUPA. Do you find that to be true, or have you found a different experience?
A: It is hard to tell at 9 months whether it is shedding from the finasteride or that the medication is just not working. Since there is no way to tell, I would stay on the medication for 2 years for any possible shedding from the medication to have passed and to see if your hair loss actually stops.
Q: I am 26 years old and in the beginning of losing my hair and not ready for hair transplant surgery. It seems to have stopped now but 4 months ago I shed a lot of hair and can visually see that my hair on the scalp is thinning out. I have looked into and read up on taking Propecia or more exactly Finpecia (I’m a student so cost is a factor), but can I trust this generic drug? Have looked at the company (Cipla) website but I’m still a bit scared of taking something I don’t really know what it is. What is your opinion on choosing Finpecia over Propecia?
A: Finpecia is manufactured in India by a slightly different method than the way Propecia is produced in the U.S. Since finasteride 5mg is now available in a generic from in the U.S., I suggest that you use finasteride 5mg and quarter the 5mg tablet with a pill cutter and take 1/4 tablet a day. The parts do not need to be the same size. In the U.S., generic finasteride and Propecia (1mg) and Proscar (5mg) are all made the same way. Cipla is a large company, but is not under U.S. FDA supervision.
Q: I have been on Propecia for approximately 5 years. What does Propecia do to your PSA level, lower it or make it higher? Also, what would you consider a normal level while on Propecia?
A: Finasteride 1mg a day lowers your PSA around 50%. Therefore, when patients are taking finasteride, the PSA reading should be doubled.
Finasteride does not appear to decrease the sensitivity of the PSA test to detect prostate cancer – its main purpose.
Q: I believe I am an “early” IIIA or IVA. I am not losing any hair on the back of the scalp. There is no substantial hereditary hair loss on either side of the family, but I began taking Propecia four months ago and recently noticed a dramatic thinning of hair on the top (front) of the scalp, extending back to the rear of the head.
A: Often people experience some shedding the first six months on finasteride as the new hair essentially pushes out some of the old. I would wait a full year before making any judgments about a hair transplant since you may see significant regrowth from finasteride in the second six months and may not need surgery at this point, particularly if the hair loss is early.
Q: 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?
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.
Q: If I use the dutasteride for one year and do not see a noticeable improvement can I quit the Avodart, continue the daily dose of Propecia and expect to retain the same “holding pattern” I have now?
A: If Avodart is helping to maintain the status quo then you can expect to lose some hair, i.e. return to where you would have been if you had used finasteride alone.
Q: Will Propecia and Minoxidil reverse some of the miniaturization going on with someone with thinning hair? If I do need a hair transplant will I have to stay on these medications?
A: Yes, both minoxidil (Rogaine) and finasteride (Propecia, Proscar) affect the miniaturization of the hair follicles and help restore the shrunken follicles to cosmetically viable hair.
Minoxidil works by directly simulating miniaturized follicles to grow, whereas finasteride blocks DHT, the hormone that causes hair to miniaturize and eventually fall out.
Finasteride is much more effective than minoxidil in preventing or reversing the miniaturization process and it is so much more convenient to use that we generally suggest finasteride after a hair transplant procedure, but rarely recommend minoxidil.
Q: I am a 22 yr. old male and have been on Propecia for exactly 4 months. When I started taking the medication, I was in the beginning stages of hair thinning/loss in the front and crown areas, with no change in my hair line. During the time I have taken Propecia, my hair loss has increased drastically. Is it that I just have to bite the bullet and am one of the few unlucky individuals that do not respond to Propecia? Could it be that I am taking the medication incorrectly? Wrong time of day? With or without food? Or, do I just need to give it more time? Is there still a chance I could at least regain the hair I’ve lost over these past 4 months?
A: You are probably experiencing an accelerated phase of hair loss that is possibly made worse by the finasteride. The shedding from finasteride is common during the first few months of treatment and is temporary. The full effects of Propecia are not seen for 6 to 12 months.
I would continue to take the medication for at least a year before you judge if it is working. It does not matter the time of day or relationship to food.
Q: 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.
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.
Q: Is Loniten good for treating hair loss?
A: Loniten (oral minoxidil) is not useful for treating hair loss. The reason is that it stimulates hair growth all over the body (hypertrichosis) and has a number of serious side effects.
Even when used to treat blood pressure, for which it is FDA approved, it is a medication reserved only for severe hypertension, used after at least three other types of blood pressure medications have been tried and are unsuccessful.
In addition to increased body and facial hair growth, it can cause fluid retention and heart disease. When used topically (topical generic minoxidil or Rogaine) the medication generally does not cause any significant problems other than local skin irritation and occasionally increased facial hair (which can be real nuisance for women).
Q: My friend just came back from Paris and said that his cousin was taking Avolve for hair loss. Can you tell me what that is and is it available in the U.S.?
A: Avolve is the European trade name for dutasteride 0.5mg made by GlaxoSmithKline for prostate enlargement. In the U.S. dutasteride 0.5mg, under the brand name Avodart, is FDA approved to treat prostate enlargement (BPH). It has not been FDA approved for hair loss.
Q: I have some early thinning in my crown and the doctor said I am too early for a hair transplant. I don’t want to take Propecia, but using Rogaine twice a day is a big nuisance. Can I use Rogaine once a day?
A: The tissue half-life of minoxidil is 22 hours.
This means that 22 hours after it is applied, about 1/2 of the compound is still bound to the skin and exerting some effect. Because of this, once a day dosing is probably OK.
Please note that this is hypothetical and that there have been no controlled studies to confirm this.
Q: I have been on Propecia for a year and my hair loss has not stopped or slowed down. How much longer should I give the drug? Can Propecia speed up hair loss in some patients?
A: If you have not responded to Propecia in one year, it is unlikely that you will.
Finasteride may cause shedding in the first 6 months of treatment, but should not accelerate hair loss long-term. It is most likely that you have progression of your hair loss.
In addition, be sure that you have a correct diagnosis i.e. that you actually have androgenetic alopecia.
Q: My query is prompted by your answer to another query “Is Avodart Safe?” My son, who is in his mid-20s, has been taking Dutasteride for hair loss for about two years now. He had tried Finasteride earlier but without much benefit. Medical supervision regarding Dutasteride is not available in Australia as the drug has not been released here yet.
I am concerned by your remarks that there is no biologic model to show the long-term safety of Dutasteride (as opposed to Finasteride). Would you suggest that he goes back to taking Finasteride? We would be grateful for your advice.
A: It is a tough call as I have never met or examined your son, so I can only offer an opinion based on limited information. If you feel your son will be emotionally or socially debilitated by the hair loss, then I think that it may be worth the risk (if there is any) of taking the medication; otherwise, I would use Finasteride.
Please keep in mind that you don’t need to make the final decision now. You may want to defer the decision until he is 28 or so, at time when he is more mature. It is a tough call. Please let me know what you decide.
Q: A friend of mine is taking Finpecia, is this the same as Propecia?
A: Both Propecia and Finpecia contain the active ingredient Finasteride 1mg. Finpecia is manufactured in India by the company Cipla. It comes in packets of 10. Finpecia contains the same chemical ingredient as Propecia, i.e. 1mg of Finasteride, but it is manufactured differently and it is less expensive.
Indian patent law allows companies in India to make medications that are patented by drug companies in other countries, since Indian law protects only the processes by which drugs are made and not medication itself. Therefore, if an Indian company finds another way to make a drug, it can legally do so.
Cipla has not published any studies showing that their generic Finasteride is identical or as effective as Merck’s original product in treating hair loss. These alternative processes and drugs are not regulated by the FDA, so there is no assurance that the medication manufactured in India has the same biologic activity or potency as the FDA approved counterpart made in the United States.
Q: My friend is taking Avodart, he bought it over the internet. Is it safe to take?
A: Avodart (dutasteride 0.5mg) was approved by the FDA for the treatment of prostate enlargement in men in 2002. Avodart has not been approved for the treatment of androgenetic hair loss, although physicians can use an approved medication in ways other than for which it was specifically approved. That said, the use of dutasteride certainly requires a doctor’s supervision.
Q: I heard that Propecia was being used originally for shrinking the prostate, is this true?
A: Propecia (finasteride 1mg) is not a prostate medication that was serendipitously noted to have a side effect of re-growing hair, it is a medication that was known all along that it might be able to slow hair loss and/or to grow hair.
Although finasteride was first approved for the treatment of prostate enlargement, the researchers at Merck knew, at the outset, that there were families whose members were deficient in the 5-alpha reductase Type II enzyme and that the men in these families neither developed prostate disease nor went bald. In addition they had no long-term problems from the lack of this enzyme.
Merck used this natural model to develop a medication that could block the 5-alpha reductase Type II enzyme – the result was finasteride. Because the only approved treatment for symptoms related to prostate enlargement at the time was surgery, Merck developed finasteride as a medical treatment for this condition prior to developing finasteride as a potential treatment for men with male pattern hair loss.
This also meant that Merck would understand the safety profile of finasteride, and have it approved for a medical disease (symptomatic prostate enlargement), before developing it for a cosmetic condition.
The drug was first submitted to the FDA for the treatment of prostate enlargement as Proscar (finasteride 5mg) in 1991 and it was approved for this use in 1992. The drug was submitted for the treatment of men with male pattern hair loss as Propecia (finasteride 1mg) in 1996 and was approved for this use in 1997.
Q: What is the difference between Rogaine for men and Rogaine for women?
A: Rogaine for men is 5% minoxidil and Rogaine for women is 2%. Another difference is that the 5% solution has propylene glycol in it whereas the 2% is alcohol based. The propylene glycol helps the minoxidil penetrate the skin better and makes the medication more effective. Although both the alcohol and propylene glycol based preparations can irritate the scalp, propylene glycol can cause actual allergic reactions in those who are sensitive.
Propylene glycol is greasier to have on the scalp than the alcohol based formulation. For patients who complain of the greasiness, we advise Minoxidil 5% at bedtime and 2% in the AM.
Q Do Rogaine and Propecia work synergistically?
A: They are synergistic, since the mechanisms of action are different.
Rogaine directly stimulates hair growth, while Propecia is permissive for hair growth by blocking DHT, the byproduct of testosterone that causes hair to miniaturize and eventually disappear.
The important thing to remember, however, is that for most people, Propecia is far more effective.
Q: I have early thinning on the top of my scalp and I was told to use Propecia, but I heard that is was only for men. What do you think?
A: Women can’t take Propecia during the child-bearing years because, if ingested, it can cause birth defects in male offspring.
In post-menopausal women, where we see the greatest frequency of hair loss, it doesn’t seem to be effective.
In pre-menopausal women who do not plan to become pregnant or who already have children, we are still cautious about using the medication, since there effectiveness has not been proven and its long-term safety in this population has not been tested.
Q: If Rogaine is used only once a day will it still be effective?
A: Once a day topical use of Rogaine (topical minoxidil 2% and 5%) is probably almost as effective as using it twice a day. The reason is, although minoxidil has a relatively short half-life of several hours when given orally, when topically applied, it has a half-life of 22 hours in the skin.
This suggests that once-a-day dosing is a reasonable option. It is important to realize that Pfizer, the company that now makes Rogaine, specifically states that it will be less effective if used only once a day.
Q: I heard that Proscar, the 5mg version of finasteride, is now generic. Is that correct and is Propecia going generic as well?
A: Yes, Finasteride 5mg (Proscar) is now available in a generic formulation. It is my understanding that Finasteride 1mg (Propecia) will not be available generically until the year 2012.
Q: I am currently taking Propecia 1mg a day for hair loss and heard that Proscar 5mg now comes in a generic form. If I get that, how should I take it?
A: If you are currently taking Propecia 1mg a day, and want to switch to Proscar (Finasteride 5mg), you can either take Proscar 5mg, 1/4 pill every day or 1/2 pill every other day.
If you break up the pills, be mindful of the potential risk to pregnant women from handling crushed tablets. You can purchase a pill cutter in any pharmacy.
Q I am 35 years old and have been using Propecia for the last 3 years, waiting to save enough money for a hair transplant. I no longer feel comfortable using it due to side effects. Can hair transplantation still be effective even without continuing to take this drug afterwards?
A Many people choose not to take Propecia or choose not to take it due to side effects and the surgical hair restoration is just as effective. The only difference is that medications can prevent further hair loss whereas surgery cannot.
Medications are not needed for the hair transplant to be successful or the transplanted hair to grow and be permanent.
Q: I have read on numerous websites that Propecia and Minoxidil work synergistically, and that a hair loss suffer will see better results using them together than either one alone. Do you believe this is the case, or do you think Propecia is enough treatment by itself for someone who just began to experience slight hair thinning and is too early for hair transplantation?
A: They may act synergistically since their mechanisms of action are different.
Rogaine (Minoxidil) stimulates the hair follicle directly, but Propecia (Finasteride 1 mg) permits hair growth by blocking the negative effects of DHT. Of the two, Propecia is far more effective. It is reasonable to use the two together as long as the medications are used regularly.
Q: I recently turned 22 and have been on Propecia for about 2.5 years. The amount of hair that de-miniaturized with daily 1 mg peaked about a year ago and I have seen steady thinning since. I feel that I am too young for a hair transplant. My question is whether or not an increase in dosage of Propecia is indicated here or if I should seek other options entirely?
A: At 22 years old, I would increase the dose of Propecia before considering hair restoration surgery. However, it is important to realize that there is no scientific evidence that increasing the dose will have any additional effects. There are published data by Roberts et al in the JAAD in 1999 demonstrating that 5 mg is no better than 1 mg from controlled clinical trials.
Q: I am 28 years old and was told that I have early Norwood Class 3 hair loss. I want to have a hair transplant but my doctor told me to use Propecia for 6 months and then come back to discuss surgery. I don’t want to wait that long, what should I do?
A: Actually, you should wait a full year.
If you are an Early Norwood Class 3, the Propecia can work so well (in actually growing hair back) that you may not even need a hair transplant.
The important point is that Propecia only starts working at 3-6 months and during this time there may actually be some shedding as the new growing hair literally pushes out the old.
Q: I am considering taking Propecia, but it I went to my local pharmacy in New York City and it is so expensive. Is there a way I can get it cheaper?
A: The website www.drugstore.com sells Propecia online at a reasonable price. A doctor’s prescription is required.
Please note that Propecia is not yet available in generic form.
Q: 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)?
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.
Q: I have heard that you should take Propecia for 6 to 12 months following a hair transplant. Is this correct?
A: I would only use Propecia if you plan to continue the medication long-term. That said, Propecia — the brand name of the hair loss drug finasteride — is very helpful in preventing further hair loss. I do recommend that patients who have hair loss stay on the medicine for an extended period, regardless of whether or not they decide to have a hair transplant procedure.
Q: I am taking a baby aspirin to prevent heart disease and I heard that I should stop this medication before my hair transplant. How long should I stop for?
A: You should discontinue the aspirin 10 days prior to your hair restoration procedure. Other NSAIDs (non-steroidal anti-inflammatory drugs) need only be stopped 3 days before the hair transplant. Both aspirin and other NSAIDs can be resumed three days after surgery.
Q: I have been taking Propecia for three months. Would it help to up my dose?
A: For most people (of average body weight of approximately 150 pounds) 1 mg is the ideal dose.
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.
Q: I was wondering why you chose two years as the amount of time one should wait to judge the effectiveness of Propecia. Have you had patients who only saw results after that long? Why does Merck say 3-6 months and Dr. Rassman at New Hair say 6-8 months? I know these numbers aren’t arbitrary, but I’m just wondering what the logic is behind this and how does this relate to planning a hair transplant?
A: The Merck data showed that over 90% of patients had peak response at 1 year and this has been my experience as well.
Most patients show the most dramatic response between 6 to 12 months with some getting additional benefit up to two years. Prior to 6 months, the results are quite variable and there may even be a net loss due to shedding during this period, as the Propecia stimulates a new anagen cycle…