Here is a question we receive often from patients: Which hair loss medication works best, and do I need to take it orally, or is topical application sufficient? Read on to hear what Dr. Christine Shaver, dermatologist at Bernstein Medical – Center for Hair Restoration, says on the topic.

Which is more effective—topical or oral finasteride?
It has been our experience that the oral route is more effective than the topical. One recent clinical study has shown that the effectiveness of topical finasteride and oral finasteride are similar, but both the oral and topical forms have shown to decrease DHT in the blood, so it is not clear if the topical formulation is truly safer. Another issue is standardization of the topical formulation, since it is not FDA approved. Until the formulation (i.e., the way it is compounded) and application method have been standardized, it is very difficult to draw broad conclusions.

Which is better, oral minoxidil or oral finasteride?
Oral minoxidil can lengthen the growth cycle of the hair follicle, but unlike finasteride, it has no effect on reducing DHT, the main culprit in hair loss. We find that finasteride alone can be quite effective, whereas minoxidil alone rarely affects the long-term course of a patient’s hair loss. While oral minoxidil is not as effective as oral finasteride, the two drugs are complementary, as they work by different mechanisms and should be used together to have the most benefit.

Which is better, topical Rogaine or oral minoxidil?
Oral minoxidil is significantly better than topical minoxidil (Rogaine) for a number of reasons. Most importantly, topical minoxidil must be converted in the scalp to its active form, minoxidil sulfate, by the sulfotransferase enzyme SULT1A1, but only 40-50% of patients have sufficient amounts of this enzyme to complete the reaction. Also, it is very hard to apply the medication evenly and cover the same areas every day and so compliance is poor. With respect to side effects, the oral version eliminates the main complaint of the topical, which is scalp irritation. On the other hand, it has its own risks such as increased body and facial hair, water retention, and risk of arrhythmia in patients with irregular heart rhythms. Fortunately, these side effects are uncommon.

Do these medications work to promote hair growth in certain areas or the entire head?
There are common misconceptions that the medications only work at the crown, but the reality is that the medications work anywhere where the hair is miniaturizing (thinning) but not completely bald. Neither medication can regrow hair in a bald area, whether it is the temples, top of the scalp or the crown.

I heard that Minoxidil can make my hair loss worse. Is this true?
Of course not. It is a treatment for hair loss. That said, in the first three months following the initiation of treatment, minoxidil often causes temporary shedding. This is due to the fact that minoxidil initiates a new growth cycle and essentially pushes out the old hair. This is a good sign and means the medication is working. Therefore, one should neither be concerned nor stop the medication if this should happen. In fact, the oral form, which is more effective, is more likely to cause this temporary phenomenon.

Interestingly, finasteride may also cause shedding, but is much less likely to do so.

What is your advice to get the most efficacy out of topical medication?
There are several ways to maximize the effectiveness of any topical medication – including finasteride and minoxidil. The medication should be applied evenly and consistently over the same areas once per day. It is important to emphasize using it once per day so that patients can focus on applying it well. The second application is unnecessary since the effects last more than 24 hours from a single application. As in all topical medications, they will be more effective when applied to a clean scalp and one that is preferably well-hydrated. Hydration is particularly important and can increase the potency five-fold by making the scalp more porous to the drug. Therefore, the best time to apply the medication is immediately after quickly towel drying the hair after a bath or shower while the scalp is still damp. It is important to know that if you increase the absorption through the skin, you will also increase systemic risks.

Should microneedling be used to increase the effectiveness of a medication?
No. Microneedling makes random holes directly into the scalp. Microneedling bypasses the follicles and allows the medication to enter directly into the blood stream. Therefore, it will increase the systemic side effects of a medication without increasing the direct effect on hair follicles, which is the purpose of using the topical medication in the first place.

Let us elaborate. Skin protects us from the outside environment due to a keratin layer formed by the outer-most cells of the skin. The scalp is unique in having a dense distribution of hair follicles. Medication applied to the scalp is mainly absorbed through the pores i.e., the openings of the hair follicles where the scalp is most porous. Medically, this is called the infra-infundibulum and differs from the rest of the scalp by not producing this dense keratin layer.

If you want to increase the absorption into the follicles, you can do so by hydrating the scalp which has its greatest effect on making the openings of the hair follicles even more porous.