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? — H.L., Gowanus, Brooklyn, NY
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.
Read more about propecia and the effects and effectiveness of the medication.
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? — H.F., Eastchester, NY
A: For several reasons:
1) you will lose some of the medication 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? — S.S., Long Island, NY
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? — V.C. Greenpoint, Brooklyn
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.
I think the most interesting question relates to the 10% who continued to lose hair in the treated group. Did these men lose hair at a slower rate than the non-treated group? Based on the action of finasteride on blocking DHT and DHT’s central role in causing male pattern hair loss, it is reasonable to assume that even these “non-responders” did have some benefit from the drug, albeit small. If half of those on the medication who continued to lose hair did so at a rate slower than the placebo group, then 95% of patients actually benefited from the medication to some degree – an extraordinarily high success rate, in my opinion.
Q: Is using Minoxidil combined with Retin-A better than regular Minoxidil for Hair Loss? — L.W., Gowanus, New York
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.
If person wants to add Retin-A to the minoxidil regime, the Retin-A should be applied only once a day, since the Retin-A will bind to the skin and will last for at least 24 hours.
Applying Retin-A more frequently will not increase its effectiveness (in facilitating the absorption of minoxidil); it will only increase the incidence of side effects. Retin-A can be applied to the scalp at the same time as Minoxidil, or by itself.
Explore the pro’s and con’s of Minoxidil — also known by its over-the-counter product Rogaine — at the Rogaine/Minoxidil page or by viewing posts tagged with Rogaine (minoxidil).
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? — S.F., Rolling Hills, California
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? — B.J., Garden City, N.Y.
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? — E.U., Short Hills, NJ
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? — P.V., Chelsea, N.Y.
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? — N.N., Dallas, TX
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? — V.C. Greenpoint, Brooklyn
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? — L.B., Rye, NY
A: I would definitely stay on Propecia (finasteride) and, if you like, you can add Rogaine (minoxidil) – it may have a little additional benefit. The 5% foam formulation is less irritating and can be started a week after the hair transplant.
The only problem with Rogaine is compliance. If you think that you will use it long-term, it is worth using. If, however, you think that you will get tired of it and stop, then it is not worth starting.
Any shedding with either medication is temporary and usually indicates that the drug is working.
Read about Rogaine (minoxidil)
Read about Propecia (finasteride)
Q: Are there DHT blockers that are sold in the pharmacy over the counter? — C.C., — Fairfield County, Connecticut
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? — H.F., Eastchester, NY
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.
If there are signs of genetic hair loss (i.e. male pattern alopecia), then finasteride should be considered.
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? — 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.
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? — B.M., Lower East Side, N.Y.
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? — E.M., Astoria, N.Y.
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.
It is interesting to note that testosterone stimulates growth of axillary and pubic hair, but not scalp hair. Scalp hair growth is not androgen dependent, only scalp hair loss is.
DHT stimulates terminal hair growth of the beard, trunk and limbs, external ears and nostrils. Of course, it also is responsible for the bitemporal reshaping of hairline as one passes into adulthood and causes male patterned baldness (androgenetic alopecia).
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? — 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.
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? — M.M., Boston, Massachussetts
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. — J.N., London, United Kingdom
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? — D.D., New Haven, Connecticut
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).
The reason for the misconception that it will not work in the front is because the clinical trial performed by Merck in the 1980’s, that led to FDA approval, only studied the vertex (crown) and thus the company was limited to this labeling. Several years later, Merck realized that this was a misjudgment in the design protocol and ran a new study (approximately one fifth the size of their Phase III vertex trial) to document effectiveness of the drug in the front of the scalp. This allowed them to avoid the vertex restriction in their label.
Another reason for the confusion is that since the hair in the crown seems to have a longer miniaturization phase than hair in the temples, there is a greater window of time in which the medication can act on these hairs. This goes for both minoxidil and finasteride (Propecia).
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? — M.M., Boston, Massachussetts
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? — T.T., White Plains, N.Y.
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.
Since the natural history of DUPA is so unpredictable, I would give it the full two years rather than the 1-year trial the company recommends. There is no real scientific data to support this recommendation, however.
Please take heart in the fact that people with DUPA often look great (even without any hair transplants) if they keep their hair very short, since they never develop that cosmetically unappealing wreath of hair around the back and sides that is normally associated with extensive balding.
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? — E.E., Midtown East, N.Y.
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? — H.K., Long Island City, N.Y.
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.
PSA levels vary by age and by lab so I would check with your internist/urologist to evaluate your specific level.
In very general terms, for adults, it is ideal to have a PSA < 1.0 off Propecia and < 0.5 on it, but higher levels can also be fine.
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. — B.M., Lower East Side, N.Y.
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? — 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.
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.
Read more about Hair Loss Medication
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? — C.C., — Fairfield County, Connecticut
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.B., St. Louis, Missouri
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. — 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.
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.? — N.W., Portland, Oregon
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? — L.B., Cleveland, Ohio
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? — N.V., East Hills, N.Y.
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. — N.V., Melbourne, Australia
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. — A.B., St. Louis, Missouri
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? — T.G., Denver, Colorado
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.
Like finasteride (the active ingredient in Proscar and Propecia), dutasteride blocks the enzyme 5-alpha reductase that converts testosterone to DHT (DHT is a key hormone that causes hair loss). However, unlike finasteride, which only inhibits the Type I form of the enzyme, dutasteride inhibits both the Type I and Type II forms. This combined effect lowers circulating DHT more with dutasteride than with finasteride, but also increases the incidence of its side effects.
The Type II form of the enzyme (blocked by finasteride) is found predominantly in the hair follicle. The Type I form of the enzyme has been found in the scalp and sebaceous glands, and many other parts of the body, but its exact role in hair growth has not been determined. It is felt that dutasteride’s ability to dramatically lower serum levels of DHT is what makes it a more potent medication in hair loss.
When considering the safety of dutasteride, one should consider the following:
- It acts on other parts of the body besides the hair follicle.
- Unlike finasteride, where families that had a deficiency of the Type II 5-alpha reductase enzyme were followed for years without any adverse effects, there is no natural biologic model to show the safety of dutasteride.
- Dutasteride has been approved for prostate enlargement in an older male population. It is not approved for hair loss and, in fact, the clinical trials for hair loss were discontinued, so there is no safety data for its use in younger patients. There is a greater incidence of sexual side effects with dutasteride compared to finasteride.
- The 1/2 life of dutasteride is 5 weeks compared to 6-8 hours for finasteride. Serum concentrations of dutasteride are detectable up to 4-6 months after discontinuation of treatment.
Q: I heard that Propecia was being used originally for shrinking the prostate, is this true? — M.D., New Hyde Park, N.Y.
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? — G.K., Hawthorne, N.Y.
A: Rogaine, the brand name of generic minoxidil, comes in formulations for both men and women. The men’s versions come in a 5% solution and a 5% foam while women’s products are the 5% foam and 2% solution. Of these, the strongest and most effective is the 5% men’s solution. This is due to the inclusion of propylene glycol, which is a vehicle that helps the active ingredient, minoxidil, to more readily penetrate the scalp. As the other products do not contain propylene glycol, they may be slightly less effective.
Instructions for use also differ on the label between the men’s and women’s products. All products (5% men’s solution, 5% men’s foam, 2% women’s solution) recommend twice daily use, except for the 5% women’s foam which recommends once daily application. In reality, a thorough once daily application seems to be nearly as effective as twice daily for all version of topical minoxidil.
While the 5% solution may be stronger, it is more irritating to the scalp and more difficult for some to tolerate. Some people have a sensitivity to the added propylene glycol and will experience redness, burning, itching, and irritation. If this occurs, patients should switch to the 5% foam or 2% solution. We also recommend that patients use enough of the medication when they apply to adequately cover the treatment area of the scalp. Often, this means using 2 or 3 capfuls of foam or 2-3 droppers full of the solution (2-3mL).
It is important to understand, that contrary to the more restrictive package indications, it works in all areas of the scalp where there is thinning. It is not only for use in the crown. Many patients find that evening application allows the full 4-6 hours of contact time necessary for absorption and that the product will dry overnight and no longer look greasy in the morning. Results can appear as early as 3-6 months, but we often advise using minoxidil for a full year before judging its efficacy. As the hair is always cycling and growing, the product will need to be continued daily for ongoing benefit.
Q Do Rogaine and Propecia work synergistically? — N.W., Chappaqua, N.Y.
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? — T.G., Staten Island, NY
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? — I.P., Hempstead, Long Island, NY
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.
Read about Rogaine (minoxidil)
Read Tips on Using Rogaine
Q: I heard that Proscar, the 5mg version of finasteride, is now generic. Is that correct and is Propecia going generic as well? — F.J., Red Hook, Brooklyn, NYC
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? — G.A., Fort Lauderdale, FL
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.
You should be aware that this dosing is not recommended by Merck and that there are no studies showing that either breaking up the pills or taking alternate day dosing is as effective as taking Propecia (Finasteride 1mg) a day.
That said, finasteride lasts in tissues for several days, so these alternate day dosing schedules seem reasonable.
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? — Y.C., Matinecock, New York
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 sufferer 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? — K.V., Hewlett Bay Park, New York
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.
For patients contemplating surgical hair restoration, we generally have them continue Propecia only, since applying Minoxidil is too fussy and offers only incremental benefit.
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? — N.W., Portland, Oregon
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.
I usually increase the dose when someone has been on the same dose of medication for about three years, although there is no good data on how exactly to increase the dose, or that it will actually make a difference.
For this purpose, I generally use finasteride in the form of Proscar 5mg every other day (or Proscar 1/2 pill every day).
If you break up the pills, be mindful of the potential risk to pregnant women from handling crushed tablets.
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? — L.B., Oyster Bay Cove, NY
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.
A hair transplant performed at 6 months may not only be unnecessary, but growth from the medication may be attributed to the hair restoration surgery. I suggest to wait and see what the medication can do before going for hair restoration surgery.
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