Non-Surgical Treatment: Hair Restoration Drugs

Hair Restoration Drugs

Hair loss medication such as Rogaine® (minoxidil) and Propecia® (finasteride) are targeted to halt or slow hair loss and even in some cases reversing hair loss. A better understanding on how these medications work can give you the insight to plan a course for stopping and restoring hair loss.

Rogaine® (Minoxidil)

This is an over-the-counter nonprescription medication clinically approved for both men and women. This medication comes as a liquid or foam that is meant to be rubbed into the scalp daily for best results. The foam is less drying to the scalp and can be less irritating, but both are equally effective. It is advised to use this product for at least 6 months to prevent further hair loss and promote hair regrowth.

The anti-hypertensive drug minoxidil was shown in the early 1980’s to stimulate new hair growth and was eventually approved as a topical treatment for male pattern baldness, and baldness in women (specifically “androgenetic alopecia”, AGA). Multiple clinical trials have demonstrated the efficacy of minoxidil in AGA. Minoxidil is known to act as an opener of potassium channels and appears to normalize the hair follicle, and to increase the “growth phase” of hair follicles. Despite its labeling, Minoxidil® does slow or reverse the balding process in the frontal hairline area. Multiple clinical trials have demonstrated the efficacy of minoxidil in AGA: in most patients treated with topical minoxidil 2% or 5 % for 12 months, hair counts increased, and in some patients hair counts continued to increase for some time afterwards.

Things to know about Rogaine®

  • Rogaine® for Men Extra Strength 5% starts to work in about 8 weeks of treatment
  • The active ingredient in Rogaine® is minoxidil, which has undergone extensive medical testing for safety and effectiveness.
  • Rogaine is typically applied topically on the scalp twice a day.
  • IMPORTANT: Once usage is discontinued the hair loss which had been inhibited will resume and the “re-growth” hair will most likely be lost.

Minoxidil has not been approved for systemic use because of potentially serious side-effects, notably cardiovascular, due to its antihypertensive action, and because extraneous hair growth has occasionally been seen even with topically applied minoxidil thought to be due to absorption and systemic action. Users of Extra Strength 5% Rogaine have claimed success rates of 50-60%. Currently, the average price for a 2oz. bottle of Rogaine is about $20-30 per month. Rogaine originally required a prescription, but it is now available over the counter as Rogaine, or as generic Minoxidil without prescription.

A small percentage of users, about 6%, experience scalp irritation with Rogaine, users can use a mild dandruff shampoo twice a week to help keep the scalp healthy. There may also be an increase in hair shedding at the start of the treatment, this is typically part of the hair growth cycle and may actually be a signal that the treatment is working. Users with severe, refractory high blood pressure experienced some problems. One such problem was “hypertrichosis,” hair growth on the face or other bodily areas. This side effect appears in about 3-5 % of women who use the 2% solution, and higher among women using the 5% solution. The unwanted hair growth disappears when the treatment is discontinued. It’s important to note that Rogaine (minoxidil) is not a cure for baldness.  The real benefits of Rogaine (minoxidil) is stopping or slowing hair loss. Rogaine’s success depends on how advanced your hair loss has become.

Propecia® (Finasteride)

Propecia is a prescription drug clinically approved for men. It is taken daily by mouth in the form of an oral tablet. In 1997, the FDA approved 1mg dose of Finasteride for the treatment of Androgenic Alopecia. Finasteride works by inhibiting 5 alpha-reductase, the enzyme that converts testosterone to DHT.

Propecia’s 1mg does of Finasteride can effectively lower dihydrotestosterone (DHT) levels in the scalp by as much as 60% daily. The only medically proven way to arrest the hair loss process is to lower DHT levels. The American Hair Loss Association recommends Finasteride as the first line of attack for all men interested in treating hair loss.

Things to know about Propecia® (Finasteride)

  • Requires prescription.
  • Stops hair loss in approximately 90% of men in the top and crown.
  • Effective in front and hairline areas but not as much as the top and crown.
  • Women who are or may potentially be pregnant must not use PROPECIA and should not handle crushed or broken PROPECIA tablets because the active ingredient may cause abnormalities of a male baby’s sex organs. If a woman who is pregnant comes into contact with the active ingredient in PROPECIA, a doctor should be consulted. PROPECIA tablets are coated and will prevent contact with the active ingredient during normal handling, provided that the tablets are not broken or crushed.
  • PROPECIA is a daily medication. Patients may see results in 3 to 12 months. If use of PROPECIA is discontinued, results will gradually go away over 12 months.
  • In clinical studies for PROPECIA, a small number of men experienced certain sexual side effects, such as less desire for sex, difficulty in achieving an erection, or a decrease in the amount of semen. Each of these side effects occurred in less than 2% of men and went away in men who stopped taking PROPECIA because of them.
  • IMPORTANT: Once usage is discontinued the hair loss which had been inhibited will resume and the “re-growth” hair will most likely be lost.

A very small number of patients claim that despite stopping the drug, persistent sexual side effects occur. We are monitoring this and have never had a patient whose side effect did not disappear once the drug was discontinued.

Pros and Cons of Hair Restoration Medication

If you’re like most people, the big question is “Where do I start?” Trying to decide the answer to this question is one of the toughest because starting something means a major commitment. So the two major players are Propecia and Minoxidil. Here are some benefits of Minoxidil over Propecia: You can buy Minoxidil without Prescription, whereas Propecia requires one. Minoxidil works locally, and since it is a topical, its systemic (internal) effects are minimal, whereas Propecia directly alters the Male Hormonal system. Minoxidil in its 2% form is safe for use in both Men and Women, whereas Propecia is only for use in Men.

The Ultimate Combination: Propecia and Minoxidil

If you are male and looking to kick start some re-growth, and maintain what you have, but have had no success on other treatments, or on Propecia or Rogaine alone, combining them is a sure way to optimize your results.

The Ultimate Combination: Propecia and Minoxidil

If you are looking to kick start some re-growth,and maintain what you have, but have had no success on other treatments, or on Propecia or Rogaine alone, combining them is a sure way to optimize your results.

Manipulating Androgen Metabolism

The most promising treatments modulate the metabolism of androgens in the scalp. Currently, only one pharmaceutical is available to the physician for the treatment of men with AGA. Finasteride (Propecia) is a potent, specific inhibitor of the type 2 5a-reductase that is responsible for the conversion of testosterone to DHT. Given orally, Finasteride reduces DHT levels systemically and in the target tissues (i.e. scalp). In an animal model of AGA, the stump-tailed macaque, daily oral Finasteride given over a period of 6 months significantly reduced circulating DHT levels and increased scalp hair weight. 8 Finasteride at a dosage of 1 mg/day has been approved by the Food and Drug Administration (FDA) for the treatment of male pattern hair loss in men. Its efficacy has been demonstrated in three double-blind, placebo-controlled, randomized studies. Men with AGA, aged between 18 and 41 years, were given either oral Finasteride 1 mg/day or a placebo. Assessed by scalp hair counts, self-assessment by patients using a validated questionnaire, investigator assessment using a standardized seven-point rating scale of hair growth from baseline, and an independent expert review of photographs taken every 6 months, Finasteride treatment was evaluated as resulting in improvement.

Finasteride produced a progressive increase in hair counts at 6, 12 and 24 months, while placebo treatment resulted in significant hair loss. By 24 months, 72% of patients on placebo had lost hair compared to baseline, while 83% of patients on Finasteride had experienced no further hair loss. Similarly, at 14 months, the expert panel considered 66% of Finasteride-treated patients greatly, moderately, or slightly improved vs. only 7% of those on placebo. The incidence of side-effects reported by men on Finasteride (4.2%) vs. placebo (2.2%) resolved after discontinuation and in many of the men who remained on drug treatment. These results are in line with our current understanding of the effect of DHT on hair physiology. Although, as mentioned previously, the molecular details of the mechanism by which androgens affect hair growth are not known, it is apparent that, in the androgen-sensitive scalp of genetically susceptible individuals, they cause a gradual miniaturization of the follicles and conversion of long, thick pigmented terminal hair to short, fine, un-pigmented vellus hair. Prevention of the androgen-mediated miniaturization will inhibit or retard the process leading to hair loss, and in some cases result in new hair growth. Furthermore, there is demonstrable heterogeneity in 5a-reductase activity in scalp hair roots from patients with AGA, which may account for some of the variation in response to Finasteride.

The Study

Merck conducted a two-year clinical trial, in which 1,553 men ages 18 to 41 with mild to moderate thinning / balding at the top of the head took this treatment daily. At the 2-year mark, 83% of them had maintained their hair (based on hair count) and 66% of them had experienced re-growth A side assessment by the doctors in the study rated 80% of men as improved, at the end of the period.


The likelihood is that the modulation of androgen metabolism will prevent further hair loss in the majority of patients, and induce hair growth in a smaller proportion, depending on the extent of their condition and their genetic background. It is vital therefore for the prescribing physician to bear in mind that the patient may suffer anxiety over the possible progression of hair loss in the future, while being able to tolerate his present condition. For many patients, prevention of further hair loss alone will constitute acceptable management. For the physician, the important message is that the best therapeutic prospects lie in drug modalities that utilize our increased understanding of normal and pathologic hair growth. Although topical minoxidil was the first effective drug to benefit some of these patients, targeting of type 2 5a-reductase in the scalp hair follicle using oral Finasteride is now a realistic option for the prevention of further hair loss in the patient with male pattern baldness.


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