Finasteride, an efficient non-surgical hair treatment

While surgery might seem like a faster treatment for hair loss, not everyone is a hair transplant candidate, and even when they are, it is recommended to have at least two modalities of medical therapy when considering hair maintenance and regrowth.

Finasteride is commonly used in non-surgical hair restoration therapy and has proven to be overall effective. The drug was approved in 1992 in the United States for the treatment of BPH and was approved for the treatment of androgenic alopecia in 1997.

For whom is finasteride typically recommended?

Finasteride is often used to treat male-pattern hair loss. This is because finasteride helps hair growth by blocking the action of 5-α-Reductase. 5-α-Reductase catalyzes the conversion of testosterone to DHT and DHT is what can cause the miniaturization of the hair follicles when it binds to androgen receptors.

Finasteride is typically not the first choice in women for hair restoration, but it can be a helpful adjunct in therapy. The medication is usually reserved for postmenopausal women and is not recommended for women who are pregnant or may become pregnant. This is because there is a risk of defects occurring in the male fetus. Other primary side effects include the risk of occasional headaches and gastrointestinal discomfort. 

What type of finasteride is recommended?

Many chose oral finasteride since it has been shown to rapidly lower serum and scalp DHT levels. For androgenic alopecia, it's typically taken orally at a dose of one milligram per day. 
Some would argue that Propecia, which is the brand name of finasteride, is more effective than generic finasteride. Generic brands of finasteride are made in different places around the world that sometimes have quite varied manufacturing protocols and so, even though they contain the same active ingredient, the efficacy of the actual medication has been shown to differ at times.

Some opt for topical finasteride since it has been shown to be safer when it comes to systemic side effects.

When choosing between these two formulations of finasteride, keep in mind that its topical use is currently off-label and has not been FDA approved for hair loss. There have been gels and solutions at varying concentrations that have been tested and all of them have resulted in improved hair growth.

These results sound promising, but, when assessing them, we should consider publication bias. Although there is a possibility that negative results aren’t being published, topical finasteride does appear to be at least non-inferior to systemic oral finasteride for hair regrowth. We need more studies to determine the efficacy of long-term hair regrowth from topical finasteride, how safe it is, its cost-effectiveness, and patient tolerability and satisfaction.

We don't yet know the most effective concentrations and recommended frequency of the therapy, but the most commonly used application protocol is 100-200 microliters of a 0.25% topical solution.

Topical finasteride can be applied alone or in combination with minoxidil and/ or dutasteride, combinations that have been shown to be more effective for hair regrowth than topical minoxidil alone.

What are the side effects?

Based on the literature, finasteride is overall safe to use. Although there are possible negative consequences to taking it, they are not likely or common. If side effects do develop, stopping the medication will almost always reverse them.
  • The most commonly reported side effects are sexual (erectile dysfunction, ejaculatory dysfunction, and loss of libido). According to the studies, there is about a 2% risk of sexual side effects occurring.
  • Finasteride has been shown to lower the risk of prostate cancer due to its effects on BPH, but it can increase the risk of high-grade prostate cancer.
  • Depression has been associated with the use of finasteride.

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Post-finasteride syndrome (PFS)

PFS or post-finasteride syndrome is the occurrence of persistent adverse events including sexual dysfunction and depression in some men who have used 5-α-Reductase inhibitors such as finasteride. PFS has been recognized for over a decade, but it is difficult to form an opinion about the prevalence of the issue.

This is partly because of the multifactorial background of the adverse events and partly because of the subjective criteria of diagnosis and the variable reporting. Sexual dysfunction and depression are issues that both people who do and do not take finasteride struggle with and that can develop with no relation to the medication. It should also be mentioned that there was a study that showed a 14.3% increase in reported sexual side effects when patients were informed about them.

Of course, there should be available information on the possible side effects of any drug, but be careful not to excessively focus on the negative side effects because of the nocebo effect.

How to minimize the risk of side effects?

Some people decrease the dosage of finasteride they take in an attempt to avoid or lessen side effects. Based on the literature, there are no major benefits to doing this. Most studies that are done for androgenic alopecia include a one-milligram dosage and one of the papers shows that the side effect profile is very similar within the range of usage of 1-5 milligrams.

What is recommended by some doctors is checking your testosterone levels before starting finasteride. This is because the side effect profile for finasteride is worse in men who are at lower baseline testosterone levels when starting the therapy.

When considering starting the medication, you need to properly assess its pros and cons and consult with a trusted doctor. 

Papers used: 

The content of this newsletter is for entertainment and educational purposes only. This content is not meant to provide any medical advice or treat any medical conditions. Patients must be evaluated by an appropriate healthcare provider on an individual basis and treatment must be tailored to meet that patient’s needs. Results and particular outcomes are not guaranteed.

Written by
Aleksandra Božović
Edited by
Dr. Gary Linkov
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