Treating Hair Loss Pharmacologically and Alternatively

Author: Christine Zink, MD

Hair loss (androgenetic alopecia) or a receding hairline is primarily a concern in men. However, women can also experience diffuse hair thinning that can impact their quality of life. A wide array of pharmacological, surgical, and alternative therapies are available to slow or reverse hair loss. There are a variety of FDA-approved treatments available.1 However, it can be challenging for the public and clinicians to know which agents are the best. This article will help break down the benefits and risks of different hair loss therapies and shed some light on their effectiveness and cost. Here are the key takeaways.

  • Topical hair loss therapies that include minoxidil, finasteride, and prostaglandins are effective in promoting hair growth, but they are less effective than oral pharmacologic options.
  • Oral medications are effective at promoting hair growth, but they can be riddled with debilitating unwanted side effects. 
  • Light therapy is also effective and FDA-approved for the treatment of hair loss.
  • Hormonal therapies have been tried for hair loss. Only spironolactone seems effective, yet not as effective as other treatment options.
  • Platelet-rich plasma is an injectable option that patients enjoy, but it is more expensive since it is an office procedure.

Topical Therapies

Topical treatments are an excellent place to start for mild-to-moderate hair loss since oral medications typically have more systemic side effects.

Topical minoxidil

  • FDA-approved.1
  • Available in 2% and 5% foam and liquid solutions. Higher concentrations (6-7%) can be created at a clinician’s request.1
  • The effectiveness can vary depending on the individual, but in general, after one year, 60% of patients experience a decrease in hair loss, and 80% of patients report hair regrowth when using 5% topical minoxidil twice daily.1
  • Side effects can include allergic contact dermatitis, scalp irritation, itching, and facial hair growth.1
  • The cost is generally less than $100 per month.1

Topical finasteride

  • Studies regarding efficacy are less robust for this treatment. Furthermore, topical finasteride does not appear to be as effective as its oral formulation, particularly past six months.1
  • Side effects are more debilitating and include skin redness, contact dermatitis, transaminitis, headaches, nocturnal enuresis, testicular pain, and oropharyngeal pain.1
  • The cost is generally less than $100 per month.1

Topical prostaglandins

  • Studies have indicated that certain prostaglandins inhibit hair growth while others have stimulating effects. Clinical trials evaluating different prostaglandin analogs are underway, but latanoprost has been shown to increase hair density.2
  • Thus far, topical prostaglandins are not as effective as other topical therapies.2
  • Like other topical agents, side effects are mild and include itching, irritation, dry skin, and redness.
  • The cost is generally less than $100 per month.

Oral Therapies

Oral therapies are typically easier to use, but they have the potential for significant systemic side effects. Oral treatments are also the most often prescribed.

Oral finasteride

  • FDA-approved and available over-the-counter.1
  • The drug blocks the conversion of testosterone to dihydrotestosterone and is available in 1 mg and 5 mg tablets given daily.1
  • It has consistently been effective in stimulating hair growth and stabilizing hair loss.1
  • Side effects include orthostatic hypotension, dizziness, erectile dysfunction, and decreased libido.1 Several studies have shown that these sexual side effects can continue for years after discontinuing the drug.1 Furthermore, the sexual side effects can be accompanied by depression.1 There is also growing evidence that suggests decreased sperm counts in patients taking the medication.1 However, they also show improvement in sperm counts three to six months after drug discontinuation.1
  • The financial cost is generally less than $100 per month.1

Oral dutasteride

  • This is a second-generation 5-alpha reductase inhibitor that is more potent than finasteride.1
  • The drug is given in 2.5 and 5 mg daily doses, both of which have been shown to be more effective than finasteride 5 mg.1
  • Like finasteride, the side effects include decreased libido, erectile dysfunction, and ejaculatory dysfunction.1
  • The cost is generally less than $100 per month.1

Oral minoxidil

  • The medication is available as a 2.5 mg tablet, but it can be cut in half or quartered.1
  • More efficacy studies have been conducted in women, demonstrating the effectiveness of this treatment and safe dosages of 0.625 mg and 1.25 mg daily.1 The drug has also been effective in men.
  • Systemic side effects include increased heart rate, weight gain, hirsutism, hypertrichosis, and lower extremity edema.1 Side effects generally make it a less tolerable drug than its topical formulation.
  • The cost is generally less than $100 per month.1

Light Therapies

Light therapies may sound unusual as an effective therapy, but light is effective for hair loss, and the therapies are FDA-approved.

Low-level laser therapy

  • Low-level laser therapy can be used at home with devices in the form of combs, helmets, and caps.1 Some of these devices are FDA-approved for the management of hair loss.
  • Multiple trials have shown improvement in hair loss, and some studies used light therapy in combination with topical minoxidil or oral finasteride. These studies also demonstrated efficacy.1
  • It is difficult to determine the best utilization of light therapy as studies range from using it daily to several times per week.
  • There are minimal side effects with this type of therapy. A small number of people report acne, dry skin, itching, and a burning sensation.1
  • Light therapies are more expensive than topical and oral therapies but still cost less than $1,000.1

Light-emitting diode devices

  • In contrast to low-level laser therapy that delivers a single wavelength of red light, light-emitting diode devices deliver a small band of wavelengths that include dark orange and red light.1
  • This is another form of light therapy that seems effective for hair loss in men and women, and it can be combined with topical or oral treatments.1
  • Light-emitting diode devices can also be used at home. Treatment is generally recommended for 10 minutes each day.1
  • The side effects of light-emitting diode devices are minimal and similar to the effects of lowe-level laser therapy. 
  • Similar to low-level laser therapy, the cost is less than $1,000.

Hormonal Therapies

There are a few hormonal therapies that have been used off-label for the treatment of hair loss. However, their efficacy is not as good, and some combinations can have significant side effects.

Spironolactone

  • This medication has been widely used for women with hair loss.1
  • The standard dose is 100 to 200 mg daily.1
  • Although there is efficacy in this treatment, trials have found that approximately half of people experience hair regrowth, whereas the other half had no change in their hair density.1
  • Side effects are usually mild, including electrolyte changes, worsening kidney function, and hypotension.1 However, this medication has been on the market for a long time to treat cardiovascular disease, and generally, side effects are well tolerated.
  • The cost is usually between $100 and $1,000 each month.1

Flutamide and bicalutamide

  • This combination includes an oral antiandrogen and a nonsteroidal antiandrogen that is rarely used. There have been case reports and small studies showing the effectiveness of this combination, but there are significant side effects, and frequently patients drop out of study protocols.1
  • Significant side effects include hepatic injury, and flutamide carries a BlackBox warning for hepatic failure.1; Other side effects include peripheral edema and gastrointestinal discomfort.1
  • The cost of this medication is usually less than $100 per month.1

Injectables

There are newer alternative therapies that include injectable treatments. There is less research behind these therapies, and some are still under investigation, but early analysis seems to show effectiveness with platelet-rich plasma.

Platelet-rich plasma

  • This is an alternative procedure where approximately 10 to 30 mL of blood is drawn from a person, centrifuged for 10 minutes to separate the plasma from the red blood cells, and the platelet-rich plasma is injected into the deep dermis or subcutaneous tissue.1
  • There are relatively few studies on the effectiveness of this method, but thus far, studies demonstrate efficacy in promoting successful hair growth after 3 to 6 months of treatment.1 This method is particularly effective early in the hair loss process.1 The sessions are conducted monthly.1
  • Side effects are minimal, and patients are generally delighted with these treatments.1
  • Since this type of treatment is an office procedure that requires a trained clinician, the cost is higher but still less than $1,000 each month.1

Other Alternative Therapies

Several other alternative therapies are sometimes used in combination with more efficacious topical and oral hair loss treatments. These treatment options are often cheap, easily attained, and have few side effects. Primary care clinicians are less likely to choose these options unless they understand more about them. Studies on these alternative treatments can be small, but efficacy has been demonstrated. 

Microneedling 

  • This treatment releases growth factors and stem cells, which activate hair growth mechanisms.1
  • Microneedling has mainly been studied in combination with topical therapies, and researchers have shown enhanced hair growth when topical minoxidil is used with microneedling.1 The thought is that the procedure allows better absorption of the topical agent.1
  • There are few side effects, including pain at the injection site, bruising, and folliculitis.1
  • Since microneedling is an office procedure, it raises the cost of topical treatments to up to $1,000 monthly.1

Oral nutraceutical supplement

  • Supplements have been evaluated to determine their ability to promote hair growth. A supplement containing Synergen Complex seems to show a reduction of hair shedding and promotion of hair growth in women.1 However, studies are small and few. 
  • There are several active ingredients in this supplement that inhibit 5-alpha reductase, lower cortisol levels, reduce inflammation, promote homeostasis, and maintain collagen stores.1
  • This nutraceutical supplement is given in four capsules daily.1
  • There were no side effects noted in clinical trials.1
  • These supplements cost less than $100 each month.1

Marine complex supplement

  • Small trials have also studied the efficacy of a marine complex supplement called Viviscal. This is a blend of extracellular matrix components of shark and mollusks, vitamin C, horsetail extract, and flax seed extract.1
  • This extract is available in tablet form and as a shampoo, conditioner, or cream.1 Tablets are typically taken twice daily.1 
  • Although clinical trials are small, they have shown decreased hair shedding and increased hair growth after several months of treatment.1
  • Although no side effects were demonstrated in clinical trials, experts caution that side effects can include joint pain, bloating, constipation, diarrhea, and nausea.1
  • This extract costs less than $100 each month.1

Serenoa repens

  • This supplement contains saw palmetto, a palm tree berry extract that inhibits 5-alpha reductase.1
  • Again, there are only a few small studies, but a trial has been conducted comparing this extract with oral finasteride. While nearly 70% of patients treated with finasteride noted hair growth, so did about 40% of patients treated with Serenoa repens.1
  • This is an oral once-daily regimen.1 However, the extract is also found in lotions and shampoos.
  • The cost is less than $100 each month.1

Transplantation

For those who have failed all other therapies or who have a large area of the scalp that can only be treated with hair implantation, there is a hair transplant option.

Hair Transplantation

  • Hair transplantation induces a naturally-appearing look to the hair.1
  • This is typically an office procedure done with local anesthetic.
  • There are two donor harvesting options: the ellipse and the robotic follicular unit extraction.1 They have similar efficacy.1
  • Side effects can include typical adverse reactions to anesthesia, bleeding and pain from the procedure itself, and problems with wound healing.1
  • Since this is a complex office procedure that takes several hours, the cost is much higher, between $5,000 and $15,000.1

There are several treatment options for hair loss, and clinicians must choose a suitable choice for their patients based on the severity of the disease, efficacy, safety, cost, and patient preferences. Newer research studies are also evaluating the effectiveness of combination therapies, which hold strong promise.3 One of the most common combination therapies used is topical minoxidil with oral finasteride. In a meta-analysis, this combination has shown superior efficacy to monotherapy.3

Read more about hair loss treatments and earn CME/CE credits in What are the Best Agents to Treat Male Baldness? Visit Pri-Med for more learning opportunities and to get ahead of the game in CME/CE. 

 

 

References

1. Nestor MS, Ablon G, Gade A, Han H, Fischer DL. Treatment options for androgenetic alopecia: Efficacy, side effects, compliance, financial considerations, and ethics. J Cosmet Dermatol. 2021;20(12):3759-3781. 

2. Wall D, Meah N, Fagan N, York K, Sinclair R. Advances in hair growth. Fac Rev. 2022;11:1. 

3. Zhou Y, Chen C, Qu Q, et al. The effectiveness of combination therapies for androgenetic alopecia: A systematic review and meta-analysis. Dermatol Ther. 2020;33(4):e13741.