What Are The Hair Growth Medications That Work? (
www.minoxidil.com)
(Written by Dr. Lee for those who wish more detailed information)
Knowledge of the normal hair physiology and the understanding of the pathophysiology of alopecia androgenetica, more commonly known as male pattern baldness or MPB, has dramatically expanded in the past decade. Currently, there are two effective approaches to treating MPB: (1.) Stimulate the hair follicle to produce a hair shaft and remain in the anagen (growth) phase. (2.) Decrease the dihydrotestosterone [DHT] in the scalp to prevent the immune inflammatory reaction that harms and miniaturizes the follicles.
There is only one FDA-approved, safe, and effective way to stimulate the hair follicles, which is to use topical minoxidil. Topical minoxidil is dose related, so the more minoxidil that can be delivered to the hair follicles, the better its ability to stimulate hair growth.
On the other hand, there are several ways to decrease the amount of DHT that can affect the hair follicles. Oral finasteride (aka Propecia or Proscar) has been in use for many years to decrease the amount of DHT in the prostate. Several years ago, the FDA approved this same medication in a decreased dosage to treat MPB.
DHT in the scalp can also be reduced by topical medications. The most effective topical medication for this purpose is azelaic acid. Azelaic acid is also an FDA approved medication and has been used for the treatment of acne. Many well-designed studies have proven that azelaic acid very effectively inhibits the synthesis of DHT in the skin.
An alternative topical medication for decreasing DHT in the scalp is a spironolactone solution. Spironolactone is an anti-androgen. It prevents the formation of DHT in the scalp and locally increases the amount of the female hormone, estrogen. Spironolactone also is a competitive inhibitor of DHT at the androgen receptor sites, helping to prevent DHT from attaching to the receptor sites on the hair follicles.
There is one other medication that can be used in conjunction with minoxidil, spironolactone, azelaic acid and finasteride: retinoic acid (Retin-A). Retinoic acid acts as a chemical peel. It will cause the superficial layers of the skin to slough off, resulting in stimulation to new cell growth of the skin and an increased absorption of topical minoxidil
In summary, the best approach to treating MPB is to simultaneously stimulate hair growth and to decrease or eliminate the DHT in the scalp. The available medications are 5% Minoxidil Daytime and Nighttime Solutions, Xandrox 5% Daytime and Nighttime Solutions, Xandrox 12.5% Lotion, Propecia (finasteride), and topical spironolactone.
How to apply 5% Xandrox and/or 5% Minoxidil solutions
Start your treatment by using 5% minoxidil or 5% Xandrox liquid twice daily. It is important to apply the topical minoxidil or Xandrox directly to your scalp, where the medicine will be most effective. Fill the medicine dropper with 1 mL of liquid. If you have pattern baldness, apply the 5% minoxidil or Xandrox liquid to the areas of hair recession or balding areas. If your hair loss is generalized, part your hair in as many as six places and apply a portion of the 5% minoxidil or Xandrox liquid in the medicine dropper to each of these areas. You can use your fingertips to spread the fluid more evenly and to lightly rub the topical Xandrox into your scalp. In solution form, it is the alcohol that allows for penetration of minoxidil and azelaic acid into the scalp, so massaging the scalp has no appreciable benefit. Even though the minoxidil/Xandrox is not evenly distributed on the scalp, there is sufficient diffusion in the layers under the surface of the skin to allow for effective total coverage.
A consistent, twice/day application is the most efficient manner to use topical 5% minoxidil or Xandrox to treat male pattern baldness. Most patients will have a satisfactory response to 5% minoxidil (at the vertex) or to Xandrox 5% solution (at the vertex, crown and frontal areas) in 4 to 6 months. However, if after 6 months of treatment with the liquid, you find that there are remaining areas that are poorly responsive, you may want to consider using 12.5% Xandrox lotion in addition to the 5% solutions.
After two to three years of treatment, you may maintain your hair growth with a single daily application of 5% Xandrox or 5% minoxidil, but it is unlikely that you will recruit any more hair follicles to regrow a thicker hair shaft.
How to Combine the Use of 5% Xandrox Solution with 12.5% Xandrox Lotion
Apply 1 mL Xandrox 5% solution twice daily, once in the morning and once at night on all affected areas. After applying the morning or nighttime Xandrox 5% solution, allow a minute or two for the liquid to partially dry. Then apply no more than 1 mL of the Xandrox 12.5% lotion over the same area(s) of the scalp. Apply the Xandrox 5% solution and the Xandrox 12.5% lotion during that time of day when you can leave it undisturbed on the scalp for the longest period of time.
You may experience temporary flushing from the transfer agent, benzyl nicotinamide, which is contained in the lotion. The blushing is due to vascular dilatation, which is harmless and which enhances the absorption of minoxidil.
Potential Side Effects of Topical Minoxidil
It is extremely rare to have systemic side effects from using topical minoxidil because the amount of absorption (approximately 1.7%) is minimal. The systemic effects of minoxidil can include a rapid heart rate, drop in blood pressure, water retention with swelling in hands and feet, and dizziness. If you experience these reactions, stop using both the 5% Minoxidil and/or 5% Xandrox solutions as well as the Xandrox 12.5% lotion.
Temporary Shedding initiated by the application of Minoxidil based solutions
A small percentage of patients, male and female, may experience slightly increased shedding of hair when they start using any topical minoxidil product. If it occurs, this shedding is a one-time occurrence and is usually so minor that it goes unnoticed. The shedding affects only the telogen hairs, which are those hair shafts that are no longer growing. At any given time, telogen hair shafts normally represent about 10% of all hair on the scalp. Although shedding can be understandably frustrating and exasperating, in actuality, it's a good prognostic indicator that those same patients will ultimately have good results with their regrowth therapy. All such hair that is shed will be replaced with hair shafts that are thicker. This occurs because the atrophic process is being reversed. However, replacement of the hair that has been shed usually requires that the loss/regrowth cycle complete its telogen (resting) phase. The telogen phase lasts approximately 100 days.
Minoxidil 'Tolerance'
There are numerous misconceptions about minoxidil and developing a 'tolerance' to it. Minoxidil will help recruit atrophic follicles grow thicker hair again for a minimum of two to three years. Thereafter, topical minoxidil solutions normally keep hair follicles in the anagen phase. There are numerous cases in which minoxidil solutions continue to regrow hair long after the two to three year period. Dr. Lee, for example, has slowly continued to regrow hair since starting to use minoxidil solutions more than 14 years ago.
Unfortunately because many patients do not see significant 'improvement' after a few years, they assume the minoxidil has caused a tolerance and is no longer 'working' for them. If these patients are convinced to stop minoxidil therapy, all the new hair they have regrown will be shed within 3-4 months.
5% Xandrox and 5% Minoxidil with Retinoic Acid
If you use Xandrox or minoxidil solutions containing retinoic acid (Retin-A), please be aware that Retin-A may cause mild irritation and flaking and drying of the scalp where it is applied. This occurs specifically because of Retin-A’s effect as a chemical peel. Retin-A may also cause the skin where it is applied to be more sensitive to sunburn. Don’t gamble. Take preventive measures if you expect to get significant amounts of direct sun exposure. These measures include using a sunscreen or wearing a hat. Since retinoic acid acts as a chemical peel, almost all patients (at least initially) will have some 'reaction' with its use. It’s best to gradually acclimate to its use by applying it once-only at night during the first week of therapy, twice-only during the second week, etc., until it can be used for all nighttime applications. Because retinoic acid is degraded by strong light, it should be applied only at nighttime. Retinoic acid and minoxidil solutions are additive and synergistic in the treatment of MPB.
If one has continuing scalp irritation from Retin-A, it is best to discontinue using it. Instead, use only the 5% Minoxidil or 5% Xandrox formulae that do not contain retinoic acid. Minoxidil solutions containing retinoic acid are not recommended for patients who are taking Accutane. The cumulative amounts of retinoids may be harmful to hair follicles.
Allergic reactions to Propylene Glycol
Rogaine Extra StrengthTM and the generics use a 50% concentration of propylene glycol to stabilize their alcohol/water base solutions. Regrowth uses a 30% concentration of propylene glycol, and adds vitamin E as a stabilizer in our standard 5% minoxidil and 5% Xandrox solutions. If you experience scalp irritation due to propylene glycol, however, use Regrowth’s propylene glycol-free minoxidil and Xandrox solutions. Because non-allergenic glycerin is substituted for propylene glycol, these glycerin based solutions tend to have an 'oily' texture similar to that of Rogaine Extra StrengthTM and the generic versions of 5% minoxidil solution.
Finasteride for the Treatment of Androgenetic Alopecia (Male Pattern Baldness)
Finasteride (Propecia/Proscar) helps to protect the follicles from DHT. When DHT attaches to the androgen receptor sites on the hair follicles of the scalp, it initiates an immune inflammatory response, which damages and miniaturizes the hair follicles.
One mg of finasteride will lower the serum level of DHT by 60-80%. However, the amount of reduction of DHT around the hair follicles is far less than 60%-80% because the predominant enzyme that converts testosterone to DHT in the scalp is type 1 5-alpha reductase. Type 1 5-alpha reductase is not affected by finasteride.
The recommended dosage of finasteride is 1 mg/daily, but because the biological action of finasteride is so prolonged, variations on the daily dose are equally effective. Finasteride can be taken with or without food.
When male patients take finasteride, less than 10% of them report a decrease in libido, and a smaller number report an "ache in the groin area”. These negative side effects are reversible usually within two weeks of discontinuance of taking the finasteride. Even when patients continue to take the finasteride, the majority of the men will gradually regain their former libido and the side effects abate.
Unfortunately, we are also getting rare reports of "massive shedding", usually after several months of successful finasteride therapy. Apparently, the systemic reduction of DHT incites a telogen effluvium in a very small percentage of patients. If the massive shedding occurs, the consensus among dermatologist is to stop using the finasteride. However, it is recommended that you continue to use the minoxidil and use another anti-androgen or DHT inhibitor that does not cause a hormonal shift of DHT. The best alternative is the exclusive use of Xandrox formulations.
Fortunately, the massive shedding (telogen effluvium) caused by finasteride does not cause a scarring alopecia, so the hair will grow back in again.
Although finasteride can be used alone for the treatment of MPB, it is much more effective in regrowing hair, if it is used together with topical 5% Minoxidil or Xandrox.
Azelaic Acid for the treatment of Androgenetic Alopecia (Male Pattern Baldness)
Many medications have been developed which will decrease the amount of DHT in the scalp. Topically applied azelaic acid has been proven to be the most effective inhibitor of DHT synthesis in the scalp. A topical 5% azelaic acid solution will reduce the amount of DHT in the scalp by greater than 98%. Xandrox incorporates 5% azelaic acid and 5% minoxidil, so there is promotion of hair growth as well as prevention of atrophy of the hair follicles. The 5% azelaic acid in all of the Xandrox formulations is approximately 3 times the concentration necessary to obtain essentially complete inhibition of DHT synthesis.
When azelaic acid is initially used, it may cause a temporary stinging or burning sensation. There are no harmful direct or side effects to the use of azelaic acid.
Topical Spironolactone for the Treatment of Androgenetic Alopecia (Male Pattern Baldness)
Spironolactone is a potent anti-androgen, and it is effective applied topically. It successfully competes with dihydrotestosterone (DHT) for the receptor site on the hair follicles. Within the skin on which it is applied it also inhibits the formation of testosterone and converts the existing testosterone in the skin to an estrogen. However, there are inherent problems with topical spironolactone formulations. They have a disagreeable odor and are not stable in solution form.
Spironolactone is metabolized in the skin and does not affect any other organ system. In about 1% of patients, a rash can develop. If this happens, the patient should not use spironolactone solution.
Topical spironolactone can be used by men and women with MPB. Oral spironolactone is occasionally prescribed for women to treat hair loss, but it is contraindicated in pregnant women because it upsets the estrogen/progesterone ratio. If taken orally by men, there can be serious side effects such as an increased potassium level in the blood, feminizing effects (gynecomastia) and loss of libido.
It cannot be overemphasized that in treating patients with MPB, it is important to simultaneously stimulate hair growth and decrease the DHT level in the scalp. Simply decreasing the DHT level may be totally ineffective in regrowing terminal hair. For instance, men who have been castrated for the treatment of prostate cancer, and therefore have no source of DHT, will stop the balding process, but will not grow back significant amounts of hair. However, if they also use minoxidil as a hair growth stimulant, most of the men will grow back terminal hair. A combination of minoxidil and an anti-androgen or DHT inhibitor is particularly important for growth outside the vertex/crown area of the scalp.
What Can Be Expected from Treatment?
The average patient will see a positive response to treatment within 4 to 6 months. Using a combination of 5% minoxidil and a drug to effectively reduce scalp DHT (e.g. 5% Minoxidil and 5% spironolactine, finasteride or Xandrox alone) stops any further loss and regrows hair in 83% of patients with MPB. Approximately 70% of patients will see the growth of cosmetically acceptable hair. Of these patients, 50% can expect a restoration of frontal hair. An additional 13% of patients report that MPB has been stabilized, although appreciable new hair growth is not seen. The remaining 17% may continue to lose hair, but the rate of progression of MPB is slowed considerably.
Most patients see a positive response within 4 to 6 months. For other patients the response time takes longer. Most dermatologists recommend refraining from judging a treatment for MPB until there has been at least a year of treatment.
Best Regards,
Richard Lee, M.D.
Chief Consulting Physician
