So, which treatments work, and which do not…? You really want to know? Then this overview is for you… 😊
I’ll discuss the following treatments and subjects:
Table of Contents
- Finasteride (aka Propecia®) for oral use
- Finasteride as topical
- Minoxidil (aka Regaine®)
- Low level laser therapy
- Platelet Rich Plasma (PRP)
- FUE Hair transplantation
- and more…
Let’s jump right into it and begin our tour into the world of hair loss treatments…
Finasteride for oral use
No doubt, Finasteride is one of the most effective ‘non-surgical treatments’ when it comes to treating androgenic thinning.
The efficacy of oral finasteride has been proven in large double-blind, placebo-controlled, randomized, multicenter studies finding finasteride to be superior to placebo treatment.
But there is one very important thing you need to know when starting your Finasteride treatment, and that is that it takes time to get good results…
lots of time… at least several months…
Just think about that your hair loss has developed over several years.
Likewise, the regrowth of new hairs also takes time.
Therefore, one of my advises for you, if you’re ready to try out oral Finasteride (or any treatment for that matter) is that you should take monthly photos of your hair… that way you can follow your progress.
With patience you’ll see good results 😉
The effect on hair regrowth can be amazing… 😊 Just see the before and after photos below…
Figure. A, Baseline. B, Month 12: Moderately increased hair growth. C, Month 24: Greatly increased hair growth (source).
The chances of success increase even further to 94% when combining oral Finasteride and hair stimulating topicals (source).
However, if you’re not seeing any results after 1 year of treatment, I’d still suggest you continuing the treatment, since discontinuation of oral finasteride results in recurrent hair loss and further progression of hair loss.
Thus, any effect Finasteride might have had on your hair will be lost due to increase in dihydrotestosterone (DHT) levels once finasteride has been stopped…
As you might already know reading the article about androgenic thinning (aka male pattern hair loss), DHT is the main cause for baldness…
DHT causes the hair anagen growth phase to decrease with each hair growth cycle.
This is called miniaturization, which basically means that the hair follicles get smaller and thinner…
Ultimately, the duration of the growth phase becomes so short that the growing hair fails to achieve enough length to reach the surface of the skin, leaving an empty follicular pore…. And the result…?
Well, that would be hair loss…
DHT is formed from the conversion of the circulating testosterone (male sex hormone) to DHT by the enzyme 5ɑ-reductase (5AR).
This is illustrated in the figure below showing the stepwise miniaturization of the hair follicle.
Figure. Stepwise miniaturization of the hair follicle and shortening of the anagen growth phase, mediated by DHT (source).
Finasteride works by simply blocking the conversion of testosterone to DHT at the tissue level, thereby lowering the DHT concentration around the hair follicles.
Drugs which block the conversion at the tissue level are called 5ɑ-reductase inhibitors and include drugs such as Finasteride and Dutasteride.
In other words, Finasteride addresses the very root of the problem.
Figure. The negative consequence of high DHT levels in the scalp is that the hairs get smaller and thinner. Finasteride can help stopping the progression of hair loss and makes the hair regrow by lowering the DHT levels in the scalp.
When should you consider starting on oral Finasteride?
In my opinion, oral Finasteride should be considered as soon as hair loss is starting to show.
At this stage, there is a good possibility that the hair loss can be reversed because Finasteride addresses the very root of the problem (i.e. the high DHT levels in the scalp).
My other argument is that Finasteride prevents even further hair loss.
Having hair loss comparable to Norwood I-II in your early 20s or 30s, you don’t want your hair loss to progress to a III or IV (or even VII 😨) on the Norwood scale… Right…?!
Figure. Male pattern hair loss can be divided into 7 stages besides several subtypes. The Norwood scale is the leading classification system used to measure the extent of male pattern baldness (source).
By the way, you probably already have considered or tried other alternatives such as Minoxidil (aka Rogaine®) which can be bought in most pharmacies without a prescription….
And yes, I’ve been there myself!!
But, the problem with only treating hair loss with topical Minoxidil is that it doesn’t address the high DHT levels in the scalp which causes the hair loss.
Hence, Minoxidil might work for a time, but at some point, the hair loss will most likely start to progress again, and once that happens, the hair loss might become much more worse than before you started your Minoxidil treatment… the reason being that the DHT keeps on affecting the hair follicles and miniaturizes the hairs while using topical Minoxidil.
Eventually, the hair follicles have undergone so severe miniaturization that the hair loss is likely irreversible.
At this point, the only cure of the hair loss is a hair transplantation.
So… Here is why you should consider oral Finasteride even in the early stages of hair loss
- Millions of patients have benefitted from finasteride with no side effects at all, or minimal and reversible side effects.
- Finasteride stimulates new hair growth and prevents further progression of hair loss. For example, Finasteride can prevent going from being a Norwood 2 to a Norwood 3 or 4.
- There are very few effective alternatives to Finasteride.
- Finasteride is probably the best available drug to treat male baldness and the only FDA-approved drug to address the root of the problem.
- Its effects are proven in large multicenter studies.
- Several studies have shown its safety over long duration of administration. The dosage given (1 mg) is small.
Alright, so when that’s said, I owe to tell you when you should not go for oral Finasteride…
That would be if you and your wife are having problems getting pregnant or if you have a prior history of low sperm count (oligospermia), infertility, and you’re trying to raise a family anytime soon.
Since Finasteride has anti-androgenic actions, it can cause lower sperm count and make it difficult to get pregnant in men who have oligospermia.
In such cases, I’d suggest you consider topical Finasteride as a gel or topical solution…
where to get topical Finasteride by the way? In our online shop of cause… 😊
If, on the other hand, you’re not planning to raise a family anytime soon, you shouldn’t worry too much, because the sperm count increases in 1-3 months after stopping the treatment (source).
Finasteride as topical treatment
For those of you who simply dislike the idea about taking medicine or are having troubles getting pregnant (you and your wife), this is the treatment for you 😊
Topical Finasteride has been proven to help hair loss in men in several studies.
For example in one study, topical Finasteride was compared with placebo treatment (source). The trial was conducted over a 16-month period during which each patient applied 1.0 ml of the study medication twice daily to the balding area of the scalp.
During the 16-month treatment, a significant reduction in hair loss was seen in the topical Finasteride group but not in the placebo group as shown in the graphs below:
Figure. The researcher evaluated the degree of hair loss by comparing the number of hairs lost in the two groups. At month 6, the Finasteride group lost significantly fewer hairs than the placebo group. In the graphs, the up-pointing triangle (▲) is placebo, and the quadrant (■) is Finasteride.
In another double-blind, randomized clinical trial, the therapeutic effects of both Finasteride gel and Finasteride tablet were relatively similar to each other after 18 months of treatment (source).
The great benefit of topical Finasteride is that the treatment doesn’t have any side effects what so eve
Topical Finasteride comes in two forms – either as a liquid ethanol-based solution or a liposomal gel. Both forms are equally effective. It’s simple a matter of preference which one to choose…
One of the benefits of topicals is that multiple hair stimulating ingredients can be added to the same product such as Finasteride, Minoxidil, Vitamin A acid liposomes, Melatonin and more. Combining multiple ingredients with different actions might stimulate the hair growth even further.
Now, let’s take a closer look at the combination of Finasteride and Minoxidil… 😊
Combining Finasteride and Minoxidil
Hair loss treatment with Finasteride and Minoxidil can be done in two combinations.
- Both topicals (i.e. Finasteride and Minoxidil are added to the same product)
- Oral Finasteride 1mg/day and topical Minoxidil
These combinations have been examined in several studies…
In one study, combination of topical Finasteride and Minoxidil was compared to Minoxidil alone.
Well, you probably won’t get too surprised when I tell you, that the combination of topical Finasteride and Minoxidil was superior to topical Minoxidil alone in terms of increased hair density, hair diameter and global photographic assessment 😉
About 90% of the patients treated with this combination experienced moderate to marked improvement (source).
In another study, oral Finasteride alone, topical 5% Minoxidil alone, and a combination of oral Finasteride and topical 5% Minoxidil were compared. At 12 months, improvement was seen in 80.5% in the Finasteride group, 59% in the Minoxidil group, and a total of 94.1% experienced improvement in the 1 mg/day Finasteride + topical Minoxidil group.
In conclusion, oral Finasteride is superior to topical 5% Minoxidil, while the combination of oral Finasteride and topical 5% Minoxidil is more effective than oral Finasteride alone at 12 month (source).
The photos below show the results in hair thickening after 12 months of treatment … I’d expect an even further improvement at month 24 in all 3 groups as the treatments continue… 😊
Figure. First row, (a)–(c). A 23‐year‐old man treated with Finasteride at 1 mg/day. (a) Baseline (grade IV based on modified Norwood–Hamilton scale); (b) slightly increased at month 6; (c) moderately increased at month 12.
Second row, (d)–(f). A 29‐year‐old man treated with 5% Minoxidil. (d) Baseline (grade V based on modified Norwood–Hamilton scale); (e) slightly increased at month 6; (f) moderately increased at month 12.
Third row, (g)–(i). A 31‐year‐old man treated with combined medication (Finasteride 1 mg/day + 5% Minoxidil). (g) Baseline (grade VI based on modified Norwood–Hamilton scale); (h) moderately increased at month 6; and (i) greatly increased at month 12.
In an Indian study, the researchers assessed the efficacy of maintaining hair growth with 5% topical Minoxidil fortified with 0.1% topical Finasteride in patients with androgenic thinning after an initial treatment with 5% topical Minoxidil and oral Finasteride for two years.
This study is particularly relevant if you’re considering oral Finasteride but are planning to raise a family anytime soon.
As I mentioned earlier oral Finasteride can lower the sperm count during treatment and, in some men, make it difficult to get pregnant… this shouldn’t be a problem using topical Finasteride 😊
In the study, 84.4% of the patients maintained their hair density when shifted from oral to topical Finasteride indicating high effectiveness of the topical combination in maintaining hair growth (source).
Hence, if you’re thinking about starting on oral Finasteride but worry about the consequences when – at some point – you want to raise a family, the solution might be straightforward!
…Simply cease your oral Finasteride treatment and maintain your hair growth with topical Minoxidil fortified with topical Finasteride until your wife gets pregnant… 😉 The sperm count will increase in 1-3 months after discontinuation of oral Finasteride (source).….
Simple solutions rock!
Minoxidil for oral use was initially developed to treat high blood pressure.
Surprisingly, men who received this treatment started to experience an increase in hair growth… and voila… a new hair loss treatment was invented!
However, to avoid the unpleasant side effect of too low blood pressure when treating hair loss, topical Minoxidil was quickly thereafter developed.
Topical Minoxidil is today one of the mainstream treatments of hair loss in both men and women.
The product is better known as Rogaine®, Regaine® or Regaine Forte® and comes in a 2% and 5% concentration either as a topical solution or foam.
The exact mechanism of action of minoxidil on hair growth is still unclear but it probably causes an increased cutaneous blood flow, increased supply of nutrients to the hair follicles and increased production of prostaglandin E2 (source) which all together stimulate new hair growth.
The cellular actions of minoxidil stimulate the hair growth cycle to start all over.
That’s why some might experience increased hair shedding the first few weeks of treatment.
The old hairs are simply being pushed out by the new hairs.
As with all hair loss treatment, the effect of topical minoxidil is seen after some few months.
The full cosmetic effect is seen after 8-12 months of treatment.
Continuing the treatment is necessary to preserve the new hairs.
Since Minoxidil does not address the very cause of male hair loss itself, it should be combined with antiandrogen therapy, such as Finasteride (either Propecia® or topical Finasteride) which effectively reduces the DHT levels around the hair follicles.
Platelet-Rich Plasma (PRP)
Indications: Male pattern hair loss, Female pattern hair loss, and Alopecia areata.
Platelet-rich plasma… Wow, that’s a fancy pansy name… haa..?
But before you get too confused over the name, please let me explain what kind of treatment ‘platelet-rich plasma’ is. For short, we use the abbreviation PRP 😊
PRP is a non-surgical method that uses the patient’s own blood to generate hair growth via growth factors in the blood.
The treatment is performed by tiny injections into the thinning areas of the scalp as shown in the photos below…
Figure. The photos show the principle of PRP treatment injecting tiny volumes of ‘platelet-rich plasma’ into the thinning areas of the scalp (A): Intraoperative injection with PRP at 0.1 ml/cm2 in the frontal line. (B): At the end of injection with PRP (0.1 ml/cm2) (source).
Despite the use of a thin needle, PRP treatment is actually very well tolerated by most patients…
By the way, if you haven’t heard about PRP before, it’s most likely because PRP is still a relatively new method for treating hair loss and hairline recession…
However, the treatment has long been used in regenerative medicine in fields such as oral and maxillofacial, orthopedic, and cardiac surgery as well as reconstructive plastic surgery to improve wound healing 😊
What is platelet-rich plasma?
You still might wonder what PRP exactly is… below I’ve tried to give a simple explanation…
Basically, PRP is a ‘product’ derived from whole blood.
To get ‘platelet-rich plasma’, a small volume of whole blood first needs to be drawn from the patient.
Thereafter the patient’s blood is separated into its different components (red blood cells, platelets and plasma) with a centrifuge.
During the centrifugation, the heaviest cells (i.e. the red blood cells) fall to the bottom of the glass tube, while lighter components (i.e. the platelets and plasma) lie on top of the ‘red blood cell’-layer (the plasma is the substance within your body that suspends the blood cells…)
Since the platelets are heavier than plasma, but still lighter than the red blood cells, the platelets lie just on top of the red blood cells, and in the very bottom part of the plasma.
Hence, the small part of the plasma, which are enriched with platelets, is called ‘platelet-rich plasma’… 😊 Got it…?
Thereafter follows the separation of the ‘platelet-rich plasma’ from the rest of the blood…
This is illustrated in the infographic below…
Figure. Infographic of the steps to produce l-PRP. Peripheral venous blood was centrifuged using a single-spin (1) or a double-spin (2) system, during which red blood cells were first separated (2a) and then discarded (2b). The obtained platelet-poor plasma (yellow lines) was filtered through a plasma-filter to reach a higher concentration of proteins (3) and then mixed (4) with the ready-to-be-injected l-PRP (red lines) to obtain a PRP richer in fibrin and proteins (5) (source).
Who benefits from ‘platelet-rich plasma’ hair loss therapy?
Basically, PRP is one of the treatments you should really keep in mind if you suffer from diffuse ‘androgenic thinning’…. and if you have a soft spot for non-pharmaceuticals …. 😉
As far as hair growth treatments go, PRP is about as natural as you can get. After all, the method uses your own blood to generate hair growth.
PRP can be used to treat hair loss in both men and women…
And by the way, the results can be very impressive… Just take a closer look at the before and after photos below 😊
Figure. A 31-year-old woman with androgenetic alopecia (Savin II-2), before and 4 months after five ‘platelet-rich plasma’ treatment sessions (source).
Figure. 24-year-old female patient (A) at baseline (Savin II-2) and (B) at the 6-month follow-up following PRP treatment. The patient was treated with two injections of a leukocyte platelet-rich plasma (L-PRP) with the addition of concentrated plasmatic proteins at baseline and after 3 months (source).
Figure. 26-year-old male patient (A) at baseline and (B) at the 6-month follow-up following PRP treatment. At baseline, the patient had diffuse thinning. The patient was treated with two injections of a leukocyte platelet-rich plasma (L-PRP) with the addition of concentrated plasmatic proteins at baseline and after 3 months. Please note, that the visible improvement at follow-up should not be attributed to increased hair length, but rather to an increase in the hair thickness (source).
PRP has also been tested in alopecia areata, which is an autoimmune disease where the immune system attacks the hair follicles leaving bare patches of skin.
In 34–50% of patients suffering from alopecia areata, spontaneous hair regrowth is usually seen without any treatment given whatsoever…
Patients who do not experience regrowth, however, need active treatment. Few treatments have been found effective.
Meanwhile, in a randomized, double‐blind, placebo‐ and active‐controlled, half‐head study (source), the researchers randomized 45 patients with resistant alopecia areata to receive either injections of PRP, injections of corticosteroids (the standard treatment) or placebo on one half of their scalp.
The other half was not treated. Three treatments were given for each patient, with intervals of 1 month.
‘Platelet-rich plasma’ was found to be superior to both placebo and injections of corticosteroids in terms of increased hair regrowth at 1 year.
…60% of patients treated with injections of PRP achieved complete remission in comparison to only 27% of patients treated with injections of corticosteroids …
Additionally, 71% of the patients in the corticosteroids group experienced relapse of disease, while only 31% of the patients in the PRP group had a relapse.
The photos below show the result of placebo treatment (photos to the left) and the PRP treated areas (photos to the right) in a patient.
Figure. Clinical photographs of the scalp of a patient with alopecia areata (AA) who was treated on the back of the head with ‘platelet‐rich plasma’ (PRP) and on the frontal part of the scalp with placebo. The patch treated with PRP had completely resolved after 1 year (T3), while the frontal patch of AA (treated with placebo) increased in size (source).
How does PRP work?
So, why does injections of your own blood stimulate new hair growth…? It sounds strange, right? But the explanation is actually quite straightforward… 😊
And the answer… is… [“drum roll” 🥁]
…Activated platelets release numerous growth factors and signaling molecules as part of the wound healing process when injected into the scalp…
All of these growth factors play an enormously important role by promoting cell proliferation, differentiation, formation of new blood vessels, and chemical signaling that are necessary for hair regrowth (source).
And the result…
…well that would be increased growth of the hair follicles by
- prolonging the length of the anagen growth phase and preventing the catagen transition phase of the follicles
- Accelerating the resting-to-growing hair transition (telogen-to-anagen transition).
All of these effects stimulate hair regrowth… 😊
Another very interesting study which proves the hair stimulating effect of PRP therapy is a randomized, evaluator-blinded, placebo-controlled, half-head study including 23 males aged 19-63 years which compared PRP versus placebo.
PRP, prepared from a small volume of blood, was injected on half of the selected patients’ scalps with hair loss. The other half was treated with placebo. Three treatments were administered to each patient at 30-day intervals.
At the end of the 3 treatment cycles, the patients presented clinical improvement in number of hairs… 😊
There was a mean increase of 33.6 hairs in the target area, and a mean increase in total hair density of 45.9 hairs per cm2 compared to baseline values. No side effects were noted during the treatments (source).
PRP has also been tested in several animal studies. For example, in a small animal model, the researchers found that mice injected with activated PRP for 3 weeks exhibited near-complete hair regrowth, whereas mice which received placebo treatment did not.
Figure. The effect of activated ‘platelet-rich plasma’ (PRP) on the hair growth of laboratory mice. The mice were shaved when 7 weeks old and then (A) phosphate buffered saline (PBS; control), (B) fetal bovine serum (FBS; positive control) or (C) activated PRP was injected under the skin at 3-day intervals. Near-complete hair regrowth was observed in mice injected with activated PRP for 3 weeks (source).
Can PRP injection therapy be combined with other hair loss treatments?
The short answer is “yes definitely”!
The other question is whether PRP treatment can stand alone in the fight against hair loss or it should be combined with other treatments? That is still unclear due to lack of long-term data following PRP treatment…
Though, PRP does generate new hair growth via growth factors, it doesn’t necessarily protect the hair follicles from further miniaturization and thinning due to the androgenic action of DHT.
Therefore, I’d still recommend you combining PRP with any topical or oral treatment, which suppresses the hormonal component of androgenic hair loss… such as oral or topical Finasteride or topical Dutasteride for male hair loss…
And for diffuse thinning in women, I’d suggest a product such as Hair Lotion Effluvium CPA, which includes both a progesterone derivative (CPA) and 17-alpha-estradiol 😊 Both of these ingredients protect against the actions of DHT.
How often should PRP injection therapy be done?
Treatment intervals should include monthly sessions for the first 3 months, then every 3 months for the first year (i.e. 6 treatment sessions in first year at months 1, 2, 3, 6, 9, and 12).
To date there is no scientific data to determine how frequent PRP injections should be administrated after the first year of treatment to sustain the long-term results…
Our experience though is that most patients benefit from PRP treatment every 3 to 6 months to sustain the hair growth 😊
In conclusion, I’d say that ‘platelet-rich plasma’ is a very promising hair loss treatment and certainly an upcoming star … both in terms of treating hair loss in men and women 😊
Hair restoration surgery (FUE hair transplantation)
This section is coming soon… 😊
What I’ve written in this article to curing hair loss is just the beginning of your path to regrowing your hair.
Please leave a comment below if you have any kind of question you would like me to answer.
Dr. Knap, MD, Hair Loss Expert
Last Updated On