Exact mechanism of hair growth stimulation remains unknown. The Vasodilating action of Minoxidil in increasing local blood supply does not pay a role. Recent studies suggest that Minoxidil may have 2 actions:
Opens and stimulate a ATP dependent-potassium channels in human hair follicles
Upregulates the vascular endothelial growth factor (VEGF) and prostaglandin endoperoxide synthase-I, which are involved in hair growth
Applied twice daily
5% topical minoxidil is better than 2%
45% more hair growth
Earlier hair growth
Increase in hair diameter
A significant increase in terminal hair counts in the 5% group
Patients in the 5% group rated better in results
Minoxidil causes reversible hair growth when used for 4 weeks. Price’s 1999 study over 96 weeks in men showed the followings:
An increase in hair weight for those treated with minoxidil. The controlled group without using minoxidil continued to lose hair
Once treatment is stopped hair weight will be lost to the extent as if they had never been treated at all
A “saturation effect” with minoxidil – strength higher than 5% unlikely to have any addition effect
Side Effects And Safety Of Use
Minoxidil topical solution is safe. Absorption through skin is low.
1 in 20 users will develop skin irritation, a higher incidence with the 5% solution rather than the 2%. With ketaconazole this side effects is less.
Increase of facial hair is mainly seen in women. This effect lessens or even disappears after a year of continued use. It is reversible and goes away 1 to 6 months after the drug is discontinued.
May take up to 4 months to see any effect
May have a temporary increased shedding of hair about 3 to 5 weeks after the start of treatment. The hair shed is part of the natural cycle and is normal
Ideally used for a year before assessing efficacy
Minoxidil has no effect on the underlying hormonal cause in Androgenetic alopecia
Once the drug is stopped, hair loss will resume. It’s positive effects are at best temporary and long-term results are somewhat disappointing
Best result when used with combination with finasteride combined therapy
Finasteride 1mg slows the progress of hair loss and increased hair growth in Androgenetic Alopecia ( AGA ).
works as an Androgen modulator in the hair follicle
blocks the action of the enzyme type 2 5α-reductase
reduces conversion of testosterone into dihydro-testosterone (DHT)
reduces DHT level in the scalp by 40- 60%
when finasteride is stopped, its action on DHT still lasts up to 2 weeks
applying finasteride over scalp fails to grow hair. It must be taken by mouth
1mg and 5mg showed similar result, so the recommended dosage is 1mg daily.
A 5-YEAR FINASTERIDE STUDY IN MEN
90% treated had not lost hair
65% had increases in hair count.
the peak increase in scalp coverage was seen at 2 years.
over 5 years a difference of 24 FUs/sq.cm hair count from the baseline.
when pictures were taken, 48% of the treated group showed visual improvement compared to 6% in the placebo group.
Twins Study 2002
9 pairs of identical twin males with AGA were recruited. Finasteride was given to one of each paired twins. At 1 year, 100% of the finasteride group had retained hair compared to 56% of the placebo group.
Critical Rescue Hair Size
Dr. Van Neste showed that over a 2 year period :
Finasteride could not return vellus hair to terminal hair
Effect is only possible for thick hair > 0.04mm diameter
Uses & Recommendations
In 1997 the FDA approved a 1mg dose of finasteride for the treatment of AGA. It is important to counsel patients about appropriate expectations and the need for continued therapy. Reversing miniaturization is a slow process. Should take continuously for at least a year before evaluating efficacy.
The American Hair Loss Association recommends finasteride as the first line for all men with AGA.
Finasteride fails to prevent progress of hair loss in female pattern hair loss when the blood level of androgen is normal.
A very safe drug. The most atlk about adverse effects were decreased sex drive and erectile dysfunction. Incidence however was about 0.5% or 1 in every 200 treated cases. Symptoms usually occur during the first one to three months on start, and severity diminishes or disappear with continue use.
The amount of the active drug in semen is negligible. No evidence that exposure to pregnant women through semen is a risk to human fetus.
There are tons of shampoo on the market claiming to restore hair, there is only one that was reported to work according to several research studies.
What Is Ketoconazole
Ketoconazole is an antifungal drug initially used to prevent and treat skin and fungal infections. When applied to the scalp it was shown to suppress the production of androgen in the skin. Recent studies claimed that Ketoconazole shampoo helps to reverse or slow down the process of hair loss by:
Increase hair density
Increase the size and proportion of anagen hair follicles
Mechanism Of Action
It acts in both androgen-dependent and androgen-independent manners.
A study in mice indicated that ketoconazole may have a direct stimulatory effect on hair growth.
Androgen is a hormone which, when bound to receptors in the hair follicles, lead to the shrinking of these follicles. When the follicles shrink the life cycle of the hair becomes shorter with every cycle, this leads to hair miniaturization.
Ketoconazole acts as a relatively mild anti-androgen by:
Inhibiting DHT production in hair follicles
Inhibiting the binding of DHT to androgen receptors
Bald scalp in AGA was found to have a varying degrees of inflammation around the hair follicles. This inflammation when induced by a yeast called Malassezia may be partly responsible for hair loss. The anti-inflammatory and anti-fungal properties of Ketoconazole account for its beneficial effect in AGA.
Indication Of Use
It is usually used off-labelled in 2 ways:
It is beneficial for AGA patients who cannot tolerate minoxidil because of scalp irritation or contact dermatitis.
Used together, Ketoconazole may enhance the effectiveness of other hair loss treatments such as minoxidil and propecia.
In this particular study, 27 subjects used 2% Ketoconazole shampoo exclusively 2–4 times a week for 21 weeks. The remaining 12 in the control group used an un-medicated shampoo. The group using the Ketoconazole shampoo after a course of treatment showed:
An increase in hair density
An increase in hair diameter
An increase in proportion of anagen hair follicles
In another study (Pierard-Franchimont 1998) Ketoconazole 2% shampoo was reported to be almost as effective as Minoxidil 2% topical solution in improving hair density. More confirmatory studies are required.
Dosage And Frequency Of Use
Oral Ketoconazole is not advised as the high concentrations required to affect androgen production exceeds the safety limit. In AGA the only tissue that requires a high concentration of Ketoconazole is the hair follicles. A local application in the form of a shampoo is the best way to delivered Ketoconazole to the affected area. Please note that this shampoo is not used as an cleansing agent, but as a scalp treatment.
Optimal usage is every third day (2 to 3 times a week), leaving the shampoo on the scalp for 3–5 minutes before rinsing. More frequent use is unnecessary but continuous use is required to maintain the benefit. Other shampoo can be used on the other days of the week.
For Dandruff Only
3 times a week for 4 weeks. Repeated only as required.
Possible Side Effects
When first begin treatment with Ketoconazole, it is possible to have more shedding of hair. Don’t worry as shedding often indicates better response to treatment and better result.