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Learn MoreFinasteride is available in oral and topical formulations. Some hair loss sufferers opt for topicals, which have been touted as safe and effective by doctors and patients alike. Oral finasteride has stood the test of time and remains the gold standard for the treatment of male pattern hair loss. Which formulation is best for hair loss sufferers? The answer depends on an individual’s preferences for side effect mitigation, as well as their patterning of hair loss (i.e., localized versus diffuse). This post gives an overview of each formulation and offers insight into what is prescribed and why. It also explains how – contrary to popular belief – topical finasteride can still go systemic.
Finasteride is a drug approved by the FDA to treat benign prostate hyperplasia and androgenic alopecia. It is prescribed as a 1 mg daily tablet for men with androgenic alopecia. It is also prescribed in higher dosages for women suffering from female pattern hair loss. This ranges from 1.0-5.0 mg daily.
Finasteride is available in different formulations. The best option is determined on a patient-by-patient basis.
There are two main finasteride formulations: oral and topical. Doctors typically prescribe oral finasteride, as it’s a time-tested formulation with a high success rate. Many telehealth providers have sprouted up in recent years, offering topical and oral versions of the drug. Topical finasteride has become increasingly popular as more studies confirm its efficacy and relative safety versus oral finasteride.
As concluded in one study:
Topical finasteride significantly improves hair count compared to placebo and is well tolerated. Its effect is similar to that of oral finasteride, but with markedly lower systemic exposure and less impact on serum DHT concentrations. [1]https://pubmed.ncbi.nlm.nih.gov/34634163/
Clinical studies have shown that oral and topical formulations improve hair parameters equivalently in target area hair counts.[2]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9297965/ As such, many people looking to minimize their risk of side effects from finasteride often prefer the topical formulation, and they rationalize that decision by arguing that topical finasteride (1) is just as effective as oral finasteride, and (2) remains localized to the scalp, so it must not have any systemic effects elsewhere in the body.
In reality, both of these arguments are wrong.
A graph representing the daily dose exposure of topical finasteride (y-axis) versus the amount of serum DHT reductions in participants (x-axis). Across all studies referenced in the graph, topical finasteride led to hair parameter improvements.
As mentioned, finasteride is typically prescribed as a once-daily 1mg tablet. At 1mg daily, finasteride is sometimes branded as Propecia®. Using more than 1mg per day isn’t likely to improve results.[3]https://pubmed.ncbi.nlm.nih.gov/10495375/
However, it may increase the risk of side effects. Nearly all clinical studies use 1mg, as it’s the gold standard for treating male pattern baldness. 5 mg finasteride is typically used to treat men diagnosed with benign prostatic hyperplasia (under the label Proscar®).
Oral Propecia® (i.e., 1mg daily of finasteride) is prescribed under its brand name and as a generic formulation through many telehealth companies. Generic versions of the drug typically deliver similar results, and often at a fraction of the cost.
Finasteride topicals include gels, liquid solutions, and liquid sprays. Foams are available as well.
A previous post centered on the best topical finasteride dosage determined that finasteride has a highly-sensitive and dose-dependent response curve.
In other words, 0.01 mg of finasteride barely reduces any DHT, while 0.2 mg reduces almost as much DHT as 5 mg, a much larger dose.[4]https://onlinelibrary.wiley.com/doi/10.1111/jdv.17738 1% topical formulations essentially guarantee systemic absorption.
Those aiming to avoid the side effects may want to consider a formula with lower percentages of the active drug.
It depends on two factors: (1) the presence of side effects, and (2) whether a patient has diffuse thinning or localized hair loss.
When weighing the pros and cons of finasteride formulas, doctors often have patients start with oral finasteride. This is because oral finasteride has the strongest clinical evidence for treating male pattern hair loss, and it provides some degree of protection across all balding-prone areas.
If side effects occur on oral finasteride at 1 mg daily, doctors may consider lowering the dose to 0.2 mg daily to see if this reduces side effects. If issues persist, other options can be explored – such as topical formulations.
Under these circumstances, users may introduce topical finasteride at a 1-2 mL daily of 0.025% to 0.3% finasteride. If side effects persist, it may be necessary to lower that dose all the way to 0.005% x 2 mL daily, and start tracking serum DHT levels to measure – as a proxy – how much finasteride is actually going systemic (as these levels vary greatly depending on the person and any adjuvant treatments that might be influencing topical absorption – i.e., retinoic acid, microneedling, etc.).
If someone wants to use topical finasteride, they should recognize that topical formulations of the drug are most appropriate for people who have localized hair loss (i.e., hair loss only at the temples and/or crown), rather than people with diffuse thinning (i.e., hair loss throughout the entire scalp).
This is because diffuse thinners have a larger area of the scalp to cover with a topical. That requires a higher amount of mL per application daily of topical finasteride to cover all zones. When holding constance the percentage dilution of topical finasteride, the more mL applied daily, the higher likelihood some of that additional finasteride will leak into the bloodstream and cause systemic effects – thereby defeating the whole effort of the topical in the first place.
For these reasons, diffuser thinners need to take extra care to titrate down their topical finasteride doses, or perhaps consider oral formulations of finasteride to maximize their scalp coverage and thereby improve their odds of long-term success.
For those who don’t experience any sexual side effects, long-term use of oral finasteride may be advisable, given its success rate. And for those who experience adverse systemic effects of oral finasteride, or those wary about potential issues with the oral formulation, topical finasteride may be the better option.
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