Finasteride is a widely used treatment for androgenic alopecia – The most common form of hair loss in men and women. Despite its effectiveness in male pattern baldness, it has a number of different side effects, including erectile dysfunction, decreased libido, abnormal ejaculation, insomnia and depression. A topical version of the drug, i.e. local application of finasteride, is currently being studied, as scientists hope to reduce the number of side effects.
Topical finasteride is not yet commercially available, but patients can order it from a pharmacy with a prescription-processing department. However, you should keep in mind that only topical minoxidil and oral finasteride have been approved by the Food and Drug Administration and the European Medicines Agency for the treatment of male pattern baldness. The efficacy and safety of finasteride for other forms of its use have not yet been established.
While some look forward to the approval and availability of finasteride for topical use, let’s discuss what androgenic alopecia is, how finasteride works, and what its side effects are.
What is androgenic alopecia?
There are different causes of hair loss in both men and women. Androgenic alopecia, also known as male and female pattern baldness, is the most common type of this problem. It affects at least 30% of men in their 30s and about 50% in their 50s. Although the prevalence of alopecia in women is lower than in men, it is just as common.
In men, hair thinning begins at the temples and the top of the head, forming an M-shaped pattern. In women, on the other hand, hair loss begins in the central and frontal part of the head with the preservation of the frontal hair growth line. Over time, thinning hair can lead to permanent hair loss.
Of course, baldness affects a person’s self-esteem. Healthy hair signifies youthfulness and vitality, and people who suffer significant hair loss are often viewed as old and less attractive. The prevalence of androgenic alopecia and its impact on the social and psychological well-being of the patient is the main reason for the development of the hair loss drug field.
The disadvantage is that modern pharmacological treatments are not completely safe, and the long-term effect is not that great. Studies have confirmed that finasteride can cause side effects both sexually and psychologically. Also, there is evidence that side effects from finasteride can continue for a long period of time, even if the patient has stopped taking the drug.
Topical Finasteride in the treatment of male pattern baldness
Finasteride was approved by the Food and Drug Administration in 1997 to treat male pattern baldness or hereditary hair loss. It is currently marketed under the brand names Propecia, Proscar, and Aindeem. The drug was originally only available to treat benign prostatic hyperplasia (BPH) or enlarged prostate in men age 60 and older. Researchers later found that patients who were treated did not develop baldness over time. This is what prompted a large-scale clinical trial testing the efficacy of finasteride in the treatment of androgenic alopecia. Today, it may also be used for purposes other than its intended use (unconfirmed indications), for example, to treat hirsutism or excessive hair growth in women and for hormone replacement therapy for transgender women.
However, finasteride is only approved for men with the problem of androgenic alopecia. This drug is not recommended for the treatment of hair loss in women, especially those of childbearing potential, as it may lead to abnormalities of the male fetus’ external genitalia. Note that the label of finasteride (Propecia®) for oral use is stated: «Women who are pregnant or may become pregnant should not use PROPECIA tablets either in crushed form or in half». In addition, studies have shown that finasteride is ineffective in treating androgenic alopecia in women.
That being said, prescribing finasteride for women with hair loss is not illegal. As mentioned above, this drug can be prescribed to treat problems that are not included in its indications. Such use of the drug is called «off-label», And depends on the doctor’s discretion.
How Topical Finasteride Works?
It has been found that androgenic alopecia does not occur in people with a genetic deficiency of 5-alpha reductase type 2, an enzyme needed to convert the male sex hormone testosterone into the more potent dihydrotestosterone. Elevated levels of dihydrotestosterone are thought to be responsible for hair loss, but it’s not the only one. Men who are predisposed to androgenic alopecia have an increased sensitivity to this hormone (dihydrotestosterone). With a genetic predisposition, the hair follicles in these men tend to miniaturize, leading to a rapid decrease in the density of hair on the head.
Miniaturization of the hair follicle (bulb)
Normal, long, lush, thick hair and with natural pigmentation turns into thin, barely visible, depigmented hair, which is called fuzzy hair (fuzz)
Finasteride is a synthetic compound that blocks the activity of the 5-alpha reductase enzyme, causing a 68% reduction in dihydrotestosterone levels in the scalp and in the blood. This makes the drug effective in reducing the size of an enlarged prostate. Dihydrotestosterone may be the cause of hair loss in men. However, it is also an important hormone for the formation of sex characteristics during puberty. This means that finasteride should not be used by men under 18 years of age.
Safety and effectiveness of finasteride
Is finasteride effective for hair loss? The fact that finasteride was approved by the Food and Drug Administration and the European Medicines Agency means that experts found the drug to be effective in male pattern baldness. The therapeutic dose for treating androgenic alopecia is 1 mg, a tablet taken once a day, and 5 mg for enlarged prostate. When Merck released Propecia to treat male pattern baldness in the late ’90s, it became a panacea for men. Then the company warned that only about 1% of men may experience erectile dysfunction and decreased libido.
The company did not warn about other possible side effects, such as insomnia, depression, or even suicidal thoughts. Worse was the fact that they claimed that «These (sexual) side effects disappeared in men who stopped taking Propecia». As it turned out, some people still had side effects from the drug even after discontinuing the medication.
A 2015 review published in the journal JAMA Dermatology found that of 34 clinical trial reports on finasteride, none adequately assessed the drug’s safety. The fact that millions of patients had been using finasteride for years before the company decided to update the drug’s instructions in 2012 is also troubling. Since then, depression has been added to the side effects section of Propecia’s instructions and acknowledged patient reports that sexual side effects of the drug may continue even after discontinuing treatment.
Following this, once a patient stops taking the drug, the hair loss problem returns, and the side effects, in turn, may also remain. These findings raise the question of why a drug that can affect sexual function and cause depression in exchange for meager results was approved? After all, androgenic alopecia and benign prostatic hyperplasia are not life-threatening.
Normal, long, lush, thick hair and with natural pigmentation turns into thin, barely visible, depigmented hair, which is called fuzzy hair (fluff)
More than 1,300 lawsuits have been filed against Merck because patients have alleged that symptoms of erectile dysfunction, loss of libido, reduced penile size, cognitive impairment and depression have seriously affected their families, relationships and careers. The incidence of sexual side effects, depression and suicide attempts has been alarming as patients have even introduced the term «postfinasteride syndrome». This syndrome includes a group of symptoms that patients experience even after discontinuing finasteride treatment.
Post-Finasteride Syndrome Foundation, a nonprofit organization (www.pfsfoundation.org) specializes in supporting patients with «Post-Finasteride Syndrome». Also, it raises public awareness of the drug and the syndrome. Henceforth, physicians are advised to refrain from prescribing oral finasteride for patients with sexual dysfunction, fertility problems, and depression.
Common and possible side effects
Now let’s look at the side effects and risks associated with finasteride use. Side effects from the two studies are presented in decreasing order of incidence.
As with other medications, side effects occur individually in each person. Some patients may experience mild and limited symptoms. Others may experience more severe symptoms that persist even after stopping treatment.
The research team also found some unusual side effects associated with finasteride use. Subjects received 1 mg of finasteride for at least four months. Several patients experienced the following side effects:
- Melasma (1 patient)
- Dryness / thinning of the skin (4 patients)
- Tinnitus (3 patients)
- Postural hypotension (2 patients)
- Oral lesions (9 patients)
Is topical Finasteride effective?
Swiss pharmaceutical company Polichem is developing a topical (topical) version of finasteride. The test drug (P-3074) contains 0.25% finasteride compared to 1 mg in tablet form. It is currently in a Phase 3 baseline study in the European Union, but the company has not yet announced the results of these studies.
In an earlier phase of the study, scientists claimed that topical finasteride caused a systemic reduction in dihydrotestosterone levels when the dosing regimen was changed without side effects. However, the treatment in the study only lasted a week, as opposed to the lengthy treatment that is usually carried out in practice. Also, there was a conflict of interest because the company that funded the study is also developing the drug.
There is no consensus on the safety and efficacy of topical topical finasteride for male pattern baldness. Topical (topical) drugs can still be taken systemically, so caution is best.
Alternatives to finasteride
If a patient wants to avoid the unpleasant side effects of finasteride, natural supplements, dietary lifestyle and combination therapy are also worth considering. In some cases, male pattern baldness may also be related to an underlying disease. In one study, the manifestation of androgenic alopecia was directly linked to obesity or overweight.
An improper and unbalanced diet can lead to nutritional deficiencies. Some micronutrients that are relevant to hair growth include:
- B vitamins (biotin, niacin, folic acid, riboflavin, pantothenic acid, pyridoxine, and cyanocobalamin)
- Antioxidants (vitamin A and E)
- Micronutrients (iron, zinc, and selenium)
Hair loss is often the result of more than one cause, but a combination of several factors that must be considered for successful treatment. To cope with male pattern baldness, it is important that patients and doctors be aware of the variety of treatment options currently available.