Toppik on 28 November 2014

Drug therapy for the treatment of hair loss is a relatively new development that a doctor and his or her patients may add to their arsenal against hair loss. There are currently two products on the market that have been proven in clinical trials to be beneficial. These are Rogaine (minoxodil) and Propecia (finasteride).

The best candidates for treatment are people at the very early stages of hair loss. Prolonged androgenetic alopecia can kill off hair follicles and no amount of treatment thereafter is going to revive them. However, treatment for people with partial hair loss can prevent further loss.

Rogaine (Minoxodil)



Rogaine has been around for some years as a solution applied to the scalp to arrest or, in some cases, reverse hair loss. It is a trademark of Upjohn Pharmacia Pty Ltd. The active ingredient of Rogaine is minoxodil, which was originally prescribed in tablet form for the treatment of high blood pressure. As well as reducing blood pressure, it was found to grow hair on the scalp. Unfortunately it also induced hypertrichosis, or hair growth on the face, shoulders, arms and legs of women and on the entire body of men. While growth of hair on the scalp was seen as an encouraging side-effect, the collateral growth everywhere else was unacceptable. This resulted in the delivery system being changed to a solution applied topically to the localised area where hair growth was desirable. This solution is what is now currently available in Australia over the counter at chemists, as a 2 per cent or 5 per cent Rogaine solution.

How Does Rogaine Work?

We know Rogaine works, but we are unsure of the exact reasons why it works. We know that Rogaine is a powerful vasodilator, effectively increasing the blood flow to the scalp; however, the positive growth aspects occur irrespective of this. There are many credible theories. It is known that the use of Rogaine holds the hair in the anagen or growing phase longer, warding off the catagen or destruction of the follicle phase.

How Well Does Rogaine Work?

The best results with Rogaine have been achieved by patients in their twenties with a recent onset of hair loss, and a small area of loss. A cosmetically significant improvement in regrowth occurs in less than 10 per cent of patients. However, a larger percentage have found that with continued use it is possible to stop further loss in the short term. However in the long term, hair loss generally continues.

How Do You Use Rogaine?

Rogaine is administered in a liquid form of varying strengths from 2 per cent to 5 per cent. The recommended dosage is twice-daily applications of 1mL to the areas affected by hair loss. It is available without prescription from pharmacists. Some pharmacists have a generic form available with added tretinoin. The tretinoin acts as a surface irritant, helping the absorption of the Rogaine into the skin.

Who Can Use Rogaine?

Rogaine can be used by both men and women.

What Hair Loss is Best Suited to the Use of Rogaine?

The crown area of the scalp appears to respond best to Rogaine. It appears to have little effect on the front hairline or the temple region.


Rogaine has been shown to cause the following side-effects in some people:

  • Hypertrichosis: Strong hair growth has been seen in the forehead and eyebrow region and in some cases new hair growth on the tip of the nose has been noted.
  • Scalp irritation: Itching, inflammation and redness of the scalp, which can be exacerbated by the inclusion of tretinoin in the solution.
  • Irregular heartbeat: Due to Rogaine’s vasodilating effects, people with heart problems or on blood pressure medication should consult their doctor before using it.

Propecia (Finasteride)

finasterideI and many other hair transplant doctors were initially very sceptical about the use of Propecia in treating male pattern baldness. Propecia is a trademark of Merck Sharp and Dohme Pty Ltd. With talk before its release of side-effects including deformed male babies, loss of sex drive and ineffectual results, I also asked myself: ‘How will it affect my patients?’ However, after reading the clinical trial information, I realised that Propecia appeared to be a very effective treatment, with minimal side-effects and an excellent safety profile, and ultimately it would be in the best interests of some of my patients to treat them with it. Since those early days, hair transplant surgeons around Australia, including myself, have embraced this medication for use on its own and in conjunction with a hair transplant.


Propecia is the first treatment of its kind that deals with the actual cause of the problem in those individuals with a genetic predisposition towards hair loss. The drug was originally developed by Merck Sharp and Dohme to treat benign prostatic hyperplasia, a non-cancerous swelling of the prostate gland that affects middle-aged men and can make it difficult to urinate. As such, Propecia has been on the market for many years and has a proven safety profile for the treatment of enlarged prostates.

Over time, patients on the medication began to notice that thinning areas of their scalp now had hair that was thicker and stronger than before. Merck Sharp and Dohme were understandably quite excited at the prospect of a drug that could retard hair loss and, in some cases, regrow hair – particularly as the drug had already undergone trials and had an established safety record.

How Does Propecia Work?

As discussed previously, androgenetic alopecia occurs because of two factors: family history and DHT. It is impossible to change the genetic makeup you inherited from your parents. To recap, the male body produces testosterone, which is reduced by an enzyme (5 alpha reductase) to form dihydrotestosterone (DHT). This DHT attacks those hair follicles that are genetically predetermined to whither and die under its effects. So far, however, Propecia is a powerful suppressant of the 5 alpha reductase enzyme, which results in a lower amount of testosterone being converted into DHT. Lower DHT levels in the body allow the DHT-sensitive hairs to defy their natural destiny and continue to grow and renew themselves after falling out.

How Well Does Propecia Work?

The results from the trials of Propecia have been quite impressive in one-year clinic trials:

  • 48% of men taking Propecia had improved hair growth
  • 38% maintained their present status
  • 14% noticed some deterioration of hair quality

Compare this with those who did nothing:

  • 7% of men who took no action had improved hair growth
  • 35% maintained their present status
  • 58% noticed some deterioration of hair quality

How Do You Use Propecia?

Propecia is administered in a tablet form and is generally prescribed as one tablet per day. You need to take it continuously for six months to a year to determine how beneficial it will be to you.

Who Can Use Propecia?

Propecia is intended for use by men only. It is only beneficial in treating androgenetic alopecia. Theoretically it can cause birth defects in male babies of women who take it. It is not considered dangerous for a woman to conceive while her partner is undergoing treatment, however, a number of male patients have elected to cease treatment while their partner is trying to conceive.


Propecia has a couple of side-effects relating to sex, which may not please men who are considering this medication:

  • Reduced sex drive: what good is a full head of hair if you can’t realise the supposed benefits of the new, more attractive you? In reality, this unwanted effect was an issue for less than 1% of people on the clinical trial.
  • Erectile dysfunction: This is related to the above side-effect and was found to be an issue for less than 1% of people on the trial.
  • Decreased semen volume: Less than 1% suffered this side-effect and none of my patients have mentioned this problem.

The vast majority of my patients have encountered no adverse side-effects from the medication. A small number have commented that they feel a slight reduction in their sex drive. I believe that the sexually adverse side-effects are more common among smokers.

Of all the hundreds of my patients who have commenced using Propecia, only a few have come back and told me the side-effects were so bad they would have to discontinue therapy.

If an individual does suffer any of the listed side-effects, they will quickly go away after the treatment has stopped. Some people on the trial suffered the side-effects only temporarily and reverted to a pre-treatment sexual state while continuing with the therapy.

Long-Term Side-Effects

Finasteride (the active ingredient in Propecia) has been used very effectively by the middle-aged and older with prostate problems for many years, and no long-term side-effects have come to light at this stage. However, Propecia is very often used on an ongoing basis by people as young as their late teens to early twenties, albeit in a weaker dosage.


Propecia is metabolised and disposed of by the liver and subsequently requires healthy liver function for it to be taken effectively. Hepatitis, sclerosis of the liver, and indeed any condition that interferes with the proper function of the liver should be discussed with your prescribing doctor.

Propecia lowers the amount of prostate-specific antigen (PSA) in the body. Levels of PSA in the body are used as indicators for prostate cancer screening tests. Effectively, Propecia can mask one of the early warning indicators of prostate cancer. If your doctor is performing any PSA tests, you must advise them that you are taking Propecia so they can accurately determine results.

Saw Palmetto

saw palmetto

Saw Palmetto is a naturally occurring plant extract that has been offered as a more natural alternative treatment to Propecia. Saw Palmetto has been beneficial in the treatment of benign prostatic hyperplasia, a condition that is also believed that Saw Palmetto could be beneficial for treating hair loss. However, it has no effect on PSA or prostate volume and therefore no effect as a 5 alpha reductase inhibitor. As such, there is little evidence to support the claims of Saw Palmetto’s efficacy in the treatment for androgenetic alopecia.


nizoralNizoral has been available in Australia as an over-the-counter anti-dandruff medication for some years. The active ingredient in Nizoral is ketoconazole and it is available as either 1% or 2%. Ketoconazole is beneficial for more than just dandruff, as it is also a powerful anti-androgen. This means that for those affected by male or female pattern baldness, shampooing with Nizoral may be beneficial. The results of a recent study were presented at the American Academy of Dermatology. Investigators found that Nizoral 1% used 2-3 times weekly over a six-month period yielded the following gains:

  • Hair diameter increased by an average 8.5%
  • Hair shed over a 24-hour period was reduced by 16.5%
  • Hairs remaining in the anagen growing phase increased by 6.4%

For those currently using topical Rogaine, Nizoral can also be beneficial to reduce itchiness or dryness resulting from the Rogaine.

So, for any hair loss sufferer, the research suggests that regular use of Nizoral will in many cases have a positive effect on hair growth.


Medical treatment is best for those in the early stages of hair loss, those whose focus is to stop further loss, or in combination with a hair transplant.

In my opinion, people with extensive hair loss will, in most cases, get no benefit from medical treatment other than to delay further hair loss.

Rogaine is a topical solution applied to the scalp, for use by both men and women. Possible side-effects include unwanted facial hair growth, scalp irritation and irregular heartbeat.

Propecia is a drug taken in tablet form, suitable only for men. Possible side-effects include reduced sex drive, erectile dysfunction and decreased semen volume.

Saw Palmetto is a naturally occurring plant extract believed to be an herbal form of Propecia. It has not been proven in clinical trials.

Nizoral is an over-the-counter anti-dandruff medication whose active ingredient is an anti-androgen that can be beneficial for treating hair loss.