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Q. Is topical medication better than oral medication in treating androgenetic alopecia?

Answered by
Dr. Dhepe Snehal Laul
and medically reviewed by Dr. Infanteena Marily
This is a premium question & answer published on Feb 24, 2022

Hello doctor,

I am 34-year-old and have been suffering from androgenetic alopecia since my early twenties, causing social anxiety and depression. Finally, I was able to successfully fight further loss and regain a few of the already lost hair by getting on tablet Finasteride First 1 mg (finasteride) every other day. After two years, there was no further improvement. I have been on it successfully for over eight years without ever experiencing any side effects. But, unfortunately, did not start early enough with the treatment. I could not get all my hair back and have a higher hairline as well as my crown is thinned out on a small spot (Norwood 2 to 3 vertex) what concerns me the most for a long time. So I visited a hair restoration surgeon who told me he could only do surgery on my hairline since the crown is still full of too many more or less miniaturized hair. He prescribed me topical Dutasteride for regaining more hair thickness and regrowth. But after reading about the possibility of androgen receptor upregulation on 5ARIs, what means they can stop being effective if you block almost all DHT (oral Dutasteride reduces it approximately 94%, Finasteride only 60 to 70%) production and some stories of people having adverse effects like more hair loss on them made me worrisome. Is the so-called reflex hyperandrogenic a justified concern or just an internet rumor, and if not, how can I reduce or check the risk of it appearing? It would be disastrous for me if I lose more hair again and, in the end, perhaps have to quit all 5ARIs to downregulate the androgen receptors again. Please help me.

Thank you.

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Hello,

Welcome to icliniq.com.

I understand your concern. Androgenic Alopecia is due to sex hormone imbalance and is also genetic. An increase in DHT (Dihydrotestosterone) causes shortening of the hair growth cycle and delays new hair growth. The causes of male baldness are hormonal imbalance, insufficient protein intake, iron deficiency, autoimmune disorder, aging, hairstyles, cosmetic hair procedures, rough handling, drug usage, injury or burns, radiation, and chemotherapy. Tablet Finasteride (Propecia or Proscar) oral preparation blocks DHT. Side effects are chills, rigors, and erectile dysfunction. Topical Dutasteride inhibits DHT, and another option is topical Spironolactone. To help you better, I would suggest the following:

1) Consume Zinc-fortified cereals.

2) Drink lots of water.

3) Drink green tea.

4) Do not take caffeine, tea, or soda.

5) Consume oranges, avocado, carrot, yogurt, sweet potato, salmon, spinach, green vegetables, eggs, and chicken.

6) Manage your stress and anxiety.

7) Scalp massage with aloe vera gel and onion juice extract can help.

8) Stop smoking (if applicable).

Other therapies like derma roller plastic, low-level laser therapy to stimulate the growth of hair follicles, stem cell therapy or fibroblast growth factor, hair transplant FUT (follicular unit transplantation), and FUE (follicular unit extraction) under local anesthesia are options.

Attach clinical picture to assess scalp hair density and type of hair loss to guide you further.

Thank you.

Thank you doctor,

I just wanted to know whether there is the chance of loss of effectiveness of 5 alpha-reductase inhibitors and an increase of hair fall if I add topical Dutasteride to my oral Finasteride treatment and block almost all DHT production? Please advise.

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Hello,

Welcome back to icliniq.com.

The efficacy of topical Dutasteride is more as compared to tablet Finasteride. The side effects of both are the same as mentioned previously. It will not cause reflex hyperandrogenicity. I suggest 0.5 percent topical Dutasteride for 12 to 24 weeks to show effective results. To guide you better, please follow-up with the following:

1) Do you have an itchy scalp?

2) Do you have greasy scales on the erythematous base?

3) Is it Seborrheic capitis?

4) Any dandruff issues?

Thank you.

Thank you doctor,

What gives you the certainty an androgen receptor upregulation can not appear? Do you have experience with similar cases and prescribing a combination of Finasteride and Dutasteride? Is reflex hyperandrogenicity on 5ARIs medically possible? Have I already stopped the acute hair loss by inhibiting around 70% of my DHT production with tablet Finasteride and depriving my system of perhaps all the remaining DHT with adding topical Dutasteride could be risky? I want to be sure of my new treatment. Yes, after using a topical containing alcohol, I am experiencing mild seborrhoeic dermatitis and dandruff. I will perhaps add Nizoral shampoo with Ketoconazole if my natural treatment with apple cider vinegar, and aloe vera juice is not working.

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Hello,

Welcome back to icliniq.com.

Reflex hyperandrogenicity is not yet well studied and documented. It occurs at higher doses or due to atypical patient response in very few patients. Also, this phenomenon is extremely rare. The attached pictures (attachments removed to protect the patient's privacy) show hair thinning with patterned balding over bitemporal and vertex areas. Androgenic alopecia has a gradual onset with patterned thinning. This can be due to genetics, systemic hormonal effects due to androgens, local hormonal effects-increased local production of DHT, or reduced local degradation of DHT, the role of oxidative stress, hair cycle dynamics. Evolving therapies include platelet-rich plasma, microneedling, low-level laser therapy, Botox injections of 150 U injected all around scalp muscle. Topical Dutasteride inhibits type 1 and type 2 isoenzyme of 5 alpha-reductase, which is more potent than Finasteride. Efficacy of tablet Finasteride decrease serum DHT by 70 percent, compared to Dutasteride, Tablet Finasteride reportedly reduces scalp DHT by only 34 to 41 percent. In contrast, topical Dutasteride decreases serum DHT by more than 90 percent. I hope this helps.

Thank you.

Thank you doctor,

I have also already read that it appears rarely. Why is it also not yet studied? Even if receptor upregulation seems to be a logical and common physiological pathway to restore hormonal balance and efficacy, I found two studies about androgen receptor expression in prostate (cancer) cells treated with Finasteride confirming it but also one debuting it by even measuring a partial downregulation. If someone has it, it possibly just can be cured by the withdrawal of any 5 alpha-reductase inhibitors over several months while having accelerated alopecia, I have read, which would be disastrous. So I will be better safe than sorry and try to exclude any possible risk occurring.

Do you already know how it can be determined if someone is prone to it? Should I get my hormonal levels checked? I got recommended using 2 ml of 0.1% of Dutasteride trichosol solution first once and after a month without side effecrs twice a week in addition to continuing my oral Finasteride 1 mg therapy. Would you somehow change the dosages or proceed only with one of the treatments as you wrote you would suggest (topical) Dutasteride? Did you use it successfully on your age patients?

But since I have read that Dutasteride seems to be known for a little higher rate of gynecomastia development in patients than Finasteride, I should perhaps also mention that I have already tried out a bunch of different alternative treatments, including oral Saw Palmetto tablet together with Finasteride tablet 1 mg until I developed a slightly enlarged mammary gland on my right chest and so had to quit the Saw Palmetto tablet for fortunately again losing it.

Considering this and with Dutasteride inhibiting both isoenzymes I and II of the 5-alpha reductase just like tablet Saw Palmetto but much more potent and longer-lasting, would you still recommend it for my case? How much does Dutasteride lower scalp DHT? I know about it achieving a reduction of more than 90% in the serum. If oral treatments lower serum levels more than scalp levels, do you have any data or experience if topical aRI- application has higher efficacy than oral medicine?

Looks like trouble, I have already tried with an at-home device without much success. Unfortunately, it gave me shock loss on my temple points which the photos from last time. I have sent you are not yet showing. Still, eventually, I would try it again at a specialized physician, microneedling. So I think I would instead consider the idea of botox injection into the scalp. But at first, I want to stick with the more promising DHT reduction therapy.

Regarding seborrheic dermatitis, I already use Nizoral 2% shampoo. But as it only appeared after more prolonged usage of an alcohol-containing topical. On my relatively dry scalp and the usage of apple cider vinegar and aloe vera juice already seems to reduce the redness, itch, and dandruff significantly, I would look at first try to avoid the shampoo with all its harsh ingredients (sulfates, parabens, etc.) until symptoms are continuing or worsening.

#

Hello,

Welcome back to icliniq.com.

I would suggest you get a hormonal assay done. Oral Dutasteride is more effective than topical.

Get a prescription from your local dermatologist as he knows about your previous treatment details and dosage.

Thank you.


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