In a recent post, we discussed the use of topical finasteride (Propecia) and went through the benefits and limitations of this agent. A recent study published by Haber et al. in the Hair Transplant Forum International looked at 762 men (663 on oral finasteride and 99 not on oral finasteride) and assessed whether or not they experienced any sexual dysfunction. The short answer seems to be that there was no evidence of increased sexual dysfunction in this study, which supports a previous systematic review of the literature that also did not show any evidence of increased sexual dysfunction from the use of oral finasteride.
Based on these studies, it seems that we can be even more confident about the lack of sexual side effects from the use of oral Propecia in male pattern hair loss. We will therefore continue to prescribe Propecia in the management of male pattern hair loss.
The first study on topical finasteride was done in 1997 and showed a decrease in rate of hair loss at 6 months.
In 2009, another study compared topical finasteride to oral finasteride. This study was a double blind, randomized clinical trial. Both topical and oral led to increased hair counts, although the increase occurred 1 month earlier with oral finasteride. Another difference between the two groups was that the size of the area of hair loss decreased by the fourth month of treatment in the oral finasteride group, whereas there was no significant change in the topical group.
In 2018, Lee et al. reviewed 7 studies that looked at the use of topical finasteride for the treatment of pattern hair loss in men and women. They looked at several concentrations, including finasteride 0.005%, 0.25%, and 1%. The good news is that they all showed some efficacy with limited systemic effects. Overall, topical 0.25% finasteride solution applied once a day seemed to be the most effective. The downside is that topical finasteride did cause some scalp irritation in some participants, which could be a limiting factor for some patients. It is not clear if the irritation came from the finasteride itself or from one of the other components in the solution.
Number of Grafts: 407 Areas Treated: Right retroauricular region, right temple, and mid frontal region Number of Procedures: 1 Type of Surgery:Follicular Unit Excision (FUE)
This friendly gentleman came to see Dr. Nakatsui regarding a bout of scarring alopecia that occurred over 20 years ago. He had no complaints or issues with hair thinning, rather just 3 areas of scarring alopecia. The patient advised us that he had surgery elsewhere where the surgeon excised a portion of scar. This led to a linear scar line. When dealing with hair transplants into a scar region, we know that approximately 80% of the hairs will grow and survive whereas transplanted hairs into virgin scalp will have a success rate of approximately 96-98%. The patient was made aware of the decreased survival rate and still proceeded with the surgery. Ultimately, the end result is very natural, thick, and blends in well with his surrounding hair.
Hairs come in different angles and directions all throughout the scalp. The angle the hair will be different in the front of the scalp compared to the back of the scalp. The in the retroauricular region (behind the ear), the angle of the hair is fairly flat and facing downward. If hairs were transplanted perpendicular to the natural angle of the hair, the end result will be very unnatural. For more of Dr. Nakatsui’s before and after results, please click here.
Number of Grafts: 3,000 Areas Treated: Hairline and Frontal Region Number of Procedures: 1 Type of Surgery: Follicular Unit Transplant (FUT)
This gentleman came in with progressive hair loss throughout his scalp. Dr. Nakatsui transplanted approximately 3,000 grafts for his final result. The nice thing about this patient is that he grew out his hair demonstrating that hair transplanted hairs grow just like regular hair because it is natural hair. To view more of Dr. Nakatsui’s before and after photos, please click here.
Areas Treated: Hairline and temples and mid region.
Number of procedures: 1
Type of surgery: Strip (FUT)
This gentleman came to our centre with recession to his hairline that extended back to his mid scalp. Dr. Nakatsui transplanted approximately 3,000 grafts for the final result. Close examination of the hairline demonstrates the absolute importance to angle and the use of follicular units (the very basic units of hair) when performing a hair transplant. The wonderful thing about hair transplant surgeries is that, once the transplant is complete, the hairs are generally permanent. They will act the same way as the hair from the back of your scalp; meaning they will grow at the same length and change colour at the same time generally. The best part about hair transplant surgery is that, it is your hair. To view more of Dr. Nakatsui’s before and after photos, please click here.
Number of Grafts: 2,200 Areas treated: Vertex and temples Number of procedures: 2 Type of surgery: Follicular Unit Excision (FUE)
This young man came to our clinic complaining of thinning to his vertex (crown) and his temples. After going through the options, he opted to have follicular unit excision surgery (FUE) because he did not want any noticeable scars on his scalp. Using the FUE method, Dr. Nakatsui transplanted 2,200 grafts into the vertex and temples.
At our centre, when a FUE surgery is performed, Dr. Nakatsui makes every tiny incision around every follicular unit graft. At many other clinics, technicians or sometimes robots perform this aspect of the procedure. Dr. Nakatsui prefers to perform this aspect of the procedure himself as the donor hair can change angle below the surface of the skin. If care is not taken and change in angle is not accounted for, the risk of transecting (cutting through) a graft increases, thereby rendering the graft unusable. Learn more about follicular unit excision (FUE) here. For more of Dr. Nakatsui’s results, please click here.
This patient experienced recession to the frontal aspect of his scalp. As with any hair transplant surgery, angle and direction of transplanted hairs is of utmost importance. Dr. Nakatsui transplanted approximately 2,400 grafts and followed the patients specific hair directions throughout the frontal region. In the photos seen from the various angles, care and precision were important in order to produce a natural looking result.
For more before and after results, please click here.
This is a patient who came in and was concerned about the progressive thinning of his hair. We decided to fill in the frontal scalp as it was this area that concerned him. He received 596 single grafts, 1440 double grafts, and 536 big grafts, for a total count of 2572 grafts. He is ecstatic about his results so far and his post op photos are about 11 months out. The anticipation is that the hair will become slightly thicker over the course of a few months from when these photos were taken.
FYI, the patient’s preoperative photos show that his hair is dyed brown. We had asked him to do this so we could make the recipient sites without damaging his pre-existing, very, very white hair.
For additional before and after photos, please click here.
Finasteride (Propecia) is a medication that has been used for years for the management of male pattern hair loss. It is a 5-alpha reductase inhibitor, which decreases levels of dihydrotestosterone (DHT). The pivotal studies showed significant benefit for men with respect to slowing down hair loss. In addition, a meta-analysis (an analysis of multiple studies on the same subject) by Gupta and Charrette showed that 5-alpha reductase inhibitors are significantly more effective than placebo in increasing hair counts.
2. It does have sexual side effects but it is not high risk
A very common question is about the sexual side effects of Propecia. Sexual side effects from finasteride have been well-described and include erectile dysfunction and decreased libido. However, the true risk of adverse sexual side effects remains controversial. Some meta-analyses show an increased risk and some show no increased risk. However, a recent 2018 report published by Lee et al analyzed randomized, double-blind, placebo-controlled trials (the best kind) and found 15 such trials. The data from these studies were analysed together in a meta-analysis. The relative risk was approximately 1.66. In layman’s terms, if 1 out of 100 untreated people were expected to develop sexual side effects, then 1.66 out of 100 treated people would be expected to develop these side effects. This is not a huge increase. A recent study suggests there is no increased risk at all.
3. It only works as long as you take it
I frequently get asked “What happens if I stop taking Propecia?” Unfortunately, the benefits only last as long as finasteride is being taken. Studies show that hair counts drop back to pre-treatment levels within one year of discontinuation of the medication. On the other hand, you can stop it anytime you choose. You don’t have to take the medication any longer than you want to. If you decide six months from now that your hair loss is not an issue anymore, you can stop it completely with no ill effects.
