Author: Dr. Ben Behnam, MD FAAD
Board Certified Dermatologist
The gold standard for hair loss has always been oral finasteride, also known as Propecia(R). However, over the last several years, many physicians have stopped prescribing oral finasteride due to the risks of sexual side effects, which may be permanent in some cases. Doctors have started to look into other alternatives to oral finasteride and this is why the popularity of topical finasteride has surged in the last 4 years. This article will use evidence based medicine and the current clinical studies available to evaluate the safety and efficacy of topical finasteride.
Oral Finasteride is an oral pill that has been prescribed by physicians for decades for hair loss. It works in the majority of patients in stopping hair loss and growing hair however there are side effects. The popularity of oral Finasteride has been decreasing due to its sexual side effects, which occur in 1.8% to 3.8% of patients who take it. The majority of cases of these sexual side effects are temporary, which means that the side effects will resolve once the patient stops taking the oral medication. However, according to the FDA, there are some cases where the side effects can be permanent. Examples of sexual side effects of oral Finasteride include decreased libido, erectile dysfunction, testicular pain, testicular numbness, penile curvature changes, lack of morning erections, decreased ejaculate, decreased sperm count and any form of sexual dysfunction. Other side effects of oral Finasteride include breast enlargement, depression, fogginess of head, and diabetes (please note that this is not a complete list).
Topical finasteride is a compounded medication prepared by compounding pharmacies. It doesn’t exist commercially in the US market. This means that it is not a product that is available right off the shelf. It’s a formula that has to be written specifically by your physician and the compounding pharmacy has to make it monthly. A review of the literature on Pubmed shows that there are so far about 67 articles, case studies, and clinical trials on topical finasteride worldwide. This article will review some of those articles examining efficacy and safety of topical finasteride compared with oral finasteride.
In a clinical trial of 45 male patients comparing the therapeutic efficacy of topical finasteride vs oral finasteride1, the study showed that the therapeutic effects of both finasteride gel and finasteride tablets were relatively similar to each other. There were no significant differences between the two groups as a viewpoint of hair thickness, hair counts and the size of bald area. This the authors concluded that there were similar increase in hair counts and terminal hair counts between the two groups.
In another study of 50 patients who were on oral finasteride, 84.4% of those patients showed good maintenance of hair density while switching over from oral finasteride to a topical finasteride + minoxidil combination2. This study showed that patients don’t have to be on oral finasteride forever; topical finasteride was a good alternative in maintaining the results of the oral finasteride.
In a systematic review of 119 studies involving topical finasteride studies, authors concluded that topical finasteride showed a significant decrease in the rate of hair loss, increase in total and terminal hair counts, and positive hair growth assessment. No changes in serum testosterone were noted3.
Finasteride works by inhibiting conversion of testosterone into DHT. When finasteride is taken orally, it reduces scalp DHT by ~50% but it also affects serum DHT by around 60-70%. This study showed that oral finasteride significantly reduces systemic DHT levels. In contrast, topical finasteride applied at certain dosage resulted in an appropriate inhibition of scalp DHT (47-52%), while serum DHT level reduced only by 24-26%, potentially minimizing the untoward sexual side-effects linked to a systemic DHT reduction4. Since topical finasteride is not taken orally, its effect on serum DHT may be less, according to this study, thus potentially reducing the unwanted sexual side effects.
In another study comparing minoxidil 3% vs Minoxidil 3% fortified with topical finasteride, the authors stated that global photographic assessment showed significantly greater improvement in the group where minoxidil was fortified with finasteride compared to minoxidil alone by itself5. More importantly, at 24 weeks, the authors concluded that using topical .1% finasteride did not show any sexual side effects.
Topical Finasteride has clinically proven, evidence-based, scientific data to show its efficacy in growing hair while lowering the risk of systemic side effects since it is not taken orally. Topical Finasteride is a compounded medication that is prescribed by a doctor. Sometimes it is used alone by itself or it can be fortified with other medications such as Minoxidil, Retinoic Acid etc. to boost efficacy.
1. Comparing the therapeutic effects of finasteride gel and tablet in treatment of the androgenetic alopecia. Hajheydari Z1, Akbari J, Saeedi M, Shokoohi L.; Indian J Dermatol Venereol Leprol. 2009 Jan-Feb;75(1):47-51.
2. Topical minoxidil fortified with finasteride: An account of maintenance of hair density after replacing oral finasteride.; Chandrashekar BS1, Nandhini T1, Vasanth V1, Sriram R1, Navale S1. Indian Dermatol Online J. 2015 Jan-Feb;6(1):17-20. doi: 10.4103/2229-5178.148925.
3. A Systematic Review of Topical Finasteride in the Treatment of Androgenetic Alopecia in Men and Women.Lee SW, Juhasz M, Mobasher P, Ekelem C, Mesinkovska NA.; J Drugs Dermatol. 2018 Apr 1;17(4):457-463.
4. Effects of a novel finasteride 0.25% topical solution on scalp and serum dihydrotestosterone in healthy men with androgenetic alopecia. Caserini M, Radicioni M, Leuratti C, Terragni E, Iorizzo M, Palmieri R.; Int J Clin Pharmacol Ther. 2016 Jan;54(1):19-27.
5. Efficacy and safety of 3% minoxidil versus combined 3% minoxidil / 0.1% finasteride in male pattern hair loss: a randomized, double-blind, comparative study. Tanglertsampan C1.; J Med Assoc Thai. 2012 Oct;95(10):1312-6.
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The information in this article does not constitute medical advice and should only be used for informational purposes only. The information in this article is not a substitute for professional medical advice and please do not rely on this information to make medical decisions. Please make sure to discuss the risks and benefits of any treatment with your medical doctor before beginning treatment.