Analysis of Hair Loss Treatments: The Verdicts

As I discuss in a previous post, it is important to be skeptical of the numerous “treatments” for male pattern hair loss that are available on the market, and to only invest in treatments that are supported by science.  Otherwise, you will be wasting your money and will experience no positive results.  In this post, I will examine a number of products and treatments and assign a “verdict” to each one, indicating whether they have been demonstrated to be effective or not.  This list continues to grow, as I become aware of new products on the market.  If there are any you don’t see here, feel free to suggest one.

Image from http://www.stacaravansgids.nl.

A good philosophy to have when evaluating hair growth products is “guilty until proven innocent.”  In other words, unless and until sufficient studies and clinical trials demonstrate the effectiveness of a treatment on male pattern baldness specifically, one should remain skeptical of that treatment.  So without further ado, here are some of the treatments for hair loss out there and whether or not they are effective for male pattern baldness:

The Good: Backed by Science

For the scientific papers supporting these treatments, see this post.

Finasteride (includes Propecia and Proscar)
Minoxidil (includes Rogaine)
Ketoconazole 2% Shampoo
Low-level laser therapy (LLLT)
Dutasteride (includes Avodart)
Topical Finasteride (see this study.)

The (Probably) Effective: Backed by Some Promising Scientific Studies So Far

Viviscal (Supplements).  Studies have shown that Viviscal improved hair growth in both women and men who were experiencing thinning hair (also see here).  Thus, it does seem to have some effectiveness, but more testing needs to be done, in my opinion.

Plasma-Rich Platelet (PRP) Therapy.  This is a surgical treatment that must be done at a hair restoration clinic.  While it is still in the early stages of testing, some studies have shown that it has an effect on hair growth in men experiencing male pattern hair loss (see here and here, for example).  This procedure is expensive (on the order of $1000 per injection), however, and requires multiple injections over time (every 1 -2 years).

The Possible: May Have a Mild Positive Effect, but Still Largely Untested

Alpecin Caffeine Shampoo.  Some studies have shown that it has a positive effect on hair growth, but its overall effectiveness and ability to slow or stop male pattern baldness is unknown and probably insufficient.  See this post for more information.

Cimetidine (Oral Medication).  A study has shown that it is effective against female pattern baldness (see here), but it has not been tested on male pattern baldness.

Flutamide (Oral Medication).  Studies have shown that this antiandrogen can mildly improve hair loss in women (see here), but it has not been tested for its effectiveness against male pattern baldness.

Niacin.  Definitely helps promote hair growth in females experiencing androgenetic hair loss, but no studies have been done showing that it helps male pattern baldness.

Spironolactone (Oral Medication).  Studies have shown that this antiandrogen can stop or reverse hair loss in women (see here, for example), but it has not been tested for its effectiveness against male pattern baldness.

The Ineffective: May Help Hair in Other Ways, but Won’t Stop Male Pattern Baldness
(In Alphabetical Order)

Biotin.  May help with general hair growth, but no clinical trials have been conducted that show it can effectively counter male pattern baldness (as this study points out).  Biotin deficiency could be a cause of hair loss in some cases (paper), but if the cause of hair loss in a specific case is male pattern baldness, there is no established evidence biotin can help.  Biotin does seem to have some good reviews by users on WebMD, however.

Castor Oil.  Untested on male pattern baldness, but may have anti-inflammatory properties.

“DHT-Blocking” Shampoos or Topical Formulas.  May contain some good ingredients that combat DHT, but no studies have shown specifically that the shampoos can effectively and consistently lower DHT levels to the extent that would slow or stop male pattern baldness (in contrast to ketoconazole, which blocks DHT and has been shown to counter male pattern baldness.  See above).

Folicure.  Does not appear to contain ingredients that block DHT.  Even if it did contain such ingredients, it would fall under the same category as DHT-Blocking Shampoos: its ability to reduce DHT to the extent that male pattern baldness is slowed or stopped has not been tested.

Hairomega (Supplements).  Contains some ingredients such as niacin and saw palmetto, neither of which have been proven to significantly counteract hair loss in men (see above and below).

Nanogen Hair Growth Factor (or Serum).  Does not contain ingredients that counter DHT, the cause of hair loss in men.  More importantly, it has not been tested independently for effectiveness against male pattern baldness.  It may help thicken hair in other ways.

Nizoral 1%.  Contains 1% ketoconazole, similar to Regenepure.  While Nizoral 1% has been shown to reduce shedding, it does not increase hair density in those experiencing male pattern baldness.  The concentration that helps with male pattern baldness is 2%.

Regenepure. Contains 1% ketoconazole, which slightly reduces DHT and is good for shedding, but does not increase hair density in men with male pattern baldness.

Revivogen Scalp Therapy & Shampoo.  Falls under the category of DHT-Blocking Shampoos & Formulas: hasn’t been tested enough.  In addition, the reviews on Amazon.com are mixed.

Saw Palmetto.  A study showed that 320 mg/day of saw palmetto reduced prostate DHT levels by 32% after six months.  (Finasteride reduced DHT by 80% in the study.)  However, saw palmetto did not reduce blood levels of DHT.   Thus, it is questionable whether or not it would have any effect on male pattern baldness.

Helpful – But Not Sufficient – Tools

In the fight to counteract the natural process of hair loss and maintain hair growth, it is wise to invest in one or more of the scientifically supported tools such as finasteride, minoxidil, and/or low-level laser therapy, rather than spending money on just any so-called “solution” promoted by infomercials, nutrition shops, or the Internet.  The truth is, most shampoos, supplements, and devices claimed to help hair loss are not scientifically supported, and will probably be a waste of money.  However, it turns out that there are two products which, although possibly not strong enough on their own to counter hair loss, actually produce a measurable effect on reducing hair loss.

Image from fitnessaims.com. There are a lot of hair loss “products” out there on the market; don’t be fooled by ones that are not backed by research.

 

Ketoconazole (2%) Shampoo

Probably the most important “small” but effective tool in this regard is a type of shampoo known as ketoconazole shampoo, an antifungal agent that is usually marketed for controlling dandruff.  One of the most common brand names for this shampoo is Nizoral, which you can pick up from your local drugstore.  The good news for those who experience hair loss is that this substance has been demonstrated to suppress the activity of androgens such as DHT, the hormone that causes hair loss.  Several scientific papers have discussed this:

Reversal of androgenetic alopecia by topical ketoconazole: relevance of anti-androgenic activity, Journal of Dermatological Science.

A Prospective Randomized Trial Comparing Low Dose Flutamide, Finasteride, Ketoconazole, and Cyproterone Acetate-Estrogen Regimens in the Treatment of Hirsutism, Journal of Clinical Endocrinology & Metabolism.

Interestingly, while the second study has nothing to do with hair loss in men, it does show that ketoconazole hinders the effects of the hormone responsible for hair loss, DHT.  Have studies been done specifically on the effectiveness of ketoconazole on stopping hair loss in men?  Yes, and so far, the results are promising:

Ketocazole as an adjunct to finasteride in the treatment of androgenetic alopecia in men

Comparative efficacy of various treatment regimens for androgenetic alopecia in men

Ketoconazole shampoo: effect of long-term use in androgenic alopecia

In each trial, it was found that 2% ketoconazole shampoo effectively reduced the activity of DHT and had a positive effect on hair growth in men experiencing male pattern baldness.  In the last study, ketoconazole alone produced the same effect on hair growth as 2% minoxidil.  (However, note that the more commonly used concentration of minoxidil today is 5%, which is a stronger solution.)  Interestingly enough, the “hair density” increased by a greater percentage in those who used ketoconazole compared to those who used 2% minoxidil.  In the group of men using ketoconazole, the density started at 250 hairs/cm^2 and increased to 296 hairs/cm^2 at the end of the six-month trial, which is a (296 – 250)/250 = 0.184 = ~18% increase.  In the group of men using 2% minoxidil, the density started at 276 hairs/cm^2 and increased to 306 hairs/cm^2 at the end of the trial, which is a (306 – 276)/276 = 0.0108 = ~11% increase.  (You can read about the details in the full paper.)

In addition, unlike the 2% minoxidil, ketoconazole was found to decrease the activity and amount of DHT on the scalp.  Of course, more studies need to be done to further confirm these results.  There are important things to note about this tool, however:

1. The researchers used a 2% concentration of ketoconazole in the experiment.  Over-the-counter shampoos such as Nizoral often only hold a 1% concentration, which seems to effectively stop shedding and increase hair shaft diameter, but not increase hair density.  Thus, the most effective tool would be a 2% ketoconazole shampoo rather than a 1% shampoo.
2. In the experiments, the shampoo was applied 2 – 4 times each week.
3. The shampoo was used for at least six months, and up to 21 months in one study.

It appears that 2% ketoconazole shampoo is an effective tool for combating the process of hair loss.  In addition, it is relatively inexpensive, compared to the other treatments such as minoxidil, finasteride, and low level laser therapy.  Furthermore, it only needs to be applied three or four times per week.  Overall, it seems to be a good tool to include in the arsenal.  However, as with all tools for fighting hair loss, it has to be used consistently and indefinitely, since the hair loss process is always “fighting” to weaken the hair follicles.

Caffeine Shampoo?

Another substance that does not have quite as much research supporting it, but seems to definitely have positive effects on hair growth, is caffeine, and specifically a caffeine-fortified thickening shampoo known as Alpecin, made from a formula developed by Dr. Kurt Wolff, a dermatologist from Germany.

One study was conducted and showed that caffeine delivered to the scalp has a positive effect on hair growth, and counters the negative effects of testosterone on hair:

Effect of caffeine and testosterone on the proliferation of human hair follicles in vitro, International Journal of Dermatology.

Image from http://www.alpecin.de. Caffeine complex in Alpecin shampoo seems to at the very least reduce the negative effects of testosterone on the hair follicles.  However, this study did not look at the effects of caffeine on DHT, which is the more important hormone when it comes to hair loss.

Another study specifically tested the caffeine-fortified Alpecin shampoo on those who experience male pattern baldness, and found a positive effect at the end of six months of consistent use:

Efficacy of a cosmetic caffeine shampoo in androgenetic alopecia management

While this study is interesting, it is important to note that the results were based on SELF-analysis of the participants.  In other words, unlike the studies supporting ketoconazole, the results weren’t based on precise measurements by experimenters on hair density and other factors, but on the self-reports of those who used the shampoo.  However, that doesn’t mean the results are useless; after all, if the person experiencing hair loss notices an improvement, that definitely counts for something.  At the same time, it is hard to know how effective this treatment is overall on the process of hair loss, and whether or not it actually slows or stops hair loss long-term.  In my personal experience, this shampoo produces immediate positive thickening effects, and seemed to even keep my hair thick over time.  However, while using it, I still did notice my hair loss continue to progress.

Overall, both 2% ketaconazole shampoo and caffeine-fortified Alpecin shampoo seem to be effective, inexpensive tools for managing hair loss and even increasing hair growth.  However, they need to be used properly and consistently.  Are one or both of them sufficient on their own to stop hair loss?  It is hard to say.  However, at the very least, they do seem to help in a way that is measurable.

Restore Hair that was Lost

Perhaps you have already lost a substantial amount of hair, and want to gain that hair back and have a full head of hair again. Or perhaps you have just lost a small amount of hair and are already taking steps to halt hair loss, but you still want to restore your hairline to where it was previously. Using methods that slow down or stop hair loss (such as finasteride, minoxidil, low-level laser therapy, etc.) will not cause new hair to grow in completely bald areas. Thus, in order to bring your hairline back to where it was originally or fill in the top of your head after it has gone bald, you essentially have two options:

Hair Transplant Surgery. A hair transplant surgery involves extracting hair from the back and sides of the head (where the hair is resistant to the effects of DHT) and transferring that hair to the bald areas of your head. Since the hair comes from a region where DHT cannot affect it (called the “donor site”), the new hair will grow permanently. There are two types of hair transplant surgery: FUT (Follicular Unit Transplantation), which involves harvesting and transplanting strips of hair, and FUE (Follicular Unit Extraction), which takes smaller, individual “packets” of hair. FUT is less expensive, but it leaves a permanent linear scar on the back of the head, which usually can be covered up with the hair that remains.

This is an excellent way to restore hair to areas of your head where hair was lost. However, note that the amount of hair you can use is limited by the amount of hair available on the back of your head. Thus, you may not be able to completely restore ALL of the hair you once had (depending on the stage of baldness you are at), but a hair transplant will most definitely improve the amount of hair you have.

Another thing to be aware of is the possibility of “shock loss.” Shock loss is the shedding of hair that occurs due to the effects of the surgery. Many times, the hair loss is temporary and the hair grows back. You need to be aware of the possibility of shock loss (and that you may permanently lose that hair), and make sure you thoroughly question a potential hair transplant surgeon on your personal risk for that.

Hair Replacement. Hair replacement does not have the same restrictions or risks that a hair transplant does, since hair replacement is non-surgical and there is an unlimited supply of hair available. It involves a hair “system” that is installed on your scalp and grows. The system is composed of real human hair that grows along with your real hair. It requires maintenance at a clinic roughly once every month. This is a great option if you want to completely restore your “full head of hair” look and restore your hairline to exactly where it was before you started experiencing hair loss. However, it is less natural than the hair transplant option, since it does not involve your own hair.  This video shows a good example of someone who has used a hair replacement system to restore his hairline before going mostly bald.

As noted, hair replacement does not have the same risks that a hair transplant surgery does. That is why you need to be more cautious when considering hair transplant surgery than you do if you just want a non-surgical hair replacement. When planning a hair transplant surgery, choose a surgeon with:

Many years of experience specifically in hair transplant surgery.
A good “Before & After” photo gallery with results that YOU like.
Board-certification in cosmetic surgery (at least), member of American Board of Hair Restoration.

Also, check out more than one hair transplant clinic and talk to various surgeons before moving forward. Probably the biggest risk you need to be concerned about is the possibility of permanent “shock loss” of hair you still have after receiving a hair transplant surgery. In many cases, the hair will grow back, but it is still possible that it won’t. Talk to a surgeon about this as well before moving forward.

There are many, many men who have experienced hair transplant surgery and are very satisfied with the results, so this could be a great option if you want to restore some of the hair you lost. If you don’t want the risks of hair transplant surgery and you don’t want any restrictions on the amount of hair needed, you can try the non-surgical hair replacement system. However, it will not be as natural as a hair transplant because it does not contain your own hair growing in your scalp naturally.

Maintain Current Hair (Stop Hair Loss from Continuing)

NOTE: This article discusses low-level laser therapy (LLLT) as an option for treating male pattern baldness.  This treatment is included because several scientific studies have shown that it is effective, which are referenced.  However, in my personal experience, I have only received benefit from using a 272-diode laser cap in conjunction with minoxidil.  I tried the Theradome laser cap (which contains 80 diodes) on its own for six months, and it did not stop the progression of my hair loss.  This suggests that either it is not powerful enough, it is a poor device, or my hair does not respond to low-level laser therapy.

 

There are two ways to address the root cause of hair loss in men: inhibit (block) the production of DHT, the chemical that causes hair loss, and/or stimulate hair growth to offset the effects of DHT. Either method will slow down or stop the process of hair loss, but it won’t create new hair on completely bald spots. To replace hair where it has been lost, you need to get a hair transplant or hair replacement system.

In general, it is a good idea to use at least one inhibitor in combination with at least one “stimulator” in your regimen for countering hair loss, as that will increase the effectiveness of your treatment.  A study showed that men who used both minoxidil (a stimulator) and finasteride (a DHT inhibitor) in combination experienced more benefit for their hair than men who used only one or the other on its own.

Inhibitors

One way to halt the process of hair loss is to slow down or block the production of DHT, the root cause of hair loss.

1.  Topical Ketoconazole.  As of now, the cheapest way to slow down and possibly stop hair loss is to use 2% ketoconazole shampoo 2-4 times per week.  As the link I just posted discusses, scientific studies have demonstrated that it blocks the activity of DHT on hair loss.  Those studies also show that it had a positive effect on hair growth in men experiencing male pattern baldness after six months of use.

There are two other well-tested “blockers” (inhibitors) of DHT out there on the market.

2. Finasteride (generic or Propecia) and dutasteride (generic or Avodart).  Finasteride is a FDA-approved prescription drug that is taken orally. Finasteride has been found to slow DHT production and hair loss, in multiple scientific studies:

Finasteride in the treatment of men with frontal male pattern hair loss

Clinical dose ranging studies with finasteride, a type 2 5α-reductase inhibitor, in men with male pattern hair loss

Efficacy and tolerability of finasteride 1 mg in men aged 41 to 60 years with male pattern hair loss

Finasteride in the treatment of men with androgenetic alopecia

Because there is so much research backing up the effectiveness of finasteride, this product is a good example of something that is science-based rather than hype-based. Thus, it will most likely not be a waste of money in your plan to deal with hair loss.

Note: Finasteride/Propecia may have side-effects of erectile dysfunction or decreased sexual drive. It is up to you whether or not you want to take that risk in order to control hair loss. You can opt to skip finasteride and try other strategies if you want to avoid that risk.*

To obtain Propecia or generic finasteride, simply go to your doctor or to a hair restoration clinic and ask for a prescription.

Dutasteride (generic or Avodart) is another prescription drug that significantly reduces the production of DHT. However, you should be aware of possible side effects, just as with finasteride.  You should also not take both dutasteride and finasteride over the same period of time; only one of the two should be taken at a time.

 

Stimulators

Another way to halt the process of hair loss is to over-stimulate growth in the hair follicles in order to overcome the weakening effects of DHT on hair.  Using a stimulator in combination with an inhibitor will provide an even stronger effect than using only one of the two (as the study I mentioned above suggests).  There are a few stimulators currently available on the market that seem to be supported by scientific studies:

1. Rogaine (or generic minoxidil). This is an FDA-approved over-the-counter topical solution that has been shown to usually enhance hair growth in men with progressive hair loss. It has been shown to effectively regrow hair on the crown of the head, and it may also help a receding hairline.

It has also been shown that the use of Rogaine and finasteride (Propecia) together produces better results than using either one on its own. (However, be aware that finasteride has the possible side effects of erectile dysfunction and/or low libido in some men.)

If you are experiencing a receding hairline, minoxidil may or may not work very well on its own. I recommend adding finasteride and/or laser treatment to deliver a stronger punch.*

2. Low-Level Laser Therapy (LLLT). This involves immersing your scalp in low-energy (safe) lasers that are supposed to increase blood flow and stimulate hair growth. You can obtain laser treatment via a home laser device (the most powerful of which is the Capillus Laser Cap) or at a hair restoration clinic. There are several scientific studies that demonstrate that low-level lasers can increase hair growth:

Low Level Laser Therapy and Hair Regrowth: An Evidence-Based Review

Use of low-level laser therapy as monotherapy or concomitant therapy for male and female androgenetic alopecia

Low-Level Light Therapy for Androgenetic Alopecia: A 24-Week, Randomized, Double-Blind, Sham Device–Controlled Multicenter Trial

Low-level laser (light) therapy (LLLT) for treatment of hair loss.

Hair Regrowth and Increased Hair Tensile Strength Using the HairMax LaserComb for Low-Level Laser Therapy

In addition, Laser Therapy (such as that done via the home device Laser Cap) seems to show some results in hair growth aesthetically (although you should always be skeptical of pictures):

Before & After Photos

A good comparison of many of the in-home laser devices can be found here.

The idea is that the stimulation of hair growth resulting from laser treatment may offset the weakening of the hair follicles caused by DHT. If that is the case, then hair loss will be slowed down or halted and you can maintain the hair you currently have. However, some lasers on the market are less effective than others, so make sure that the laser you invest in has a high number of lasers. The more aggressive your hair loss is, the more powerful of a laser you may need.  The laser devices I am aware of in order of increasing power are the Laser Comb ($295 – $545), the iGrow laser ($695), Theradome ($895), and the Capillus Laser Cap ($799 – $3000, depending on which device you buy).  (Note: I purchased the Theradome and tried it for 6 months, and did not notice any significant positive effect on my hair growth.  See below.)

In my experience, the 80-laser diode Theradome did not help my hair loss.  This might mean that either my particular type of hair loss is too aggressive to be affected by a device with only 80 lasers, or that the device itself is of low quality.  The 272-diode Capillus Laser Cap did seem to have positive effects on my hair growth, although I also used minoxidil at the same time, so it is not possible to draw any definite conclusions for myself.

 

Some treatments such as low-level lasers may stimulate hair growth. Image from http://www.irestorehairlaser.com.

There are no known harmful side effects of laser therapy, since the laser is not thought to penetrate through the scalp. Always ask a doctor before trying any laser treatment, however.

 

So there you have it.  If you want to slow down or halt the cause of hair loss at its “roots,” use at least one product that blocks DHT production and at least one product that stimulates hair growth.  Finasteride and dutasteride block DHT, but they sometimes give side effects in some men that you need to be aware of.  2% ketoconazole shampoo also seems to reduce the effects of DHT on the hair, but not quite as effectively as the oral medications.  Products that seem to stimulate hair growth include minoxidil and low-level laser therapy (LLLT).

If your hair loss is especially aggressive and you want to keep all of your hair, you may want to try a synergistic approach and use all three treatments: finasteride (or dutasteride), minoxidil, and laser therapy.*  See My Experience and Recommendation for more suggestions.

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*I am not a doctor. You should always consult a board-certified hair restoration doctor before making any decisions about hair loss treatments. The opinions on this blog are solely those of myself. However, I try my best to develop informed opinions by basing them on the results of clinical studies that I reference here on my website.

“My hairline has just started to recede or my hair is starting to thin on the crown.”

If you have just noticed your hairline starting to recede (or it’s only been a few years since you started noticing hair loss), then you are still in excellent shape. This is because you likely still have a good portion of your hair on the top of your head, meaning all you have to do is strengthen and maintain the hair you have. In addition, some of the hair you have lost (in “bald” areas) may still be in a miniaturized state (not completely gone), which allows the possibility of reviving those weak hair follicles. It is much easier to deal with hair loss now than it would be if you were already mostly or completely bald.

lts-hairstyles.blogspot.com

For methods to slow down or stop hair loss and maintain the hair you currently have, see this post.

Another important thing is to try and predict how much at risk you are for further hair loss. Try to match up your pattern of hair loss with someone in your immediate or extended family (your dad or grandpa). Chances are (though it’s not a guarantee), you may have inherited a similar type and pattern of hair loss. This means you can use your dad or grandpa’s current hair situation as a predictor of the hair loss you will have to deal with. If Grandpa has no hair left except around his sides and back, then you can assume that will be the condition of your hair in the future if you do not do anything. Some people, on the other hand, only lose some of their hair. Knowing how much hair loss you would experience or what type of hair loss you will have to deal with can help in your procedure for maintaining your current hair.  Note: This is just a rough way of estimating, and is not necessarily guaranteed.  It may just help provide some perspective in your plan for treatment.

If your dad, grandpa, or uncle went bald at an early age, you may need to utilize the more powerful solutions (for example, a combination of the methods discussed here, the more powerful lasers with over 200 diodes, etc.) to maintain the hair you currently have. Image from http://www.gettyimages.com

If Grandpa is 70 years old and he’s only lost a little hair on the temples, you may not have to worry about your hair. In fact, you may just decide to let nature take its course. However, if Dad is 35 and his hair is almost gone, and you don’t want to go down that same path, then you need to watch your hair closely and take steps now to prevent future hair loss, perhaps using one or more of the solutions discussed above.

Since you have caught your hair loss in its early stages, you are in excellent shape and will have much better control of the situation. In short, the options you have for maintaining your current hair and stopping (or at least slowing) hair loss are finasteride or dutasteride, minoxidil, 2% ketoconazole shampoo, and low-level laser therapy.  I discuss the scientific studies behind these treatments here.

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* I am not a doctor. You should always consult a board-certified hair restoration doctor before making any decisions about hair loss treatments. However, from what I have researched, minoxidil’s effectiveness to reverse hair thinning at the crown seems to be better documented than it is for hair at the temples. In addition, minoxidil does not block DHT; it only stimulates hair growth, albeit in a somewhat mild manner.