13.4 Nonsurgical Treatment Options

13.4.1 Medications

The only medication that is approved for both MPB and FPHL by the Food and Drug Administration (FDA) is topical minoxidil (Rogaine). While the exact mechanism of action is unknown, minoxidil has been shown to improve the growth of suboptimal hairs in cell culture, is a potassium channel opener, and acts as a vasodilator. Minoxidil is available as a 2% and 5% mixture using isopropyl alcohol as its base. Studies have shown that topical minoxidil can improve hair counts and hair weights [9]. The solution needs to be applied twice a day to a dry scalp. Side effects, occurring in less than 6% of patients, can include flaking and dryness of the scalp. Females should be warned that facial hypertrichosis can occur in 3–5% of women. Additionally, there can be increased shedding of hair for the first 4–6 weeks of use. Once treatment is stopped any benefits are lost within 24 weeks. A 5% minoxidil foam formulation that uses glycerin as its base is now available. The foam formulation has been shown to be better absorbed and has less scalp irritation when compared to minoxidil with isopropyl alcohol.

Finasteride (Propecia) acts as a competitive inhibitor of the type II 5 alpha reductase enzyme. In turn, this acts to decrease the production of DHT at the hair follicles that are genetically predisposed to MPB. Finasteride has FDA approval for MPB in men aged 18–41 [10], but is not appropriate for women of childbearing years due to the possibility of feminization of a

male fetus caused by the reduction of DHT. Studies of postmenopausal women have shown a lack of efficacy with 1 mg finasteride [11]. Concentrations of finasteride in the semen of men taking 1 mg daily were shown to be below levels that can cause risk to a male fetus. At a daily 1 mg dose, finasteride, even after 5 years of daily use, can continue to halt or slow hair loss, primarily in the vertex region and in some instances can regrow hair [12]. It is important to stress to male patients that finasteride works best at maintaining hair so that after 1 year of treatment a positive result is considered to be no change in hair counts and physical appearance. As such, compliance can wane after a period of time, so it is important for the physician to offer continued encouragement. The earlier the treatment is initiated in the thinning process, the better.

Finasteride is tolerated very well with sexual function side effects seen in less than 1.8% of men, with a return to normal levels once treatment is stopped. When assessing patients’ prostate-specific antigen (PSA) levels, it should be remembered that finasteride will decrease these levels by approximately 50%. Long-term studies in men taking 5 mg finasteride for benign prostatic hypertrophy have shown that there can be a protective value in reducing the risk of prostate cancer [13].

The use of minoxidil and finasteride play an important role in the overall treatment of young men with MBP. At the time of the initial consultation it is important for the physician to map out a plan of action that often includes both surgical treatment and medical treatments. In the young male with ongoing MPB, hair restoration can often be implemented in the frontal scalp, to reestablish a hairline and to frame the face.