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#172 Drugs for male- and female-pattern baldness: Just a hair bit more effective than doing nothing?


CLINICAL QUESTION
What is the effect of approved medications for androgenic alopecia in men and women?


BOTTOM LINE
For men using finasteride or minoxidil, one in 4-8 more than placebo will notice at least slight improvement in hair count over 6-12 months, with no clear evidence one is betterFor every 84 men taking finasteride for hair loss, one extra will experience erectile dysfunction. For women, only minoxidil improves hair countwith one in eight reporting a moderate improvement over placebo.  



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EVIDENCE
  • Men 
    • Finasteride: Systematic review1 (12 randomized controlled trials (RCTs), 3,927 men) of finasteride 1-5 mg/day versus placebo found: 
      • At least slight improvement in hair count at 3-12 months, 43% versus 26%, Number Needed to Treat (NNT)=6. 
        • At 24-60 months, NNT=4. 
      • Increase in hair counts at balding spots.  
        • 9% at 3-12 months24% at 48 months. 
      • Increase in erectile dysfunction, Number Needed to Harm (NNH)=84.  
        • No difference in other sexual adverse effects. 
      • Limitations: Publication bias, selective reporting (under-reporting sexual adverse effects),3 high loss to follow-up (up to 30%), clinically important differences undefined. 
      • Recent, low quality systematic review found similar.2 
    • Minoxidil: Systematic review4 (11 RCTs, 1,666 men), minoxidil 2% solution BID versus placebo over 6-12 months found: 
      • At least slight improvement in hair count62% versus 40%, NNT=5. 
      • 16% increase in hair counts.  
      • Higher (versus lower) concentrations inconsistently show slight (2-4%) increase hair count.5,6 
      • Adverse effectsApplication-site reactions most common (2-6%), more with higher concentrations.5-7 
  • Only trial comparing finasteride to minoxidil: Poor quality and unreliable.8 
  • Women: Systematic review.9 
    • Finasteride 1 mg (three RCTs, 287 women): No difference in any outcome.  
    • Minoxidil 1-5% versus placebo:  
      • Patient-rated moderate improvement or better (26% versus 14%, NNT=8) 
      • Increase in hair count, +13 hairs/cm2, at 6-12 months. 
Context:   
  • Prevalence of androgenic alopecia increases with age, with approximately ½ of men and  of women balding after age 70.10 
  • Numerous other interventions (like nutritional supplements or Handi-Dome Comb) have low quality evidence with inconsistent results.9,11 
  • Only minoxidil for women or men, and finasteride for men, are supported in guidelines.12,13   
 


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Author(s):

  • G. Michael Allan MD CCFP
  • Ricky D. Turgeon BSc(Pharm) ACPR PharmD

1. Mella JM, Perret MC, Manzotti M, et al. Arch Dermatol. 2010; 146:1141-50.

2. Gupta AK, Charrette A. J Dermatolog Treat. 2014; 25:156-61.

3. Belknap SM, Aslam I, Kiguradze T, et al. JAMA Dermatol. 2015; 151(6):600-6.

4. Gupta AK, Charrette A. SKINmed. 2015; 13:185-9.

5. Olsen EA, Dunlap FE, Funicella T, et al. J Am Acad Dermatol. 2002; 47:377-85.

6. Tsuboi R, Arano O, Nishikawa T, et al. J Dermatol. 2009; 36:437-46.

7. Olsen EA, Whiting D, Bergfeld W, et al. J Am Acad Dermatol. 2007; 57:767-74.

8. Arca E, Acikgoz G, Tastan HB, et al. Dermatology. 2004; 209:117-25.

9. van Zuuren EJ, Fedorowicz KZ, Schoones J. Cochrane Database Syst Rev. 2016; 5:CD007628.

10. Blume-Peytavi U, Blumeyer A, Tosti A, et al. Br J Dermatol. 2011; 164:5-15.

11. Blumeyer A, Tosti A, Messenger A, et al. J Dtsch Dermatol Ges. 2011; 9 Suppl 6:S1-57.

12. Tsuboi R, Itami S, Inui S, et al. J Dermatol. 2012; 39(2):113-20.

13. Blumeyer A, Tosti A, Messenger A, et al. J Dtsch Dermatol Ges. 2011 Oct; 9 Suppl 6:S1-57.

Authors do not have any conflicts to disclose.