Change In Views On How To Use Finasteride (Propecia)
I am writing this post from the ISHRS annual meeting in Chicago. I have just heard a wonderful and informative discussion on the use of of the drug finasteride. As we know, the hormone DHT is 40 times as powerful an androgen as testosterone. The treatment of genetic hair loss is to address blocking the DHT hormone. One of the worlds experts, Dr. Mohit Khera from the Baylor College of Medicine, told me privately that when DHT levels are in the low normal range, the use of DHT blockers such as finasteride will have little value and may not be effective in the treatment of genetic hair loss. With this as a suggestion, we will now optionaly offer DHT blood tests for any person who wishes to have this test prior to going on finasteride (Propecia). If the blood levels are low, we may not advise the use of this drug as the goal of using this drug is to drop DHT levels, which may already be low. This lecture is based on considerable research both in animals and human studies but it is not absolutely definitive as there was much controversy at the meeting that the doctor may have had a conflict of interest in the opinions he drew.
Could you post the literature that supports this new approach?
As far as we know finasteride is effective at least in holding your MBP for 5 – 10 years in 80% of patients (it depends on the study and its data)
I have only heard of surgeons supporting this theories.
I do not belive them, sincerley.
So let me get this straight. Propecia lowers dht. People with already low dht and still have hair loss won’t be helped by a medication that can lower their already low dht?
Boy I hope the government didn’t pay for this study.
In this case, could it be that people who are likely to develop side effects are those with lower DHT levels? It sounds like an interesting aspect of the finasteride treatment.
Would this information at all affect the dosage rates of finasteride? Specifically, I wonder if men with naturally low DHT might benefit from lower than recommended (1 mg per day), or even intermittent dosage (EOD). Although finasteride has an apparent good safety record, minimising the long-term dosage of any medication, while still maintaining the prescribed benefits, would seem to be a good idea.
Would men with low DHT levels lose hair anyway?
One of the understandable challenges non-scientist readers of this blog have is that they struggle to understand the “nature of evidence”. As a result, a letter to the editor hypothesizing about Propecia side effects becomes a “definitive” clinical study, anecdotal observations on other blogs become “fact”, and questions about finasteride side effects, birth defects, pharmacology, duration of action, efficacy with reduced dosing, etc – info that is publicly and readily available in product labels, scientific articles, and lengthy regulatory (FDA) documents – are asked repeatedly. To that extent, the characterization of Dr Khera’s hypothesis that DHT levels in the low normal range may result in poor efficacy of finasteride as “not absolutely definitive” implies some (albeit not definitive) evidence. In fact, there are zero published clinical studies addressing this interesting and rational hypothesis. Fortunately, it can be easily tested by following a cohort of men prescribed finasteride for baldness and comparing them (and their DHT levels) to men not receiving finasteride, controlling for factors (exogenous use of testosterone, etc) that could affect DHT levels. A simpler study could also just look at men receiving finasteride for baldness and correlating outcome with baseline DHT levels. Any “conflict of interest” (ie bias) of the investigator could be easily addressed by having the investigator evaluate the progression of balding without knowledge of the DHT results.
DHT is syntheized in the scalp (no mattter its levels on serum) so physiopathologically this doctor’s statement doesnt make much sense, especially if it isn’t supported by a clinical trial.
Do you agree?
This report begs a fundamental question to be asked.
If the prescribing practice of Finasteride may be affected by the “low level” of serum DHT in the balding patient, how much of a predominant role does DHT play in hair loss?
If Bob goes to his doctor seeking Finasteride to treat his thinning or balding head, gets a blood test to determine the level of DHT, is told that Finasteride is not a good option since his serum DHT is so low that it wouldn’t be of any benefit, then what is causing Bob’s thinning hair?
I am fully confident that, while DHT does indeed play a role in androgenic alopecia, it is, by far, not the only factor.
I am convinced it is a combination of micro-inflammation, apoptosis of the dermal papilla, DHT, and a possible auto-immune response.
I suggest that, for the majority of those for whom Finasteride is a non-option due to the blood test, a moderately-potent to super-potent anti-inflammatory, such as topical clobetasol propionate or topical betamethasone be used to combat the inflammatory component of the alopecia.
DHT has gotten the majority of the bad press as it pertains to androgenic alopecia, perhaps too much. There are other contributing factors that may be just as important, if not more so, resulting in alopecia.
Interesting, Tom. I have hair thinning that looks like MPB, but also have autoimmune issues. In the scalp area that is losing hair, I have experienced burning and intense itching and irritation. I went to yet another dermatologist and she said my scalp is very inflamed and attributes at least some of the hair loss to the inflammation and prescribed clobetasol (and after 4 weeks Nizoral), but I have not used it yet because I’ve read steroid meds can cause hair loss. Advice, anyone?
I’ve had good luck controlling inflammation with Neutrogena T-Gel Stubborn Itch Menthol shampoo. Nizoral didn’t help me there.