Should I start my male pattern baldness treatment with minoxidil or finasteride?
In the pre-internet days, you’d just go to a doctor, they’d tell you what to do, and you’d do it. Now, many patients either self-diagnose and begin treatment with over-the-counter medications or come to the doctor with a good idea of what they want to do to begin treatment. And that’s perfectly fine. This article should help you decide what you want to start with, so you can go to your first doctor’s appointment with an idea of what you want to do. In this article, I also discuss finasteride as though it is the only DHT inhibitor available. In reality, there are other DHT inhibitors available, but finasteride offers perhaps the best balance of efficacy and side effects for most patients.
So where should you begin your treatment?
Well the ideal is that you start with both minoxidil and finasteride and never stop either and look like Fabio for the rest of your life. The research is pretty clear that a regimen that includes both minoxidil and finasteride will result in the most hair for the longest period of time.
But this whole hair loss thing is not ideal and the reality of the situation is not everyone can tolerate both. So I do think it makes sense to start with one medication and see how you do with it before you add the other. Additionally, if you start one at a time you’ll have an idea of how each medication affects you in terms of both side effects and efficacy. And then you can sort out for yourself which side effects or inconveniences you can tolerate the best, which medication your hair responds to the best, and then be able to commit to a regimen.
So which one should you start with? Minoxidil or finasteride?
This is a tough question. To boil the question down to the most common reasons that people have for stopping each, you are trying to decide between starting with finasteride and running the risk of experiencing its sexual side effects and quitting or starting with minoxidil and running the risk that you’ll find applying a liquid to your scalp every day unacceptable and quit.
Early in my career, I was convinced that minoxidil was the thing to start with because the sexual side effects of finasteride are so concerning to patients. However, this opinion has changed over the years. I think it makes the most sense to start with finasteride and see if you tolerate it first before you either add minoxidil to your regimen if you tolerate finasteride well or switch to minoxidil if you aren’t tolerating finasteride. I’ll explain why:
1. Adherence: A medication only works if you take it. And you are talking about, on one hand, taking a pill once a day that can be taken at your convenience, anytime of the day, with or without food. It’s as easy as it gets.
On the other hand, your alternative is spreading a liquid on your scalp twice a day that is going to drip down your face, will often make your scalp itch, give you dandruff, sometimes ruins whatever hairstyle you were planning on, and has to be left on without putting a hat on or otherwise styling it for a period of time thus altering your grand fashion plan/preparations for the day.
People reliably take finasteride if it works for them, and they aren’t having side effects. It’s easy to do and can be done for the rest of your life. And the urologists I know and respect the most think taking daily finasteride is good for most men for reasons other than keeping your hair. On the other hand, I know of many patients for whom minoxidil worked, but they couldn’t handle the daily routine.
The only way to know if a medication is going to work is to actually take it. Now adherence to finasteride versus minoxidil with side effects considered may level the score a bit, but just considering adherence to the routine of taking the medication, finasteride wins hands down. Score: Finasteride 1, Minoxidil 0.
2. Stop and Start-ability: In my opinion, finasteride is a better medication to start and stop than minoxidil. There is a thought amongst many patients and physicians that once you stop minoxidil and lose the hair that it regrew for you, if you start it again, your hair doesn’t respond as well on the second go around. On the other hand, hair responds to finasteride pretty well on the second go around. There is research that supports this thought.
I am certain that you can stop minoxidil and start it again and still see much more benefit than if you didn’t take anything at all (and there is research to support that), but I am also certain that the scenario that will result in the most hair for you is starting minoxidil and never stopping it.
I see patients who stop minoxidil for 6 months or longer and decide they were better off with it after all and then restart it and are very disappointed that the results aren’t as good as they felt they had the first go around. These people often profoundly regret stopping because the second go around is not only not as good as the first, but not even close to as good.
The ideal would also be to start finasteride and never stop as well. But patients who do stop it tend to be happier with the results they see when they get back on it when compared with minoxidil patients who do the same.
The bottom line is, if you are going to start minoxidil, I think you should be EXTREMELY committed to its use for the rest of your life. Because if you stop, I do think that you’ll probably regret it, realize you should have stayed on it, and never quite achieve the same results you achieved on the first go around. I know it sounds ominous, but I really don’t think a lifetime of applying minoxidil is as bad as it sounds.
I think if a patient starts out with minoxidil and the going gets rough there is this allure of an easier option in finasteride, and they are more likely to quit and switch to finasteride.
Whereas, if the going gets rough on finasteride (due to sexual side effects or otherwise), they are generally less likely to quit minoxidil once they start because they are committed knowing that the easier option was a no-go for them. Score: Finasteride 2, Minoxidil 0.
3. Side effect suckiness: Well this one appears to be a no-contest on the surface but actually ends out being closer than you’d think. Finasteride: sexual side effects are the most common cause of discontinuation. Minoxidil: itchiness, scalp irritation, dandruff, and problem with regimen compliance are the most common causes of discontinuation.
No contest right? You got into this whole “save my hair” campaign to try to attract the babes and if things downstairs aren’t working then what’s the point? The problem is, the babes aren’t generally crazy about dandruff and you generally won’t be crazy about both that and continual itchiness.
But still, sexual side effects are no joke and just about every man would rather find out if a medication is going to make their scalp itch or not rather than find out whether a medication is going to mess with the performance of their unit or not. Score: Finasteride 2, Minoxidil 1
4. Side effect reversibility: I am just making up word concepts here with “start and stop-ability” and “side effect reversibility” but I think you get the idea.
I think you’ll meet people who think they weren’t quite the same sexually after taking finasteride but when you weigh the fact that the incidence of erectile dysfunction increases by 1% for each year of age, I believe that many of these subtle differences that people detect are likely due to the natural effects of aging. So although I believe the low incidence of sexual side effects that Merck claims in their package insert may be a bit on the low side, I do believe that their report that that all sexual side effects are reversed upon discontinuation of the medication is, as far as can be medically determined, true.
Of course, the effects of minoxidil are also reversed upon discontinuation. And as I mentioned in “Point 2: Start and Stop-ability”, I would rather have a fickle patient start and stop finasteride than start and stop minoxidil. So although I give finasteride a slight edge here because of that, I can’t give finasteride two wins on account of Point #2, thus this is a tie. Side effects from both medications should be reversed upon stopping the medication. Score is still: Finasteride 2, Minoxidil 1
5. Efficacy: I guess this is what we all care about right? Well, both drugs are clinically demonstrated to work both for hair regrowth and maintenance. Is minoxidil a little better at regrowing hair and finasteride better a maintaining rather than regrowing? I think so. But they both work and that’s what matters. Trying to dissect this topic further is a completely different discussion and, at this point, is just splitting hairs . Tie again. Score: Finasteride 2, Minoxidil 1
Well, it wasn’t exactly a high scoring game. And it was close. But a win is a win, and thus I like to have my patients start on finasteride.
SUMMARY
I tell patients to start finasteride first. If it works and there are no side effects or the side effects are minimal/tolerable, then awesome, and we can start to talk about adding minoxidil to the mix for maximal hair regrowth.
If there are issues with finasteride, then we have a good conversation and make sure the side effects are something you find intolerable because if we quit finasteride, it means we are going to minoxidil (or a topical finasteride) because that’s the only proven medication we have left and thus, if you are serious about keeping your hair, staying on minoxidil is a lifetime commitment. And if later on you decide you want to start finasteride again, then it’s fine, and I don’t think your missed opportunity is as great for having started and stopped finasteride than if you had done the same with minoxidil.