Shampoos: What Should I Use?

Shampoos and hair washing are obviously going to get special attention from any hair loss sufferer; anything that touches the scalp gets closely scrutinized. 

Is my shampoo contributing to my hair loss?  Is there a shampoo I could be using to help?  Why do I see so many homeless guys that appear to never wash their hair with great heads of hair; should I stop washing my hair?

You can find a lot of baseless speculation on the subject of washing your hair from hair loss doomsayers on the internet.  For this post, I’ll just take on the subject of shampoos.

Can Shampoos Be Causing My Androgenetic Alopecia?

If you know you suffer from male pattern baldness, and you understand the mechanism of this form of hair loss, a lot of the shampoo witch-hunting will go away.  There is no known chemical or shampoo that can cause male pattern baldness.   There are thousands, if not millions, of people using shampoos with the same chemicals as the ones you use, and they are not affected by male pattern baldness.  So unless you have NairTM in your shampoo, there isn’t much more to say other than: your shampoo isn’t causing your male pattern baldness.

Is There a Shampoo I Can Use to Help With My Hair Loss?

Now how about the other question: is there I shampoo I can use to slow or prevent hair loss?  The answer to that question is a definite maybe.  There are some studies that, although not robust by any means, suggest that some agents with anti-fungal properties such as ketoconazole and piroctone olamine may help.  Additionally, pyrithione zinc may help prevent or slow hair loss in androgenic alopecia.

I will mention one caveat with regard to the info I’m about to cover: compared to the robust clinical trials that have been done on minoxidil and finasteride, the studies I’m going to mention here aren’t nearly as scientifically robust.  Not even in the same category.  That doesn’t mean that they should be discounted.  They are one thousand times better than some guy on some internet forum claiming benefit with some herbal regimen and similarly better than some fly by night snake oil claiming similar benefits.  But I just want you to be aware that I’m not claiming that the studies here definitively show a necessity to use any particular shampoo.  But my philosophy is: if you are going to be putting shampoo in your hair anyway, might as well pick a good one.  So let’s see if we can help you pick a good one.

KETOCONAZOLE

Ketoconazole is an anti-fungal that has received the most attention of any shampoo as an anti-alopecia agent.  Really, there is enough interest in ketoconazole as an anti-alopecia agent that it merits its own article.   But for the purposes of what we are covering here, I point you to a 1998 study in Dermatology by Pierard-Frenchimon et al that got most of the hype started1.

Suffice it to say that the Pierard-Frenchimon article suggested that, first, men with androgenic alopecia who used ketoconazole shampoo had greater hair density and size as well as more hair in the anagen phase compared to those that used a placebo shampoo over a 21-month period.  They also presented evidence that those who used ketoconazole shampoo had an equal improvement in hair density and size as well as just as much hair in the anagen phase as men with MPB who used once daily 2% minoxidil and a placebo shampoo. 

In essence, they said shampooing with ketoconazole was as good as a once daily application of a medication proven to work in robust clinical trials (minoxidil).  And that’s saying a lot for doing something (shampooing your hair) that you were planning on doing anyway.

PYRITHIONE ZINC

Pyrithione zinc (PZ) is most famous as being the active ingredient in the shampoo Head and ShouldersTM.  It’s well known for its use in treating dandruff and seborrheic dermatitis.  But just as Pierard-Frenchimon’s study gave ketoconazole its moment in the spotlight, a 2003 study by Berger et al in the British Journal of Dermatology gave PZ its moment to shine2. 

They did a 6 month, 200 patient, randomized, parallel group clinical study.  They had three groups: one group using daily 1% PZ shampoo, another group using 5% minoxidl and a placebo shampoo, and the final group using 5% minoxidil and PZ shampoo. 

Interestingly, they found an increase in hair count in the PZ only group (cool!), an even greater increase in hair count in the minoxidil + placebo shampoo group (not surprising but also very cool!), and in the minoxidil + PZ group (drum roll, crescendo in excitement levels)………basically the same as the minoxidil + placebo shampoo group (major let down). 

So hard to know what to make of that.  The findings would suggest that if you are using minoxidil then it doesn’t matter if you use a PZ-containing shampoo or any other shampoo off the shelf but if you can’t tolerate minoxidil then a PZ-containing shampoo would help. 

Frankly, my opinion is that this is too small of a study with too ambiguous of findings to really hang your hat on anything.  I hate to break it to you, but as a published author of medical journal articles I can vouch for the fact that, no matter how much you try to be impartial, there is a subconscious and irresistible tendency to find a positive outcome with whatever you are studying. 

But hey!  Its just shampoo!  Knock yourself out and use Head and Shoulders if you’d like.  Just don’t go broke buying out all the available PZ shampoos you can find.  It’s going to be small potatoes compared to the benefits you would see with minoxidil and/or finasteride.  But maybe, just maybe, if you can’t tolerate minoxidil, PZ could be a good shampoo for you.

PIROCTONE OLAMINE

Piroctone olamine is another anti-fungal agent just like ketoconazole.  I hesitate to give it its own category but there is a decent study to review related to it. 

Remember Pierard-Frenchimon?  The guy who showed us that there is some benefit in using ketoconazole shampoos?  He is a fellow Belgian, and it turns out this guy (girl?) loves shampoo.   He did another study on shampoos and hair loss.  Unfortunately, this paper didn’t get accepted by a very prestigious journal and I’m sure he wasn’t happy about it.  But doing a study and getting it published is hard work so let’s review what he did.

Somehow, he found 150 men in active telogen effluvium related to androgenic alopecia and had them use ketoconazole or pyrithione zinc or piroctone olamine on their hair for 6 months.  He didn’t find an increase in hair density, but he did find a decrease in hair shedding and an increase in hair shaft thickness for those using ketoconazole and piroctone olamine.

My thoughts?  Another study suggesting that shampoos with anti-fungal activity may be good in the fight against hair loss.  Piroctone olamine is just another example of an anti-fungal agent.  If you really like the name, you can find a shampoo that contains it.  Otherwise, I personally would stick to ketoconazole: same mechanism of action and more studies supporting its use.

ROSEMARY, ARGAN OIL, WHO KNOWS WHAT ELSE

In general, I don’t recommend that patients spend their hard-earned money on some expensive shampoo with an active ingredient that has no proven benefit whatsoever.  No matter what made up testimonials are associated with it and how real those testimonials sound, my job is to sort through products like these and find what has actual clinical evidence supporting its use.  Feel free to ask me if you think I’m missing something, but if it worked, I would probably have covered it.

You are more than welcome to try these out, who am I to judge? But just don’t do it INSTEAD OF a proven medication.  There are dozens and dozens of such shampoos out there, and you can make yourself crazy trying to decide which fake testimonials to believe and whether you are looking at a “legit” site or one that is just there to take your money.  I’m desperately trying to save you from this struggle by presenting available medical evidence of what to use (incidentally, if you see a study or an agent you would like me to review, just let me know).  But its 100% up to you if you want to head down a different path.

MY RECOMMENDATION

My personal experience with patients is that a shampoo is nothing more than a complementary agent.  There is soft evidence that they could possibly help lessen hair loss but in and of itself it is absolutely not going to save the day.  Small potatoes compared to what minoxidil and finasteride will do for you.  Consider it an adjunct in your fight.

Of the agents available, I have anecdotally been the most impressed with ketoconazole and there are the most studies to support this.   You can add pyrithione zinc to your ketoconazole shampoo.  You can alternate ketoconazole and pyrithione zinc.  But if you are choosing just one to put in your arsenal, I would pick ketoconazole containing shampoos.