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Jump to Key Points SAN DIEGO — There’s good news about hair loss, Marc Avram, MD, dermatologist, told colleagues here at the Masters of Aesthetics Symposium: “We’re in an era where we have really good treatments that not only prevent it from getting worse” but also can result in hair regrowth, he said.
In a presentation at the meeting and a follow-up interview with Medscape Medical News, Avram, who practices in New York City, offered these recommendations on treating hair loss with topical and oral therapies, as well as regenerative and surgical options.
Topical and Oral Minoxidil
Two treatments available as oral and topical therapies — minoxidil and finasteride — both can result in hair regrowth, Avram said.
Patients sometimes express skepticism when Avram mentions topical minoxidil, the only FDA-approved medication for both female- and male-pattern hair loss (androgenetic alopecia) because it is available over the counter, he said. But he often convinces them to consider the product when he says it works well, as long as patients are compliant.
- Topical minoxidil: FDA-approved for female/male AGA; full effect 8-12 months.
- Low-dose oral minoxidil: effective, inexpensive, well tolerated; AEs = dizziness, palpitations, edema, hypertrichosis 15.1%.
- Finasteride concerns center on rare post-finasteride syndrome; exact incidence unknown.
- Minoxidil + finasteride may be synergistic; topical finasteride shares oral risk profile.
- Non-drug options: low-level laser, PRP, and FUE/FUT transplants; surgery doesn't stop ongoing hair loss.
The key to topical minoxidil treatment, he said, is that it takes 8-12 months to fully work. As he explained, it’s crucial to help patients understand this so they don’t give up after 2-3 months when they aren’t seeing enough improvement.
Low-dose oral minoxidil (LDOM), which requires a prescription, is another option. It’s become more popular in recent years because it’s convenient and is “inexpensive, effective, and well tolerated,” Avram said. Adverse effects include dizziness and heart palpitations. He also highlights the risk for edema to patients and advises them to stop treatment if they develop signs of edema.
A 2021 study on the safety of LDOM for hair loss in the Journal of the American Academy of Dermatology highlighted other adverse effects such as hypertrichosis — by far the most common adverse effect at 15.1% in the study — plus less frequent side effects such as headaches (0.4%) and insomnia (0.2%).
Fears About Finasteride
About a third of male patients with hair loss in his practice say that they are not interested in finasteride (Propecia), another commonly used hair-loss drug. Their concern is post-finasteride syndrome, a condition that can occur following the use of finasteride and dutasteride, 5-alpha reductase inhibitors that are used to treat benign prostatic hyperplasia and, at lower doses, male-pattern hair loss. (Dutasteride is not approved for treating hair loss). Patients with the syndrome can suffer from persistent effects on mood and sexual function.
The condition “appears to be rare, although the exact incidence is unknown, and I cannot give patients a reliable numerical estimate,” Avram said. “Ultimately, patients must decide whether they are comfortable with that uncertainty.”
Combination Therapies: Look for Synergy
Several hair-loss treatments can be combined, Avram said, such as minoxidil and finasteride, which are synergistic when used together. “They can be used orally or topically,” he said, but keep in mind that topical finasteride has the same risks as the oral version.
The ophthalmic drugs latanoprost, retinoic acid, and spironolactone (also used off-label to treat acne) can be used as adjunctive therapies, he said. However, they are not FDA-approved for treating hair loss.
Regenerative Options for Patients Who Don’t Want Meds
Avram estimates that about a third of his patients resist the idea of taking daily medication for hair loss. For them, low-level laser therapy is one option. He highlighted a 2018 review of low-level laser therapy for alopecia that found 10 of 11 trials demonstrated significant improvement in androgenetic alopecia with this treatment compared with baseline or control individuals.
On the high-energy laser front, the FDA in 2024 cleared a fractional laser for hair loss. Clinical trials show a 13%-16% increase in the number of follicular units per square centimeter with treatment, Avram said.
Yet another regenerative option is platelet-rich plasma (PRP) therapy. Avram highlighted a 2020 review that supported its use in androgenetic alopecia and alopecia areata over 3-4 monthly sessions. He cautions patients that while the treatment is painful, “it just hurts in the moment, and people really get through it.”
Both PRP and laser therapies allow hair regrowth, he said.
Hair Transplant Surgery: Understand the Limits
Avram makes sure that patients understand that hair transplant surgery doesn’t stop hair loss. He points out that there are limits on how much hair can be harvested.
With regard to harvesting strategies, he said, “both follicular unit extraction (FUE) and follicular unit transplantation using strip harvesting (FUT) are state-of-the-art techniques that can produce excellent results.”
The best approach depends on the patient. “FUE often appeals to patients — particularly men — who want to wear their hair short in the back and prefer harvesting without sutures or a linear scar. It does leave small individual scars,” he said. “FUT is often practical for women with longer hair who do not want the donor region closely trimmed for FUE. It is also an option for men who intend to keep their hair long enough to conceal a linear scar.”
What’s next on the hair transplantation front? “I see a future where we’re going to have better and better medical therapies,” he said, which will reduce the need for surgical procedures such as hair transplants.
Avram reported consulting for Lumenis.
