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Why So Pessimistic About Ketoconazole?

Dr. Rassman,

I enjoy reading your blog, and nearly always agree with you, but I do feel you are a bit to pessimistic about ketoconazole. In another response to another member you dismissed of a Japanese, justifiably I suppose, because of the small sample size. (Have you seen the pictures of the impressive regrowth seen in three of the six patients? They shows an obvious reversal of AGA.)

What about this controlled study: “Comparative efficacy of various treatment regimens for androgenetic alopecia in men”

In this study men were divided into four groups: “Group I (30 patients) was administered oral finasteride, Group II (36 patients) was given a combination of finasteride and topical minoxidil, Group III (24 patients) applied minoxidil alone and Group IV (10 patients) was administered finasteride with topical ketoconazole. Treatment efficacy was assessed on the basis of patient and physician assessment scores and global photographic review during the study period of one year. At the end of one year, hair growth was observed in all the groups with best results recorded with a combination of finasteride and minoxidil (Group II) followed by groups IV, I and III. Subjects receiving finasteride alone or in combination with minoxidil or ketoconazole showed statistically significant improvement (p<0.05) over minoxidil only recipients. No signifcant side-effects related to the drugs were observed. In conclusion, it is inferred that the therapeutic efficacy is enhanced by combining the two drugs acting on different aetiological aspects of AGA.”

I don’t believe this has been mentioned on your blog before, and the results are exactly as most men would expect them to be:

Finasteride + Minoxidil > Finasteride + Ketoconazole > Finasteride Alone > Minoxidil Alone after one year.

I’m sure, like every study, this one also has it’s flaws, but together with all the other research — from Piérard-Franchimont C (1998) to Rajput RJ. (2010) — I’d say that the evidence for the efficacy of ketoconazole in AGA is highly suggestive. It’s certainly much stronger than for the majority of the things men try outside of finasteride/dutasteride and minoxidil.

And we know that all anazoles are somewhat antiandrogenic, but only ketoconazole will compete for the AR, and is used in androgen modulated prostate cancer.

How can you be so pessimistic about it in light of the totality of the evidence? Do you believe it to be dangerous?

I am not pessimistic about ketoconazole. Our job on this site is to educate you, the reader, on the realities of such claims and treatments and warn you if there is danger in using such “stuff”. While I don’t see ketoconazole (better known as Nizoral) as dangerous, it has yet to be proven to my satisfaction that it’s a treatment for hair loss. I’ve always maintained that Nizoral is a good shampoo for treating dandruff and fungal infections.

What I have always maintained is that nothing stops a genetic trait. There are drugs that slow it down and there may be other remedies that also work, but my mantra has always been “buyer beware”. The small study you referenced is indeed suggestive of positive benefits, and if the readers out there want to try it, I think that is their choice to make. But keep in mind that while the 1% ketoconazole is available as an over-the-counter shampoo, 2% ketoconazole (as used in that small study) is a prescription medication and as such, you need a physician to oversee the treatment. Side effects include burning and itching sensations.

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You asked me to raise my eyebrows for a photo, why?

Raising the eyebrows gets the forehead to wrinkle and this shows the anatomy of the muscles under the skin. The distances between the Glabella (the bridge of the nose) and the highest wrinkle on the forehead tells me a great deal when measuring the leading edge of the hairline. A normal mature hairline is usually one finger breadth distance between the highest wrinkle and the midline hairline. A picture of your entire face allows me to judge general proportions, chin to nose, nose to Glabella and Glabella to hairline. Michaelangelo in his status of David, put the proportions of these distances 1/3rd, 1/3rd, and 1/3rd however most normal people find that the distance between the chin and the tip of the nose is equal to the distance between the Glabella and the leading edge of the midline hairline.

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Why Not Take 2 Propecia Doses Daily?

Hi Dr. Rassman,

If Finasteride has a half-life of only 5 hours, how can it be so effective at stopping hair loss? If we take 1 mg or 1.25 mg of it, it would be pretty much out of our system before the end of the day. Does only a small amount of it prevent DHT from being created? Is it’s efficacy only dependent on a miniscule amount being present? Why is taking 2 doses per day not more effective than 1? And also, what are your current thoughts on what time of day to take it?

Just because a drug’s half life is 5 or 6 hours does not mean you need to take the medication according to its half life. Although half of the drug is out of the blood stream in 5-6 hours, some of the drug remains in the tissues for as long (possibly) as a week or so. Doubling the dose was not shown to be effective for better response in the original tests for Propecia.

In addition, the drug has been tested at different intervals and different doses, with trials determining that taking it once daily was just as beneficial as twice a day for treating hair loss. The best time to take Propecia is when you can remember to take it on a consistent basis.

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Why not go bald?

At this point, I want to let it go. There are several reasons for that.

  1. All my male relatives have male pattern baldness. So one way or another, it’s going to happen. Feels like I’m fighting a losing battle.

  2. I feel pretty vain acting upon hair loss. Especially when you see others not caring at all. I want to feel good without being attached to my looks. Looks fade.

  3. The time invested in combating hair loss could be used for more productive stuff, especially knowing since my hair is ought to go anyway.

Many men want hair because they are more attractive to themselves and more confident in themselves. I have performed hair transplants on many celebrities who all tell me that it improved their self-confidence. You would be surprised by this if I revealed their names.

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Why No Photos of Hair Transplants 3-4 Years After Surgery?

hi doctor,
in most of the hair transplant sites one mostly see the after photos of 6 months or 1 year after the procedure. my question is what happens thereafter ? could you provide some 3-4 years after photos so to see the longetivity of results of transplant.

The hair transplants are permanent. At the 1 year mark, the results will be fully visible. I’m not sure the benefits of seeing 2-3 years later, as the transplants will be the same as after 1 year. I have seen patients transplanted in the 1960s and 70’s with the terrible old plugs, and other than turning gray, they still have those same terrible old plugs. I have seen many patients 10 years out and they are happy and their hair is about the same as it was in their 1 year picture, so I just make a note on the chart saying “no change” and do not take routine photographs. If you are implying that some terrible disaster happens to the new hair and that is a concern for you, don’t worry about that one.


2008-11-05 12:36:45Why No Photos of Hair Transplants 3-4 Years After Surgery?

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Why Might Xanax Cause Hair Loss, Rather than Anxiety?

Hi,
First of all I’m a 29 yr old male with extreme anxiety. I’ve read a couple of posts on this site about Xanax & hair loss. In every question asking about whether Xanax can cause hair loss, you mention that it definitely can.

As I stated earlier, I have an anxiety disorder & have just recently started taking the generic version(1mg 3 times a day) of Xanax again. Can you explain to me how & why the Xanax would cause hair loss? I’m just REALLY concerned now after reading about that. I was thinking that extreme anxiety would be more likely to cause hair loss than Xanax?

If you could just give me any kind of explanation, I’d be extremely grateful.

Occurrence of hair loss can be due to several factors. Although most the common cause of hair loss at your age is male pattern baldness, anxiety could be considered an aggravating factor for your hair loss. Hair loss is not one of the commonly known side effects of Xanax. We hear from our patients who just got started on Xanax that they lose hair, but it is hard to prove that their hair loss is really associated with Xanax or if it has to do with anxiety itself.

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Why Might a Patient with 6000 Grafts Have a Thinner Appearance Than a Patient with 3000 Grafts?

Dear Dr.,
First of all thank you very much for the help you have given on this forum. I have had two HT operation 1000 FUE(1.5 years ago, worked very well) and 2000 FUT (3 months ago). My question is has to do with HT results and I would appreciate if you could answer;

  1. I saw pictures of more than 5K-6K grafts but has poor coverage/appearance compared to some 3K graft transplantation? Even, the pictures are from the same clinic. What are the reasons of this inconsistency?
  2. Most of the pictures show hairlines and first half of the top. How about the crown? Is it a common practice to leave crown bald? Is it because the budget or a bald person does not have enough donor for front and crown so has to select one?
  3. Does hair loss stop or decrease rate with the age? My lost started at age 26-27 with diffuse pattern now I am 31. A diffuse pattern goes till NW-7 or NW-6 or NW-6 with some diffuse hair still on top and crown?

Thank you very much.

Regards

Three months after a hair transplant should not produce enough hair to show any significant results. Wait a full 8 months to see the results of the second surgery.

  1. There could be a variety of reasons for that. Patient A and Patient B could have different hair color, skin color, hair characteristics, degree of balding, etc. Or it could be different techniques used (many clinics have damage problems with FUE grafts, for example). There’s just a lot of variables that could be the reason.
  2. The transplantation of hair in the crown does depend upon many factors, again including donor density, scalp laxity, thickness of the hair shafts, and the degree of balding. It may not be possible to transplant an entire head with a Norwood class 7 pattern of balding, but I have done it in patients with great hair qualities (see Patient ZU here, for example).
  3. Only about 7% of men go as far as a class 7 pattern, about 20% a class 6/7 pattern… and most of these men with the class 7 pattern have clear signs of it before the age of 30. You need to be evaluated by a doctor like myself or Dr. Pak that specializes in this field if your doctor does not answer this question for you.


2009-01-16 12:26:10Why Might a Patient with 6000 Grafts Have a Thinner Appearance Than a Patient with 3000 Grafts?

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Why microscopes are critical in hair transplants (photo)

Here is a photo of what appears to be a single hair for grafting, but because it can be viewed with a high powered microscope, we see that there is at least one if not two telogen hairs present (see arrow). If this graft was put in the frontal hairline, then it would look pluggy. Does your surgeon use a high powered microscope to make sure that the hair transplant is done correctly?

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Why Isn’t Topical Finasteride/Dutasteride More Popular?

It’s expensive when compared to the oral pills. Dutasteride is not FDA cleared for hair loss so doctors don’t write the Rx for it very often. Topical finasteride in the liposomal form costs around $70/month. The finasteride pill from Costco costs about $27/year. Big difference