Finasteride remains one of the most effective medical treatments for androgenetic alopecia. It is licensed for use in men with pattern hair loss in the form of a once-a-day pill called Propecia in the UK. Finasteride is also available without a licence in topical hair growth treatments. It works by inhibiting the enzyme 5-alpha reductase, which reduces scalp dihydrotestosterone (DHT). This DHT is the main hormonal driver of follicular miniaturisation which leads to hair loss. However, despite its impressive actions, there is a darker side. Finasteride is not suitable for everyone. Additionally, some patients can experience serious and persistent side effects including sexual dysfunction and mood disorders. In this article we explore alternatives to finasteride for hair loss and how they compare for safety and effectiveness.
Why is There a Need for Alternatives to Finasteride?
First of all, finasteride isn’t suitable for everyone. This includes premenopausal women and people with a history of mental health conditions like anxiety or depression. It might also not be appropriate for patients requiring ongoing PSA monitoring as it can falsely lower these results. Even for appropriate patients there are rare but very severe side effects that can persist even after stopping treatment. Additionally, like all hair loss treatments, finasteride requires ongoing long-term use to maintain results. As such, the main reasons people seek alternatives to finasteride include:
- Risks: there are potential serious sexual side effects (such as reduced libido or erectile dysfunction), anxiety, depression, loss of concentration and suicidal thoughts.
- Fertility: finasteride can affect the development of male embryos.
- Practicality: some people prefer not to use a long-term systemic medication.
- Effectiveness: it does not work for everyone, even if they have DHT-associated hair loss.
Alternative Treatments to Oral Finasteride
There are a number of topical and oral alternative medications to oral finasteride. Like most hair loss treatments, these are mainly unlicensed or off-label medicines that doctors use based on scientific research data. The main alternatives to oral finasteride include:
- Topical finasteride: this works locally to reduce the effects of DHT on the scalp but with significantly lower absorption into the bloodstream than oral finasteride. As such, there is a lower risk of systemic side effects. This might be useful for patients who are nervous about the side effects of oral finasteride. However, whilst systemic absorption is reduced, it is not eliminated. Topical finasteride is not a risk-free alternative and is probably best to avoid if you have had negative side effects to the oral form.
- Spironolactone: both oral and topical forms of spironolactone can help block androgen hormones. Studies have shown both to be useful in men and women suffering from pattern hair loss. They are associated with fewer serious side effects than finasteride. However, neither form of spironolactone is licensed for use in hair loss and as such they are less commonly available. Given their mechanism of action, it is, however, reasonable to assume that patients who experienced sexual dysfunction from finasteride may not find spironolactone useful as an alternative.
- Minoxidil: this is available over the counter in 2 and 5% topical treatments or by prescription in higher strengths or oral form. Minoxidil does not affect DHT. Instead, it prolongs the anagen (growth) phase of the hair cycle and increases blood supply to the follicle. As such, it does not have the same side effects as finasteride but it is also less effective at suppressing DHT-mediated hair loss.
- Dutasteride: another unlicensed treatment that is available in oral and topical forms. Dutasteride inhibits both type I and type II 5-alpha reductase enzymes. This makes it more potent than finasteride at blocking DHT. It has similar potential side effects as finasteride. As such, it is not suitable for patients needing an alternative to finasteride due to side effects. It is, however, suitable for those who tolerated finasteride but saw limited progress or who have plateaued.
- Experimental: there are a number of promising new androgenetic hair loss treatments that are still under investigation. These include deoxyribose hair gel, PP405 molecule, VDPHL01, MLPH and Breezula. The latter is most exciting as a finasteride alternative because Breezula is a topical androgen-receptor inhibitor. As such, it can help block DHT activity on hair follicles. However, none of these treatments are available yet as they are still undergoing clinical studies.
Non-Pharmacological Alternatives
If the idea of using oral or topical treatments daily for life does not appeal or is not possible, there are some alternatives. However, it is important to be aware that on their own, most of these treatments are insufficient for anything more than very mild hair loss. They’re also not permanent and require maintenance, often with some form of topical treatment for best results:
- Platelet-rich plasma (PRP): this treatment involves injecting concentrated platelets from your own blood into the scalp to stimulate hair follicle activity. Although it is increasingly available and there are some promising results, research is still limited. PRP also does not block DHT but for people where it works, it can help increase hair density and quality.
- Microneedling: professional microneedling helps stimulate growth factors from the scalp which can promote regrowth in some people. At-home microneedling can help enhance absorption of topical treatments like minoxidil. Whilst the data shows that microneedling can be beneficial, its effects are modest and it isn’t really useful by itself.
- Low-level laser therapy (LLLT): regular use of LLLT devices can help boost hair thickness in some people. However, evidence is variable and research is limited. As such, they’re unlikely to be useful as a main or single treatment.
Supplements & Non-Medical Treatments
Alongside prescription and professional treatments, there is a bustling market in non-medical hair growth alternatives. These options vary widely in terms of their supposed mechanisms of action and the quality of evidence behind them. As always, take with a grain of salt any products that claim to be “natural alternatives” to finasteride as no such thing exists. There are, however, a few ingredients that may help as adjuncts to other hair loss treatments:
- Saw palmetto: this may weakly inhibit the 5-alpha reductase enzyme and hence block DHT damage to hair follicles. It is, however, significantly weaker and less predictable than finasteride. As such, any benefit from saw palmetto is usually modest and slow.
- Fluridil: available in over-the-counter creams or serums, this compound has mild anti-androgen effects. In small clinical studies, fluridil shows some promise in helping reduce androgenetic hair loss.
- Pumpkin seed oil: the phytosterols in this oil may have anti-androgen activity. Small studies suggest a possible benefit in treating hair loss but data is limited and inconsistent.
- Rosemary oil: small studies suggest this oil may modestly improve hair density over several months, possibly via improved scalp circulation and anti-inflammatory effects. Any results are typically subtle.
- Caffeine: this may help stimulate the follicle and increase hair growth with similar results to low-concentration minoxidil.
- Ketoconazole: beyond its use in treating seborrhoeic dermatitis, some studies show that regular use of this antifungal shampoo can help reduce androgenetic hair loss.
For many patients, finasteride remains the most effective and evidence-based treatment available. Although most patients tolerate it without problems, some can experience severe systemic side effects that persist long after stopping treatment. It’s also not suitable for everyone. As such, there is a demand for alternatives to oral finasteride in particular. Whilst there are some genuine alternatives to finasteride for hair loss, none are perfect substitutes. It is best to work with your medical provider to find the best and safest treatment option for your hair loss.
At City Skin Clinic, we offer personalised hair loss treatments for men and women through our online clinic. Our doctors create custom hair treatments using actives such as minoxidil, finasteride, dutasteride, spironolactone, melatonin, caffeine and tretinoin where appropriate. To start your personalised plan, book a virtual video consultation or use our online consultation form. The journey towards great skin and hair starts here.
This article is intended for general informational purposes only and is not a substitute for medical advice, diagnosis or treatment. Always consult a qualified medical professional with any concerns about your hair or treatment options.
