Finasteride after Hair Transplant: Is it worth it?

Among the medications used after hair transplantation, finasteride is one of the most commonly prescribed. Many clinicians recommend the use of finasteride for at least 1 year post-surgery. But is this approach truly justified? In this article, we will examine this question. Finasteride is a molecule that blocks the enzyme 5-alpha-reductase, thereby preventing the conversion of testosterone to dihydrotestosterone (DHT). This helps in preventing genetic hair loss. But why is this treatment recommended after hair transplantation? To better understand this, we will examine the use of finasteride under two different headings.

1) Finasteride Use After Hair Transplantation in Individuals Aged 18-40:

Post-operative use of finasteride is common among individuals aged 18-40 who decide to undergo hair transplantation. When classified according to the type of hair loss, there may be native hair in the transplanted area, or the hair loss may be characterized only in the frontal line or the crown. If hair transplantation is performed in these areas, the native hair may continue to shed. If baldness, which is considered static, dynamically increases in an area where hair has been transplanted, patients may continue to be dissatisfied after the transplant. At this point, clinicians recommend the use of finasteride post-transplant. With the use of finasteride during the first post-operative year, both the transplanted hair and the native hair merge to create a dense appearance. However, contrary to popular belief, this appearance is maintained only as long as finasteride use continues.

When finasteride is discontinued, the native hair will shed, and only the transplanted hair will remain. Patients often return to clinics at the end of the first year, reporting that hair loss has resumed and that their hair has thinned.

At this point, we can say that the short-term use of finasteride after hair transplantation masks the true results.

2) Finasteride Use After Hair Transplantation in Individuals Over 40:

By the age of 40, hair loss in individuals is usually more established. In this case, the donor and bald areas are more distinct. Planning is done on a more static area, so significant increases in baldness in the transplanted area are not expected. However, this is not applicable to everyone over 40. Although rare, hair loss can begin in the 40s and become more pronounced in the following years. In these cases, the type of baldness, the miniaturization around the bald area, and family history should be carefully examined. In cases where hair loss is not significant, the use of finasteride after the procedure is also recommended for patients over 40. In such cases, a masking effect can also be observed. When finasteride is discontinued, hair loss generally continues in the area outside the transplanted hair.

When these two situations are examined, hair loss should be evaluated under various decision algorithms.

However, we operate under the principle that no treatment or surgical procedure should pose a greater risk than the disease itself. In this case, we limit the use of finasteride significantly, and we do not recommend it to 90% of our transplant population.

What Are the Possible Risks of Using Finasteride After Hair Transplantation?

According to an article published in The Journal of Sexual Medicine in 2012; “Finasteride has been associated with sexual side effects that may persist despite discontinuation of the medication. In a clinical series, 20% of subjects with male pattern hair loss reported persistent sexual dysfunction for ≥6 years, suggesting the possibility that the dysfunction may be permanent” (1). These side effects included a wide range of symptoms such as changes in cognition, ejaculate quality, and genital sensation.

A study conducted in Italy in 2019 also found that “In all domains, a significantly higher number of cases were present in patients treated with finasteride at the lower dose (1 mg) in comparison to those with the higher dose (5 mg). In particular, within the sexual domain, an increased sexual dysfunction, decreased or loss of libido, disorders of ejaculation, erectile dysfunction, testicular atrophy, orgasmic disorders, and hypogonadism were reported by 1 mg finasteride users, while in the psychological domain, the same dose was associated with increased self-harm, slow cognition, psychological pathology, change in emotional affect, and sleep disturbances, compared to the higher dose” (2). Additionally, “regarding the physical domain, significantly increased reports about skin rash and metabolic abnormalities were indicated by low dose finasteride users. Gynecomastia was more frequently reported by 5 mg finasteride users, although this increase was not statistically significant.” These side effects were observed even in those taking 1 mg finasteride.

Another report collected 131 web-based surveys from patients experiencing new symptoms after finasteride use. Subjects were recruited from those seeking medical help after treatment or visiting the Propeciahelp.com website (Ganzer et al., 2015). Authors divided symptoms collected from patients in five categories: physical, sexual libido, disorder of penis and testes, cognitive disorders and psychological disorders. From each category, the higher percentage of cases regarded: gynecomastia (70% of cases in physical category), decreased sex drive (93% of cases in sexual libido category), diminished semen volume and force (82% of cases in disorder of penis and testes category), mental cloudiness or brain fog (75% of cases in cognitive disorders category) and elevated anxiety (74% of cases in psychological disorders category)

When these side effects are examined, it is evident that individuals are dealing with serious health issues instead of focusing on their hair loss problem. It is likely that the number of receptors formed during finasteride use does not quickly upregulate even when the treatment is discontinued.

Finasteride also has topical forms available in some countries. Especially regarding the safety of topical use, the Journal of Sexual Medicine stated that “Topical finasteride reduces the potential for systemic side effects, including the risk of sexual dysfunction. The side effects are localized to the application site, for example, scalp pruritus, burning sensation, irritation, contact dermatitis, and erythema” (3). If finasteride use is necessary, it is important to prefer topical forms over tablet forms.

Conclusion:

How can we minimize the use of finasteride after hair transplantation to maximize outcome-related results and eliminate post-operative medication risks for patients?

• Determining the Safe Donor Area:

The safe donor area contains hair types that are not affected by DHT. Because the hair in this area is structurally resistant to DHT, they can grow healthily for a lifetime when transferred to recipient areas without the need for any medication. If the safe donor area is exceeded, hair obtained from the surrounding area may be affected by DHT and may be subjected to hair loss in the transplanted area.

• Planning Hair Transplantation Sessions:

Correctly planning hair transplantation sessions at the right age brings realistic results and meets patient expectations. We have explained the intervals between hair transplantation sessions in detail in our article.

• Planning Post-operative Treatment:

Avoid treatments such as oral finasteride use that mask the real results of hair transplantation in the short term. Instead, safer topical treatment procedures should be planned for the short, medium, and long term. Safe treatment procedures should be taught to patients for these periods.

By following these steps, it is possible to reduce the dependency on finasteride after hair transplantation and to achieve long-lasting, satisfying results for patients.

 

 

Bibliography

1)The Journal of Sexual Medicine, Volume 9, Issue 11, November 2012, Pages 2927–2932, https://doi.org/10.1111/j.1743-6109.2012.02846.x

2) Silvia Diviccaro, Roberto Cosimo Melcangi, Silvia Giatti, Post-finasteride syndrome: An emerging clinical problem, Neurobiology of Stress, https://doi.org/10.1016/j.ynstr.2019.100209

3) Michael S. Irwig, Persistent Sexual Side Effects of Finasteride: Could They be Permanent?, The Journal of Sexual Medicine, Volume 9, Issue 11, November 2012, Pages 2927–2932, https://doi.org/10.1111/j.1743-6109.2012.02846.x