Is topical medication better than oral medication in treating androgenetic alopecia?

Hello doctor,

I am a 34-year-old and have been suffering from androgenetic alopecia since my early twenties, causing social anxiety and depression. Finally, I was able to successfully fight further loss and regain a few of the already lost hairs by getting on the tablet Finasteride, first 1 mg every other day. After two years, there was no further improvement. I have been on it successfully for over eight years without ever experiencing any side effects.

But, unfortunately, did not start early enough with the treatment. I could not get all my hair back and have a higher hairline, as well as my crown is thinned out on a small spot (Norwood two to three vertex), which has been a concern of mine for a long time.

So I visited a hair restoration surgeon who told me he could only do surgery on my hairline since the crown is still full of too many more or less miniaturized hair. He prescribed me topical Dutasteride for regaining more hair thickness and regrowth. But after reading about the possibility of androgen receptor upregulation on 5ARIs, which means they can stop being effective if you block almost all DHT (oral Dutasteride reduces it approximately 94 percent, Finasteride only 60 to 70 percent) production, and some stories of people having adverse effects like more hair loss on them made me worried.

Is the so-called reflex hyperandrogenic a justified concern or just an internet rumor, and if not, how can I reduce or check the risk of it appearing? It would be disastrous for me if I lost more hair again and, in the end, perhaps have to quit all 5ARIs to downregulate the androgen receptors again.

Please help me.

Thank you.

Thank you, doctor, for the reply.

I just wanted to know whether there is a chance of loss of effectiveness of 5 alpha-reductase inhibitors and an increase in hair fall if I add topical Dutasteride to my oral Finasteride treatment and block almost all DHT production?

Please advise.

Thank you, doctor, for the reply.

• What gives you the certainty that an androgen receptor upregulation can not appear?
• Do you have experience with similar cases and prescribing a combination of Finasteride and Dutasteride?
• Is reflex hyperandrogenicity on 5ARIs medically possible?
• Have I already stopped the acute hair loss by inhibiting around 70 percent of my DHT production with tablet Finasteride and depriving my system of perhaps all the remaining DHT by adding topical Dutasteride, could be risky?

I want to be sure of my new treatment. Yes, after using a topical containing alcohol, I am experiencing mild seborrhoeic dermatitis and dandruff. I will perhaps add Nizoral shampoo with Ketoconazole if my natural treatment with apple cider vinegar and aloe vera juice is not working.

Please advise.

Thank you, doctor, for the reply.

I have also already read that it appears rarely. Why is it also not yet studied? Even if receptor upregulation seems to be a logical and common physiological pathway to restore hormonal balance and efficacy, I found two studies about androgen receptor expression in prostate (cancer) cells treated with Finasteride confirming it, but also one debuting it by even measuring a partial downregulation.

If someone has it, it possibly can be cured by the withdrawal of any 5 alpha-reductase inhibitors over several months, while having accelerated alopecia, I have read, which would be disastrous. So I will be better safe than sorry and try to exclude any possible risk occurring. Do you already know how it can be determined if someone is prone to it? Should I get my hormonal levels checked?

I got recommended using 2 ml of 0.1 percent of Dutasteride trichosol solution first once, and after a month without side effects twice a week, in addition to continuing my oral Finasteride 1 mg therapy. Would you somehow change the dosages or proceed only with one of the treatments, as you wrote you would suggest (topical) Dutasteride? Did you use it successfully on your age patients?

But since I have read that Dutasteride seems to be known for a little higher rate of gynecomastia development in patients than Finasteride, I should perhaps also mention that I have already tried out a bunch of different alternative treatments, including oral saw Palmetto tablet together with Finasteride tablet 1 mg until I developed a slightly enlarged mammary gland on my right chest and so had to quit the Saw Palmetto tablet for fortunately again losing it.

Considering this and with Dutasteride inhibiting both isoenzymes I and II of the 5-alpha reductase, just like tablet Saw Palmetto but much more potent and longer-lasting, would you still recommend it for my case? How much does Dutasteride lower scalp DHT? I know about it, achieving a reduction of more than 90 percent in the serum. If oral treatments lower serum levels more than scalp levels, do you have any data or experience on whether topical aRI application has higher efficacy than oral medicine?

Looks like trouble, I have already tried with an at-home device without much success. Unfortunately, it gave me a shock loss on my temple points compared to the photos from last time. I have sent you are not yet showing. Still, eventually, I would try it again with a specialized physician, microneedling. So I think I would instead consider the idea of Botox injection into the scalp.

But at first, I want to stick with the more promising DHT reduction therapy. Regarding seborrheic dermatitis, I already use Nizoral 2 percent shampoo. But it only appeared after more prolonged usage of an alcohol-containing topical. On my relatively dry scalp and the usage of apple cider vinegar and aloe vera juice already seems to reduce the redness, itch, and dandruff significantly, I would look at first try to avoid the shampoo with all its harsh ingredients (sulfates, parabens, etc.) until symptoms are continuing or worsening.

Please advise.