If you notice anything wrong with your hair and scalp, whether it seems it’s thinning, receding, itchy, or brittle, see a doctor and dermatologist for blood tests and scalp evaluation. Hair issues are not always the result of “androgenic alopecia” (AGA), and it could be something unrelated like seborrheic dermatitis.
First, look at treatments in the Learn section. There’s good information in there. If you want advice and opinions on photos of your hair, post to the monthly selfie thread, then start a journal if you decide to begin treatment, and use search before asking any questions. You should also try chatting with TresslessGPT, which is free to use and based on research and community experiences. You can also see best of Tressless, which is a curated set of community posts and research on a monthly basis.
My story
When I was combing my hair six years ago, I noticed there was a lot less density on both sides of my temples. Upon closure inspection, I realized that my hairline was becoming more of an M shape and that my overall hair was fine/brittle. I went to the doctor to get checked out, hoping for her to tell me that it was just a maturing hairline, but to my shock, she told me that I had early signs of male pattern baldness. I thought I didn’t need to worry about balding until I was at least in my 40s, and boy was I wrong. From that day forward I dedicated a lot of my time to talking with dermatologists, researching, reading testimonials, and surfing reddit for the answers on saving my hair. Hopefully, this guide helps simplify hair loss for newbies just starting out and provide additional solutions to those who are on treatment and still struggling.
Beginners starting out
In the world of hair loss, there is a ton of information and it can be difficult to figure out what products you truly need versus the heavily advertised “snake oil” products that you don’t need. If you have read Tressless or other hair loss resources, you might have heard people say "Do The Big 3’', which is:
1. Finasteride (also known as Propecia)
2. Topical Minoxidil (Rogaine)
3. Ketoconazole shampoo (Nizoral)
More recent research shows that it should really be “The Big 4”, adding:
Lets look at what each of The Big 4 does, how to get them, how to use them, where to buy them, and other tips/facts that will be useful to know.
1. Finasteride (Propecia)
Finasteride is the absolute first line of defense to protecting your hair. Without it, you won’t be able to target the root cause of your hair loss. DHT, which is a byproduct of testosterone, causes specific hair to miniaturize until the follicle is unable to produce any noticeable hair. Finasteride is a widely used “5-alpha reductase” (5ar) inhibitor in charge of preventing the testosterone from converting into DHT at up to 70%. In the best cases, you might gain some hair back. All you have to do is consistently take one pill a day. The most common dose for finasteride is 1mg, but some people take 0.25, 0.5 mg, and 1.25mg as well.
Stopping the conversion of Testosterone to DHT is going to be the biggest factor in this entire process.
In order to get this medication, you have to get it prescribed by your doctor or dermatologist, online or otherwise. Internet telemedicine seems to come at the cost of potentially higher prices (in the US: Hims, Keeps and Getroman). In the US, the cheapest way I found to get finasteride is to get the generic version prescribed in person or by a normal dermatologist online (not sites listed above) and use CostPlus, at a current cost of $2.50/month. Other options are listed in the finasteride products section.
If you have done any research about finasteride, you most likely came across warnings about side effects or people’s horror stories about their bodies reacting negatively to finasteride. Just like any other medication, there are always going to be some people who do not react favorably to certain drugs or medications. Fortunately, based on all studies we have, the percentage of men who experience any negative side effect was around 2.1% to 3.8%. WHILE I AM NOT A DOCTOR, if you do get side effects it would be a wise to either lower the dose to 0.5mg or 0.25mg, or quit. Another route you can take is use topical finasteride, where you apply the liquid to the head instead of taking the pill, however, it still goes systemic to some degree.
Lastly, you need time with finasteride to see results. For some, this can be 4 months to 2 years. It all depends on how good of a responder you are to the drug, so just be patient.
See more information about finasteride in the Learn section and search.
2. Topical Minoxidil (Rogaine)
Topical minoxidil is a growth stimulant that works by keeping your hair in the anagen (active growth) phase longer - so instead of having hair follicles resting, it is telling the body to move them back into a growth phase by shortening the resting phase. The idea here is that you get more ‘regrowth’ of hair follicles, as seen in the image below.
Topical Minoxidil comes in two different forms, liquid and foam. The liquid is the cheapest of the two, however, it is known to be messy and irritating for quite a few people’s scalps. Foam is more expensive but not anywhere as messy and irritating.
For application, you should apply Minoxidil two times a day to get the best results. The liquid version of the minoxidil is known to make your hair a bit greasy and also make your hair kinda clump together. As a result, this can make the appearance that you are thinning/ balding more than you actually are. I would use a good quick dry foam version of minoxidil in the morning to keep your hair looking great and use the cheap liquid version before you go to bed at night.
As far as side effects, other than it irritating some people’s scalps, there were really no common side effects that are reported by the vast majority of users. Unlike finasteride, you do not need to get a prescription for the doctor for the 5% version of topical minoxidil. You can buy it OTC (over the counter) at pretty much any store that carries simple medications.
In the US, the cheapest I have found for a 6-month supply liquid version was a tie between either Sam’s Club/ Costco at around $18 bucks. If you don’t have a membership, the second place I found was a tie between Walmart/Amazon for around $23 bucks. If you’re looking for a basic foam version 6 month supply, Walmart and Costco are the cheapest with both around $50 bucks. For other options or outside of the US, there are a lot of options in the product finder.
If you can’t tolerate topical minoxidil for some reason, other options to look into are Rosemary oil, castor oil, and possibly oral minoxidil.
Oral minoxidil seems to be very powerful at regenerating ‘baby’ hairs (or, new regrowth). Again, oral minoxidil can have some pretty significant side effects and drug interactions with blood pressure medications, so speaking through with your doctor is key!
It is not recommended to start both Finasteride and Topical minoxidil treatments at the same time since you won’t know which treatment is working. I would start Finasteride first and wait around a year or so to see if any results come up then you will know if the Topical minoxidil is helping at all
See more information about minoxidil in the Learn section and search.
3. Ketoconazole shampoo (Nizoral)
Out of all the other shampoos that claim to reverse hair loss, Ketoconazole shampoo is the best in terms of the limited number of studies available on it. It decreases the production of testosterone on the scalp, which is known to convert into DHT. With lower levels of testosterone available to create DHT, the hair follicles are a little bit healthier, denser, and fuller. Whilst the shampoo is primarily an anti-dandruff shampoo, research has also shown it may increase the proportion of hairs in anagen phase (growth phase) - resulting in reduced hair shedding. This study showed that 1% ketoconazole shampoo increased hair diameter over baseline after 6 months of use and reduced shedding. Interestingly, participants’ hair diameter also increased over baseline, showing that it may play a role in creating thicker hair.
The 1% formulation called Nizoral can be bought over the counter at pretty much any drugstore. However, the 2% version has to be prescribed by a dermatologist. It is not clear whether the 2% is more effective than the 1%, however, it is worth pointing out that the studies used 2% Ketoconazole shampoo in the testing.
While Ketoconazole shampoo sounds great in theory, it is either a hit or miss product for most people. Some people get decent results with it, while other people find it not really doing much for them. I say it is at least worth trying out since a 7-ounce bottle on amazon costs around only $15 bucks.
Most users recommend that you use Ketoconazole shampoo 2 to 3 times a week and leave it on your hair for 5 to 10 min so that it can soak into your scalp. Some users use their own personal shampoo after applying Ketoconazole, but most would agree to apply conditioner after to make sure your hair does not dry up.
See more information about ketoconazole in the Learn section and search.
4. Microneedling
Microneedling is the process of puncturing small holes into the scalp in order to encourage the body to grow new hairs and can allow for better absorption of topical medications. Microneedling (also known as dermarolling) causes your body to produce a wound healing response, with an array of tiny microneedles.
In this study, the dermarolling + minoxidil treated group was statistically superior to the minoxidil only treated group in promoting hair growth in men with balding patterns, for all primary efficacy measures of hair growth. In fact, the microneedling group outperformed even the minoxidil group in terms of how much hair was regrown after 12 weeks:
There are three different types of microneedling devices you can use: derma pen, derma roller, and derma stamp. The vast majority of users recommend the dermapen since they’re effective, affordable, and aren’t as destructive as rollers.
The most common protocol is to microneedle once every 1 to 2 weeks at a 0.6-1.5mm depth. Yes, there are many different protocols out there that have different frequencies and needle depths. As far as what is the best best “derma pen” out there, the 2 big ones you hear about will be Dr Pen and Derminator 2. Dr Pens are actually a generic brand that seem to be sold by many different companies. Derminator 2 is probably better, but has a much worse form factor, is more expensive, and is sold from a shady Eastern European company.
There are a bunch of different Dr Pen models such as the M8, A6, and N2, you just have to find one that fits your budget. They cost anywhere from $35 bucks to $180 bucks depending on what accessories you get and where you buy them from. Do not buy them for Drpen.com, DrpenUSA.com, and maybe Amazon (their prices are high). People who have bought pens from the first two websites mentioned have had scamming issues, faulty products, poor customer service, and a host of other issues. The best place to buy Dr. pens from is going to be eBay since they have a great customer protection/return policy and decent delivery times. Aliexpress is another place that other Reddit users have said is a good place to buy as well, however, it takes a long time for it to get delivered, but the prices are a bit better than eBays. The derminator 2 can only be bought from vaughterwellness.com and the cost is going to be around $200.
What is important is hygiene. With microneedling, you are puncturing your skin. Cleaning your microneedling device with alcohol before and after use is going to be your best option to stop any chance of infection.
See more information about microneedling in the Learn section and search.
How will I know if it’s working?
Your hair will probably shed multiple times. Tressless users talk about this a lot. It’s scary, but is positive in the long term, as your hair is being thrust into a growth phase and will come back stronger than ever. Tressless members have recommended tracking the general volume of shedding by getting a “hair snare” for your shower, like this one. This is not scientific, but in checking the snare once in a while, you should notice the shedding slowing down over the months.
How long until I see results?
Probably more than a year. Take photos in the same exact lighting conditions to track the visual progress, but don’t expect anything for a long time. You can see examples in the monthly selfie thread. It’s important to not obsess over small changes, just be patient.
Now onto the second half, for those who are on The Big 4 protocol, have waited at least a year, and are not satisfied with their results.
Certain medications may work better for some people, but may not work at all for other people. Some will need to upgrade to stronger medications and add more protocols to their routine/stack. The goal is not to use every single possible treatment for hair loss, but to use enough to see results. There are many other treatment options, but it’s still a matter of trial and patience.
1. Dutasteride
Dutasteride is another prescription 5-alpha reductase inhibitor. What makes Dutasteride different from Finasteride is that it blocks 90% or more of the DHT, and blocks both types (I and II), which makes it a potent solution to halt the hair loss, but perhaps has a higher incidence of side effects. Because this drug is not approved for hair loss in most countries, your doctor may not want to prescribe it. Personally, I had to go to 3 different dermatologists before one was willing to prescribe it.
The application is the same as Finasteride, and it either comes in a tablet or a capsule at a 0.5 mg dose. Due to the drug being “off label”, a lot of the US-based online telemedicine companies (Hims, et al) don’t offer it. The only two ways that I know of are to either to see a dermatologist in person or online and speak with a regular online dermatologist. The cheapest I’ve found for getting Dutasteride was around $14 bucks at my local pharmacy using Good RX.
As you can see in the study below, Dutasteride suppresses blood levels of DHT to a much greater degree than Finasteride. Not only this, but the half life of Dutasteride is significantly longer than Finasteride (~8 hours vs. 5 weeks!), and you can see that in the Dutasteride group after stopping treatment (Follow-up Period), DHT levels remained suppressed for a much longer time:
Just like finasteride, there are topical versions that you can use, which some say have fewer side effects. There are some pharmacies and online vendors that compound different topical medications to make applying topically less of a hassle. Examples that you may find are Finasteride+minoxidil, Dutasteride+minoxidil, Finasteride+minoxidil+tretinoin, etc.
See more information about Dutasteride in the Learn section and search.
2. Topical Minoxidil 5% with Mirconeedling and Tretinoin.
Topical minoxidil is one of the safest and most effective treatments we have as a growth stimulant. However, studies on its efficacy showed that only 40-60% respond positively to the treatment. Now the question is why is it that around half of the users are unsuccessful with the medication? Well, we think it has to do with if you have enough of the sulfotransferase enzymes in the scalp. Half of the people do not have enough of the needed enzymes in order for the minoxidil to do its job. There are two ways to help people to become better responders to topical minoxidil that are backed up by studies.
Microneedling can help the scalp be more permeable to topical medications, minoxidil included.
Tretinoin is a medication that is used to help fight acne and other skin problems. However, there were multiple studies showing that a small amount of tretinoin that was applied to the hair or mixed with other topicals, helped aid in hair growth. It is important to note that just like Ketoconazole shampoo, tretinoin is a hit more miss for people that use it for hair loss. I would encourage you to research about how effective this seems to be, which you can read about in the Learn section.
2A. Oral minoxidil
Oral Minoxidil comes in the form of a pill like oral Finasteride or Dutasteride. Because it is not being applied to the scalp area, the oral minoxidil runs through your body systemically.
Studies have shown that people respond to oral minoxidil better than topical since the process of of enzymes conversion is happening in the liver instead of the scalp. More of the needed sulfotransferase enzymes are found in higher concentrations in the liver, which leads to more hair growth.
Now if oral minoxidil is so effective, why isn’t it marketed and recommended by dermatologists? Because systemic minoxidil can lead to more side effects. Most people experience Hypertrichosis (excessive hair growth) but there are some that get negative side effects like low blood pressure, heart irregularities, and headaches. If you do get bad side effects, as with Finasteride you can reduce the dosage to reduce the negative effects. Unlike topical minoxidil, the oral version has to be prescribed by your dermatologist.
If you are not a good responder to the topical minoxidil even with microneedling/ tretinoin added, or you don’t want to go through all the hassle, oral minoxidil may be a good option for you. The cheapest way I found to get it will be the same way as Finasteride and Dutasteride.
3. Hair Transplant
A good/successful hair transplant is one of the most effective treatments that you can do fix your hair loss. An honest, reputable dermatologist will have to examine several things. The first thing to know is a hair transplant does not cure hair loss and if you haven’t stabilized your thinning, receding, or balding, you won’t have a long-lasting set of hair complete hair. Until you have halted the hair loss process, you will continue to recede in the original hair areas. The dermatologist won’t want to perform the procedure until they have a good idea of where the receding is going to end and that is why the mentioned medications/protocols above are critical for long-lasting hair.
The second thing to know is you have to have enough healthy “donor hair” in order to be able to have a transplant. Hair transplant surgeons like using the hairs from the back/ sides of the head since they are more DHT proof and have the best success rate of having a good hair transplant.
The cost of a hair transplant is substantially higher than the other treatments mentioned above. The cost can be anywhere from $2,000 USD all the way up to past $15,000. When it comes to how much should you spend, this is not something to shop around for the best price but to find a reputable hair transplant surgeon. The number of donor hairs you have available is not unlimited, so the procedure needs to be done right the first time so that you don’t exhaust additional donor hairs to fix cheap hair transplant mistakes. The cost to do a transplant is very high in the U.S and the UK so countries like Turkey and South Korea have become popular destinations due to the costs of hair transplants being much lower. Wherever you choose to go, you need to do your research and make sure that they have your best interest at heart. There need to be a clear understanding and communication happening so that you are happy with the results you get. Hair transplants take around 6 to 12 months for transplanted hairs to start regrowing and act like normal hair.
You can join the Tressless hair transplant community for more discussion.
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There are so many other options that I have not talked about, but if you want to look into other potential hair loss treatments/helpers here are some others to look into-
Low Laser Light Therapy, Platelet-rich plasma injections, Topical dutasteride, rosemary oil, castor oil, ru58841, vitamin D supplements, saw palmetto, realistic toupee/wigs, and micropigmentation/SMP.
Finally, if you want to go deeper, read Overview in the Learn section, it has a deeper dive on some of the same information here.
Here are YouTube channels that are well worth looking at that go deeper into each other the medications/ treatments/ protocols/ procedures that I talk about in the guide.