If you’ve started to notice the hair on your head thinning, you may have also searched the internet for potential solutions. If so, you’ll have likely come across an ocean of self-proclaimed experts selling snake oil for inflated prices. However, you may have also heard about “The Big Three”

What are the Big Three in Hair Loss?

The Big Three refers to the main products used to treat male pattern baldness (also known as androgenetic alopecia), which help to stop hair loss and in some cases even help stimulate new hair growth. The  Big Three are generally regarded as the most effective treatment combination and the holy grail of hair loss products.

The three products are Finasteride (Propecia), Minoxidil (Regain), and Ketoconazole (Nizoral). Finasteride and Minoxidil are the only medications that have been approved by The Medicines and Healthcare products Regulatory Agency (MHRA) for the treatment of hair loss in the UK. While Ketoconazole is an antifungal drug, it can be prescribed off-label for the treatment of hair loss. The use of these three products together on a daily basis is widely recognised as the optimal technique for fighting male pattern baldness.

  • Finasteride: 1mg tablet to be taken on a daily basis
  • Minoxidil: topical solution applied directly on the scalp 1-2 times daily
  • Ketoconazole: hair shampoo to be used 3-4 times weekly

Read below to find out what causes male pattern baldness and what scientific proof is behind The Big Three.

What causes Male Pattern Baldness?

Male pattern baldness is also known as androgenetic alopecia, meaning that it is caused by androgens and a specific genetic predisposition. In other words, your hair follicles are more sensitive to the changing hormonal activity in your scalp.

A hormone called dihydrotestosterone (DHT) causes a change in the hair follicles. The enzyme 5α-reductase is what catalyses the conversion of testosterone into DHT and is found producing DHT in the testes, adrenal glands, prostate, and hair follicles. DHT binds to the hair cell receptor and causes to reduce the growth phase (anagen phase) of the hair cycle.

As a result, the hair follicle will produce thinner and weaker hairs until it stops producing hair altogether and you lose that follicle.

Do The Big Three really work for hair loss?

There are really only two questions which need to be asked in order to find the answer to whether The Big Three actually work as a treatment for male pattern baldness.

  1. Do Finasteride, Minoxidil or Ketoconazole work individually as a treatment for hair loss?
  2. What are the benefits of using The Big Three together?

Let’s take a look at the three treatments individually and see how they work and what the science behind them is.

Finasteride

Background

The first product that forms part of The Big Three is Finasteride, which is more commonly known under its brand name Propecia. It was developed by Merck and approved for the treatment of androgenetic alopecia in 1997.

What is the difference between Propecia and Finasteride?

There is no difference apart from the price. Finasteride is the active ingredient in Propecia and it is identical and equally effective. Generic Finasteride is about a third of the cost of Propecia.

How does Finasteride work?

Finasteride comes in a 1mg tablet and belongs to a class of medication known as 5α-reductase inhibitors. It works by blocking the 5α-reductase from converting testosterone into DHT, the hormone that is responsible for hair loss. Hence Finasteride is also commonly referred to as a DHT-blocker.

DHT is blocked only while Finasteride is active in your body, so for Finasteride to have the full effect it must be taken every day. Once discontinued, your body will start to convert testosterone to DHT again and as a result, your hair loss will continue.

The Science behind Finasteride

Research has found that 90% of Finasteride-treated men either maintained (no further visible hair loss), or sustained visible improvement in hair growth over five year period. 65% of men saw an increase in hair count after taking 1mg Finasteride daily over a five year period.

Side Effects

About 1.5% of men that use Finasteride may experience side effects such as a reduced sex drive or erectile problems. Data from the FDA shows that for the majority of men the side effects stop once treatment with Finasteride is discontinued.

Read here for a full guide on everything you need to know about Finasteride.

Minoxidil

Background

In the 1960s Minoxidil was used to treat hypertension in but researchers found it resulted in unexpected hair growth in some of their patients. The MHRA and FDA approved in Minoxidil in 1988 as a treatment for male pattern hair loss under the trade name Regain (UK) and Rogain (US).

What is the difference between Regain and Minoxidil?

Similar to Finasteride and Propecia, there is no difference between Minoxidil and Regain apart from the price. The effectiveness is identical as they share the exact same active ingredient.

How does Minoxidil work?

Minoxidil is a topical solution which is applied directly to the scalp about 1-2 times daily. The strength of Minoxidil in the solution can vary from 2% to 6% (extra-strength), where the higher percentage is usually recommended for the treatment for men. Minoxidil should be applied for at least four months before any hair regrowth can be seen. The treatment must be used consistently to increase the chance of seeing results.

Minoxidil is believed to work by widening blood vessels and opening potassium channels, hence allowing more oxygen, blood and nutrients to the follicle on the scalp. This stimulates the follicle, increasing the size of the hair shaft diameter, and prolongs hair growth. So while Minoxidil does not technically stop hair loss, it serves to promote further hair growth.

The Science behind Minoxidil

Several academic studies using a Minoxidil 5% solution were conducted. In 2012, a twelve-month study of about 1,000 men with male pattern baldness found Minoxidil to be effective in over 65% of patients for stimulating hair growth.

Another study tested a 5% solution of minoxidil on 743 men with male pattern baldness over the course of 4 months. It was found to be either very effective or effective in stimulating hair growth for 62.5% of the men. 74% of men also reported that Minoxidil had noticeably increased the thickness of the hair.

Side Effects

As with any treatment, the use of Minoxidil may cause some mild side effects such as skin irritations on the scalp.

Read here for a full guide on how Minoxidil works.

Ketoconazole

Background

Ketoconazole is the last member of The Big Three in hair loss and is commonly better known under the brand name Nizoral. Ketoconazole is an anti-fungal shampoo that in the UK is licensed to be used to treat dandruff treatment. However, it can be prescribed off-label to treat male pattern baldness if the prescriber deems the treatment relevant.

What is the difference between Nizoral and Ketoconazole?

Once again, there is no difference. Nizoral is the brand name, while Ketoconazole is the active ingredient that works the magic behind the scenes. Usually, the branded products come with a hefty price tag, although they work in an identical manner.

How does Ketoconazole work?

While it is not entirely clear how exactly Ketoconazole works it is believed that a microbial-driven inflammatory reaction on the hair follicles might participate in the hair status anomaly and have DHT-blocking capabilities.

Ketoconazole comes in either 1% or 2% shampoo solutions and should be used 3-4 times a week.

The Science behind Ketoconazole

Even though there are no extensive long-term studies, assessing the effectiveness of Ketoconazole shampoo on male pattern baldness, recent academic research has found that Ketoconazole locally disrupts the DHT production in hair follicles and hence reduces hair loss.

While Ketoconazole is probably the least effective of the three treatments, it has shown to significantly improve the outcome when used in conjunction with Minoxidil or Finasteride.

We have written a detailed article on how exactly Ketoconazole works and the science behind it.

Side Effects

Side effects for Ketoconazole are very light and may include stinging, swelling, or irritation of the scalp. No other more serious side effects are known.

Can I use The Big Three Together?

Each of the three treatments show scientific evidence in stopping male pattern baldness and in some instances even enhance the growth of hair. However, is it safe to use all three together or could they potentially counter-effect each other?

The short answer is that the best chance of keeping your hair is to use them together. Even though they work separately, studies have shown that the efficacy of the treatments increases when combined with each other.

They are really all you need to kick-start your hair-loss treatment and get the best possible results. So say goodbye to expensive bogus treatments promising you the world and get started with The Big Three.

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