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Hair Loss/New treatment plan


QUESTION: Dr. Panagatacos,

I am a 29 year old male who has been on Finasteride since 2006 (1 mg/day for two years then 5 mg/day ever since). I also use rogaine foam twice a day, ketoconazole 2% shampoo every other day, and copper peptides once a day. I also used to use topical spironolactone 5% but since Dr. Richard Lee was shut down by the fda I no longer have a reliable source for spironolactone.

I started treatment as a diffuse Norwood 3 and managed to get to a Norwood 2 using all of the above in a span of roughly 3 years.

I have suffered from moderate seborrheic dermatitis since puberty and must use salicylic acid shampoo with either ketoconazole or coal tar daily to keep the itching and scalp buildup under control- even this combination sometimes does not work.

My hair seems to have regressed back to a diffuse Norwood 3 and I am contemplating adding in Avodart to my regimen as I feel my hair loss is quite aggressive (Norwood 3 by 20) My questions are:

1. Based on your clinical observations, Is taking avodart 3 or 4 times a week sufficient for treating hairloss that is no longer responsive to finasteride? I want to avoid daily intake as I have read it can decrease 5 alpha reductase type 1 levels by 50%. The 5 alpha reductase type 1 is present in the brain and we are not quite sure what the function is.

2. I want to continue to take finasteride on the days I do not take avodart as there has been studies that show some genotypes respond better to finasteride than dutasteride and vice versa. What are your thoughts?

3. Where can I source topical spironolactone?

4. Do you have any other recommendations for my proposed treatment plan?

I appreciate your time.

ANSWER:    Taking Avodart every other day will lower your DHT 80% and taking it daily will lower it 90%. The reason for taking either finasteride or dutasteride is to lower the DHT levels to a point where male pattern baldness is stopped. For 85% of men it only requires 1mg finasteride to lower the DHT 66% to accomplish this goal. For those men who continue to lose hair I advise gradually lowering the DHT by first taking the 5mg finasteride daily as you did, to lower the DHT by 72% and then to add Avodart once a week for a month, then twice a week for a month and then three times a week the third month.This gradual decrease of DHT rarely causes any more side effects than were noted when the patient was on only the 1mg finasteride. I think all men should respond better to dutasteride than to finasteride. The dosage will depend on the level of suppression you need to stop male pattern baldness and not have any side effects.  I do not know of any source of topical spironolactone and would be wary of any absorption of it as it blocks all androgen receptor sites. I'd advise continuing with your plan to add dutasteride to the point of taking it every other day alternating with finasteride. That should lower your DHT nearly 85%

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QUESTION: Dr. Panagotacos,

Thank you for your thorough reply. In your response you state Avodart every other day reduces DHT by roughly 80%. But you also mention that taking it every other day but alternating with Finasteride will inhibit DHT nearly 85%, so does this mean the two medications are additive?

Also, would it be beneficial to use nizoral shampoo daily? Have any of your patients seen any additional benefits from using nizoral every day?

Lastly, on your website you mention that you prescribe topical medications that work to inhibit DHT, can you please elaborate on these as I am interested?



The enzyme 5 alpha reductase Type II is suppressed very well for a day with finasteride but starts back again the next day. The suppression with dustasteride is a more even constant  lowering of DHT by suppression of Type I & II. The effect is additive by another 5% suppression if used every other day with finasteride but not as effective as Dutasteride daily which gives a 90% suppression.
 I have my patients use 2% zinc pyrithione shampoo daily however alternating with Nizoral shampoo would be just as beneficial. Daily use is superior to less frequent use. The point is to try and block DHT formation by exposure to the ketoconizole or zinc salts.
 The lotions I make up are only for patients I have personally seen and treated and contain prescription strength coritsone, andti-androgens , finasteride and dutasteride. They are not available to the general public.  

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Peter J. Panagotacos, <B>M.D.</B>


I have 30 years experience in the field of medical and surgical Hair Restoration and am Board Certified in Dermatology and Hair Restoration Surgery.


I have 30 years experience in the field of medical and surgical Hair Restoration and am Board Certified in Dermatology and Hair Restoration Surgery. More information can be found at my website

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