Hair loss is the largest men's category in which the gap between evidence and expenditure is widest. The biology is well described. The licensed options are few and well documented. The market surrounding them is enormous and largely unevidenced.
1. What is happening
In androgenetic alopecia, follicles in genetically susceptible areas respond to dihydrotestosterone by shortening the anagen, or growth, phase with each successive cycle, and by progressively miniaturising. The shaft produced becomes finer, shorter and less pigmented, until it is effectively vellus hair and then nothing. The follicle is not destroyed early on, which is why treatment can partially reverse recent loss and cannot recover an area that has been bare for many years.
The distribution is characteristic: temporal recession, then the vertex, with the occipital and lateral scalp largely spared. That sparing is genetically determined and is the fact that makes transplantation possible. Mechanistic background is in androgens and male skin.
2. The licensed options in the UK
| Treatment | How it is thought to work | Access | Key limitation |
|---|---|---|---|
| Topical minoxidil | A vasodilator whose mechanism in hair is not fully established; prolongs the growth phase and increases follicle size | Pharmacy, no prescription | Effect is lost within months of stopping; an initial shedding phase is common |
| Oral finasteride | Inhibits type 2 5-alpha reductase, reducing scalp dihydrotestosterone | Private prescription in the UK; not routinely available on the NHS for this indication | Effect is lost on stopping; recognised sexual adverse effects and other risks that require a proper consultation |
| Hair transplantation | Redistributes follicles from the spared donor area | Private surgery | Finite donor supply; does not stop ongoing loss elsewhere, so medical treatment is usually still required |
Both medical treatments share the same structural feature, and it is the one most often glossed over in advertising: they are indefinite. Stopping returns the scalp to the trajectory it would have been on.
3. Finasteride and the consent question
Finasteride is an effective treatment with a documented adverse effect profile that includes sexual adverse effects, and there is ongoing discussion in the literature and among regulators about persistence of symptoms in a small number of men after stopping. Mood effects have also been the subject of regulatory attention.
Two things follow. First, this is a prescription medicine and it warrants a proper consultation in which risks are discussed and documented, not a checkbox on a website. Second, the UK regulator operates the Yellow Card scheme for reporting suspected adverse drug reactions, and reporting is open to patients as well as clinicians. Anyone experiencing a suspected reaction can report it directly.
4. Where the evidence is weaker
Several interventions occupy a middle ground: plausible, sometimes with small or short studies behind them, sometimes widely used, but without the evidence base of the licensed options.
- Low level laser and LED devices. Some randomised evidence exists and effect sizes reported are generally modest. Devices are regulated as devices rather than medicines, so the bar is different.
- Platelet rich plasma. Widely offered, with a heterogeneous literature and no standardised preparation protocol, which makes the studies difficult to compare with each other.
- Microneedling. Studied mainly as an adjunct to minoxidil rather than alone.
- Topical finasteride and oral minoxidil at low dose. Used off licence by some prescribers, with a growing but less established evidence base.
- Ketoconazole shampoo. Reasonable for scalp inflammation, on which some men's hair appearance depends, but it is not a treatment for androgenetic alopecia.
And where the evidence is effectively absent: DHT blocking shampoos, most oral supplements marketed for hair, caffeine preparations, and anything promising regrowth in an area that has been bare for a decade.
5. It is not always androgenetic
Diffuse shedding rather than patterned recession suggests telogen effluvium, which follows illness, surgery, significant weight loss, severe stress or certain medications, and typically recovers. Discrete round patches of complete loss suggest alopecia areata. A scaly, itchy or scarred scalp with loss suggests a scarring alopecia, which is a reason to be seen urgently, because scarring is not reversible. Rapid loss with other symptoms warrants investigation, including thyroid function and iron status where clinically indicated.
The single most useful rule: patterned, gradual, over years is usually androgenetic. Anything sudden, patchy, itchy, painful or accompanied by scalp changes is not, and needs assessment.
6. Reading the hair clinic market
Hair restoration is a large, aggressively marketed, and unevenly regulated private market, in the UK and in the overseas destinations that advertise heavily into it. A few questions separate a serious provider from a sales operation: who performs the procedure and what are their qualifications, what proportion of the work is done by the named clinician, what happens if the result is poor, what is the plan for ongoing loss in untreated areas, and is there a written consent process with a cooling off period. The general framework is in assessing an aesthetic clinic.
7. Doing nothing is a legitimate choice
It is worth saying plainly, because almost nobody selling into this market will. Androgenetic alopecia is not a disease in the sense of threatening health. Shaving the head, or simply accepting the pattern, is a reasonable response that costs nothing and carries no adverse effects. The only argument for early treatment is that treatments preserve better than they restore, so a man who intends to treat is better off deciding sooner. A man who does not intend to treat loses nothing by declining.
8. What a realistic timeline looks like
Expectations are where most dissatisfaction in this area originates, and the timescales involved are longer than the advertising suggests. Hair grows in cycles measured in months, so no treatment produces a visible change in weeks.
With topical minoxidil, an initial increase in shedding in the first weeks is common and expected, since follicles moving into a new growth phase release the old shaft. Any assessment before four months is premature, and six to twelve months is a fairer point at which to judge. With a 5-alpha reductase inhibitor, stabilisation typically precedes any visible regrowth, and stabilisation itself is a legitimate outcome that is easy to undervalue because nothing appears to be happening.
Standardised photographs taken in the same light and position, three months apart, are worth more than memory. Almost nobody notices gradual change in their own reflection, in either direction, which is why men frequently conclude a treatment has failed when a photograph would show it has not.