Hair Loss Treatments

Hair today… gone tomorrow? Don and Steve are combing through the claims to find out what really works. In this episode, they separate fact from fiction about hair loss treatments, tackling everything from minoxidil and finasteride to natural remedies and trending techniques.

💊Does oral minoxidil really outperform topical versions?
🧴Is topical finasteride genuinely a safer workaround, or do the same systemic side effects still sneak through?
🌿Are “natural” options like rosemary oil and saw palmetto actually regrowing hair… or just regrowing rumors?

Bad hair days meet bold claims — and our hosts are on the case. Strands, studies, and “so‑called solutions”… they pull out the magnifying glass to uncover the clinical truth.

They’ll share research and insights into some eyebrow‑raising claims, including:

• Oral minoxidil is more effective than topical versions for hair loss.
• Topical finasteride doesn’t have systemic side effects seen with oral tablets.
• Combining topical minoxidil with oral finasteride may be more effective than using them alone.
• Saw palmetto and rosemary oil are effective for hair loss

Plus, they tackle a trio of quick-hit myths—from family “in-hair‑itance” to grooming habits...and even a surprising pet danger.

Our listeners can get 10% off a new or upgraded subscription with code rvt1026 at checkout. 

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TRC Healthcare Editor Hosts: 

• Stephen Small, PharmD, BCPS, BCPPS, BCCCP, CNSC 
• Don Weinberger, PharmD, PMSP

Guest: 

• Jeff Langford, PharmD, BCPS, BCCP (Managing Clinical Editor at TRC Healthcare for NatMed)

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CE Information:

None of the speakers have anything to disclose. 

TRC Healthcare offers CE credit for this podcast for subscribers at our platinum level or higher. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter,or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

Claim Credit

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The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Chart: Treatment and Prevention of Hair Loss
• Article: Get to the Root of Male Pattern Baldness Treatments

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📣 New Podcast!📣

🌱Natural Medicines: Evidence in Practice 

Evidence, not hype. Concise, clinician‑ready guidance on natural medicines and integrative care. Episode 1: GLP‑1s & Nutrition is live now!

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Email us: rumorvstruth@trchealthcare.com

The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

Find the show on YouTube by searching for ‘TRC Healthcare’ or clicking here.

Learn more about our product offerings at trchealthcare.com.

Chapters

• 0:30 Introduction
• 0:51 Welcome
• 1:30 CE Information
• 1:56 Overview
• 3:13 Claim: Oral minoxidil is more effective than topical versions for hair loss.
• 10:49 Claim: Topical finasteride doesn’t have systemic side effects seen with oral tablets.
• 15:16 10% off code RVT1026
• 15:41 Fast Facts: Genetics, Hats & Shampooing, Pet Safety
• 17:37 Claim: Combining topical minoxidil with oral finasteride may be more effective than using them alone.
• 20:58 Claim: Saw palmetto and rosemary oil are effective for hair loss.
• 29:20 Summary
• 29:51 Rumor vs Truth Mailbag: Black Cohosh & Estrogen
• 32:10 A few more things...
• 33:16 Find us on YouTube!

Transcript

This transcript is automatically generated. 

00:00:05 Narrator
 Welcome to Rumor vs. Truth, your trusted source for facts, where we dissect the evidence behind risky rumors and reveal clinical truths.

00:00:13 Narrator
 Today, we'll split hairs over claims about hair loss.

00:00:22 Don Weinberger
 Whoa, I think our producer started this video a little too soon.

00:00:26 Don Weinberger
 Steve, what are you doing?

00:00:28 Steve Small
 Sorry, I was getting ready. I was putting some hairspray on.

00:00:31 Don Weinberger
 Oh, is that your regimen?

00:00:32 Steve Small
 It takes a lot to look this beautiful.

00:00:33 Don Weinberger
 I guess so, yeah.

00:00:35 Steve Small
 For these episodes.

00:00:37 Don Weinberger
 Well, that's good.

00:00:39 Don Weinberger
 Sorry, folks, you should tune into the YouTube.com to see what Steve actually was doing.

00:00:44 Don Weinberger
 Anyways, I am Don the Pharmacist.

00:00:47 Steve Small
 And I'm Steve the Pharmacist.

00:00:48 Don Weinberger
 In this episode, we're going to comb through claims about hair loss.

00:00:53 Don Weinberger
 As Steve was kind of spraying there, so we're going to shed some light on why hair falls out and which treatments might actually convince it to stick around.

00:01:01 Steve Small
 Right, and before we get into the right headspace here, I want to emphasize that this podcast offers continuing education credit for pharmacists, pharmacy technicians, prescribers, and nurses.

00:01:12 Don Weinberger
 And so just log into your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

00:01:22 Steve Small
 And for the purposes of disclosure today, none of the speakers have anything to disclose.

00:01:26 Don Weinberger
 Okay, so before we jump into these claims, let’s brush up a little on some Hair Loss 101.

00:01:32 Don Weinberger
 That’s, you know, male and female pattern baldness, also known as androgenic alopecia, where the androgen dihydrotestosterone, or DHT, binds to DHT‑sensitive hair follicles.

00:01:46 Don Weinberger
 DHT is converted from testosterone by an enzyme called 5‑alpha reductase.

00:01:50 Don Weinberger
 And over time, the DHT molecule actually signals those poor follicles to just shrink and stop producing visible hair.

00:02:00 Don Weinberger
 So that’s essentially the root of the problem.

00:02:04 Steve Small
 Right, and androgenic alopecia is not the only source of hair loss we have to think about.

00:02:08 Steve Small
 There’s also alopecia areata, which is an autoimmune condition where the immune system attacks the hair follicles, causing sudden patchy hair loss, typically the size of maybe a coin.

00:02:18 Steve Small
 And then there’s also telogen effluvium, where hair loss is sudden due to increases in stress, hormone imbalances, things like that.

00:02:26 Steve Small
 And we actually talked about this type of hair loss during our GLP‑1 side effects episode just a little far back.

00:02:31 Steve Small
 So go ahead and check it out.

00:02:32 Don Weinberger
 A good call out. That’s right.

00:02:33 Don Weinberger
 So if you want to stick around to the end, we have a listener question from our last episode about menopause, asking if black cohosh affects estrogen levels.

00:02:42 Steve Small
 Yeah, looking forward to that.

00:02:44 Steve Small
 And with that, let’s jump to our first claim here.

00:02:47 Steve Small
 And let’s curl up about this first hair loss claim we keep getting.

00:02:51 Steve Small
 It’s oral minoxidil is more effective than topical versions for hair loss.

00:02:57 Steve Small
 So to kind of look back and recap on this, oral minoxidil is an old drug from the 1960s, used as a vasodilator usually to treat high blood pressure.

00:03:07 Steve Small
 And during treatment, one peculiar side effect that patients noticed at the time was increased hair growth all over the body.

00:03:14 Steve Small
 And possibly because vasodilated blood vessels bring more blood and nutrients to follicles and help feed them, help them grow.

00:03:21 Steve Small
 So minoxidil for hair loss was born after that.

00:03:24 Steve Small
 Oral minoxidil can have rare risks, including side effects like heart palpitations, swelling in the legs, and things like that.

00:03:32 Steve Small
 So in the 1980s, a topical version of minoxidil was FDA‑approved specifically for hair loss.

00:03:37 Don Weinberger
 Yeah, oh yeah, we did talk about minoxidil and hair growth in our Retro Rumors 40th anniversary episode.

00:03:45 Don Weinberger
 Okay, so let’s fast forward to recent times, right?

00:03:49 Don Weinberger
 The question is, why is oral minoxidil becoming more popular for hair loss again, especially since this is prescribed without FDA approval or what we call off‑label?

00:03:59 Steve Small
 Yeah, off‑label indeed.

00:04:01 Steve Small
 There was a New York Times article back in 2022 that stated oral minoxidil was an option for patients, when topical options maybe didn’t work.

00:04:11 Steve Small
 So the interest really did sprout from there, you could say.

00:04:14 Steve Small
 But from randomized controlled clinical trials with this that came out afterwards, the results aren’t as clear as that.

00:04:21 Steve Small
 One head‑to‑head trial that we found showed that 2.5 milligrams of oral minoxidil daily produced more hair counts and better thickness than 5% topical minoxidil at six months.

00:04:32 Steve Small
 But keep in mind, the study only enrolled 42 people.

00:04:35 Steve Small
 That’s pretty small.

00:04:37 Steve Small
 But there was a meta‑analysis of four studies published back in 2025, just a little while ago, that showed no superiority between oral and topical minoxidil.

00:04:46 Steve Small
 Essentially, both forms may help increase hair density, generally around 10 to 20 hairs per square centimeter, to give you some context.

00:04:54 Steve Small
 And they had similar side effects, but neither clearly outperforms the other overall.

00:05:00 Steve Small
 And also keep in mind, this is only in about 270 patients overall, again, a small number.

00:05:05 Steve Small
 Plus the dosing strategies even changed too. So hard to really piece that out.

00:05:08 Don Weinberger
 Important points. Important points, but even more important point based off what you said is we can’t have, or can we have those glorious locks of hair after taking this?

00:05:21 Steve Small
 Right. It’s all about the hairdo.

00:05:23 Steve Small
 And it’s not necessarily that.

00:05:26 Steve Small
 Patients may get some hair growth, but results can vary.

00:05:30 Steve Small
 And some patients may have not really noticeable hair growth at all.

00:05:34 Steve Small
 Maybe it’s just stopping their hair loss or stopping where it’s already at.

00:05:37 Steve Small
 And there’s very few comparison studies that looked at patient satisfaction between oral and topical minoxidil here.

00:05:46 Steve Small
 The evidence we do have is mixed.

00:05:47 Steve Small
 For example, one study showed that roughly one‑third of patients in both groups had low satisfaction and only one in five had high satisfaction.

00:05:57 Steve Small
 That’s quite a spread.

00:05:58 Steve Small
 So you shouldn’t expect to grow a fantastic hairdo miraculously with these meds, Don.

00:06:03 Don Weinberger
 Okay. So bummer. Thank you for that.

00:06:06 Don Weinberger
 But you know, just like that New York Times article and also from what I’m seeing from our subscribers as well as social media there may be a preference, though, for those oral minoxidil forms because of ease of use, right?

00:06:21 Don Weinberger
 Or maybe the topical minoxidil didn’t really work out in the end.

00:06:24 Don Weinberger
 So they do want to try it.

00:06:27 Don Weinberger
 What’s the advice here?

00:06:29 Steve Small
 Yeah, I’m glad you brought that up.

00:06:31 Steve Small
 I’d say the first thing is to ensure patients are given topical minoxidil a fair shake here.

00:06:36 Steve Small
 Due to the length of the hair cycle, it’s important to point out to patients that they should expect to take at least three to six months to even notice any results, maybe even up to a year potentially.

00:06:46 Steve Small
 And it’s got to be with consistent use.

00:06:48 Steve Small
 The minute you stop, you’re not going to get results.

00:06:51 Steve Small
 And again, it’s possible for patients to not see any major results and they may be unsatisfied with it.

00:06:58 Steve Small
 So I would say also, based on the evidence we do have, it’s reasonable to expect the same approach with oral minoxidil.

00:07:05 Steve Small
 But if someone really does want to try oral minoxidil because it’s only once a day rather than twice a day like the foam or the solution, here are some study doses that we found.

00:07:15 Steve Small
 You could start low and slow, maybe at 1.25 milligrams daily, increasing by 1.25 milligrams every three months to a max of 5 milligrams per day.

00:07:26 Steve Small
 And for women, it’s half that dosage, typically starting at 0.625 milligrams daily, titrating every three months but then to a max of 2.5 milligrams a day.

00:07:36 Don Weinberger
 Right. So that’s a, as far as titration schedules, you know, we’ve seen a medication that’s a pretty, you said low and slow, you meant it, right?

00:07:43 Don Weinberger
 That’s what the study was.

00:07:45 Don Weinberger
 My guess… is this due to side effects?

00:07:48 Steve Small
 Yes, you’re totally right.

00:07:49 Steve Small
 It can cause issues like swelling and rapid heart rate, things we were talking about earlier.

00:07:53 Steve Small
 So low and slow is the way to go here.

00:07:56 Steve Small
 And doses can be divided across the day.

00:07:58 Steve Small
 So maybe splitting your daily dose into a morning and nightly dose to help decrease those side effects.

00:08:04 Steve Small
 And we need to make sure patients know that oral minoxidil can cause hair growth on any part of the body, not just the head now.

00:08:10 Steve Small
 So that's something they need to expect.

00:08:12 Don Weinberger
 Right.

00:08:13 Don Weinberger
 That's actually a really good point as well, counseling point for, you know, for anybody getting this to the pharmacy.

00:08:18 Don Weinberger
 So to go back to topical minoxidil, though, let's kind of reassure people that's not necessarily side effect free either, right?

00:08:28 Don Weinberger
 There are some on the label saying that irritation of the scalp can happen, hair greasiness or like the feeling of a solution in the hair.

00:08:38 Don Weinberger
 It can be an issue, although that's due to the propylene glycol that's actually in topical minoxidil.

00:08:44 Don Weinberger
 And some other dosage forms like foam don't have propylene glycol, so that could be recommended for people who don't really want their hair greasiness.

00:08:51 Don Weinberger
 And also with topical minoxidil, systemic absorption can occur, especially when it actually runs off into those thin-skinned areas of the body, like or the face, so like the cheeks or the forehead or the neck.

00:09:03 Don Weinberger
 So make sure you're pointing those package directions for patients so they apply it correctly.

00:09:10 Steve Small
 Yeah, and really reading that packaging is key because overuse can be an issue too, where you may not see better effects.

00:09:16 Steve Small
 You might just see more side effects.

00:09:18 Steve Small
 For example, one mL of solution per dose is recommended.

00:09:22 Steve Small
 And that doesn't seem like a whole lot when you look at it, but that is what's recommended.

00:09:26 Steve Small
 So going back to this claim that oral minoxidil is more effective than topical versions for hair loss, the verdict is rumor with conditions.

00:09:39 Steve Small
 Patients will need to balance side effects here and convenience with these options.

00:09:43 Steve Small
 And we need to have realistic expectations since, like we said, results can vary with minoxidil.

00:09:49 Steve Small
 And you know, this claim reminds me, Don, wasn't there a new minoxidil extended-release oral formulation that's being developed?

00:09:55 Don Weinberger
 Yep, there was.

00:09:56 Don Weinberger
 Minoxidil ER, extended release.

00:09:58 Don Weinberger
 I believe it's an investigational oral formulation just indicated for hair loss.

00:10:04 Don Weinberger
 They're touting steadier drug levels because of the ER formulation.

00:10:08 Don Weinberger
 for hair regrowth and maybe even lower risk of side effects.

00:10:11 Don Weinberger
 But it's still in early phases.

00:10:13 Don Weinberger
 I think it was recruiting for phase two and phase three, but we will definitely keep an eye on that one.

00:10:18 Steve Small
 Yeah, we'll see.

00:10:19 Don Weinberger
 Okay, so let's keep going with the side effect topic. Okay.

00:10:23 Don Weinberger
 The next claim that leads into that is topical finasteride doesn't have systemic side effects seen with oral tablets.

00:10:31 Don Weinberger
 So, you know, as we said, oral finasteride decreases that dihydrotestosterone or DHT.

00:10:38 Don Weinberger
 by blocking the 5-alpha reductase enzyme.

00:10:41 Don Weinberger
 And side effects are pretty well known by now, which include decreased libido and erectile dysfunction.

00:10:49 Don Weinberger
 And that was during the study, but after the drug was marketed, they found that mood changes such as depression and even suicidal ideation were reported among patients actually as early as, I believe it was 2002.

00:11:03 Steve Small
 Yeah, that caused a lot of concerns.

00:11:05 Steve Small
 And didn't that lead to labeling changes for finasteride?

00:11:08 Don Weinberger
 Yep, sure did.

00:11:08 Don Weinberger
 So, oral finasteride package inserts now reflect, you know, the risk of these psychiatric side effects from that post‑market experience.

00:11:18 Don Weinberger
 I believe the depression was added in 2011 to the labeling and suicidal ideation was added in 2022.

00:11:28 Don Weinberger
 So, those are both appear on that package insert now.

00:11:31 Don Weinberger
 So, as you can see, based off that, the reason why topical finasteride kind of, you know, shot forth was to kind of have that same effectiveness as oral finasteride by applying, you know, finasteride directly to those hair follicles, but with the hopes of having less systemic absorption because it's a topical, right.

00:11:54 Steve Small
 Right, and it's important that topical finasteride is not FDA approved.

00:11:59 Steve Small
 We should point that out.

00:12:00 Steve Small
 You need to get it from a compounding pharmacy.

00:12:02 Steve Small
 And regarding its goal here, aiming and hitting the target are two different things.

00:12:06 Don Weinberger
 Yeah, bullseye.

00:12:08 Don Weinberger
 So published clinical trial evidence comparing both dosage forms directly against each other is actually, it's at this point actually, it's very limited.

00:12:17 Don Weinberger
 In terms of improving hair density and counts, they may be the same.

00:12:22 Don Weinberger
 You mentioned earlier about 10, 20 hairs.

00:12:23 Don Weinberger
 That's about here, about 20 hairs per centimeter squared as far as increase is concerned.

00:12:29 Don Weinberger
 As you know, we do need more data before we can say for certain that topical finasteride is more effective than oral versions.

00:12:36 Don Weinberger
 So that's effectiveness. What about safety?

00:12:40 Don Weinberger
 And FDA actually released something recently.

00:12:43 Don Weinberger
 It was April of 2025, whenever you're listening to this, and reported

00:12:48 Don Weinberger
 there's actually some serious systemic adverse effects with that compounded topical finasteride, including dysfunction, anxiety and depression, suicidal ideation.

00:12:58 Don Weinberger
 So the same stuff we were seeing with the oral finasteride dosing, right?

00:13:03 Don Weinberger
 And just like oral finasteride, in some patients, those symptoms actually persisted even after they discontinued that topical med.

00:13:12 Don Weinberger
 Man, we do need more studies before we can say the risk

00:13:18 Don Weinberger
 these side effects are actually lower with topical than oral.

00:13:22 Steve Small
 Yeah, we need to get the data.

00:13:23 Steve Small
 So ensure patients know the facts before they try something here.

00:13:26 Don Weinberger
 Let them know.

00:13:27 Don Weinberger
 So going back to that claim, it is topical finasteride doesn't have systemic side effects seen with oral tablets.

00:13:35 Don Weinberger
 And the verdict is rumor.

00:13:42 Don Weinberger
 Topical finasteride has been shown to have the same side effects as oral versions.

00:13:47 Don Weinberger
 And it's too soon to say if risks of them are lower with topical.

00:13:51 Don Weinberger
 More time and research will tell.

00:13:54 Steve Small
 Yeah, so there is a risk of side effects regardless if it's oral or topical here.

00:13:58 Steve Small
 But let's say patients want to try topical finasteride. What should they know?

00:14:03 Don Weinberger
 Yeah, so there will be some patients who say, I want to try topical anyways.

00:14:06 Don Weinberger
 So let's go ahead and steer them in the right direction, right?

00:14:08 Don Weinberger
 So get the product from a reputable US licensed compounding pharmacy.

00:14:13 Don Weinberger
 So looking at this, there were some fakes out there.

00:14:15 Don Weinberger
 So ensure they're getting it from that reputable source.

00:14:20 Don Weinberger
 And also, dispensing finasteride in pharmacy, the oral version anyways, there's an auxiliary label you actually put on this picture saying, make sure pregnant patients do not touch this.

00:14:29 Don Weinberger
 So of course, with topical finasteride, that's still the same.

00:14:32 Don Weinberger
 You know, with, you know, patients apply to their hair, their hair touches, you know, pillowcases or people or clothes.

00:14:38 Don Weinberger
 So make sure patients understand that to keep this away from pregnant patients in their households.

00:14:45 Steve Small
 Really good call out there.

00:14:46 Steve Small
 And before we get into our next claim, if this episode helps you cut through the clutter, here's a little something to level up your game.

00:14:53 Don Weinberger
 Are you a subscriber? Don't forget to claim CE credit for this episode.

00:14:57 Steve Small
 And not subscribed yet or thinking about upgrading?

00:15:00 Steve Small
 Access more trusted clinical insights and save 10% with our exclusive listener promo code RVT1026 at checkout.

00:15:09 Don Weinberger
 And details and links are in the show notes, so don't miss out.

00:15:13 Steve Small
 Now let's try something new here, fast facts.

00:15:16 Don Weinberger
 This is where we jump into some common bite-sized claims about hair loss and give them seal approval or debunk them quickly.

00:15:30 Steve Small
 Great, and hair we go.

00:15:32 Steve Small
 So the first claim here is that hair loss comes from the maternal side.

00:15:36 Steve Small
 And the reality here is that genes for hair loss are multifactorial.

00:15:39 Steve Small
 It comes from mom, dad, grandfathers, grandmothers.

00:15:42 Steve Small
 There is no on-off single switch or gene.

00:15:45 Steve Small
 It comes from multiple sources.

00:15:46 Steve Small
 So the verdict here is rumor with conditions.

00:15:52 Steve Small
 And I think I'm ready for another quick claim here, Don.

00:15:54 Don Weinberger
 Sure, so the claim is wearing hats or shampooing hair often can cause it to fall out.

00:15:59 Don Weinberger
 Some medical reviews confirm that no direct link between hats and hair loss, except in special cases like very tight headwear that can cause something called traction alopecia.

00:16:11 Don Weinberger
 Frequent shampooing does not cause hair loss either, because shampoo does not kill or damage hair follicles.

00:16:16 Don Weinberger
 Hair seen shedding in the shower is usually hair that was already ready to fall out naturally as part of the hair cycle.

00:16:22 Don Weinberger
 So the verdict is true with conditions.

00:16:27 Don Weinberger
 And I love doing fast facts.

00:16:29 Don Weinberger
 Steve, should we do one more?

00:16:32 Steve Small
 You betcha.

00:16:32 Steve Small
 This last claim here is that topical minoxidil is toxic to animals.

00:16:37 Steve Small
 And yes, minoxidil is highly toxic to cats and dogs, but especially cats.

00:16:41 Steve Small
 Even licking a small amount from a human skin or perhaps from a dropper applicator, can be life‑threatening for them.

00:16:47 Steve Small
 So like any other medication stored in the home, keep it up and away from children and pets.

00:16:53 Steve Small
 So the verdict here is true.

00:17:03 Steve Small
 That was a great rapid session, Don. I liked that.

00:17:07 Steve Small
 All right, so let's talk about if patients want to try more than one product.

00:17:11 Steve Small
 This next claim is combining topical minoxidil with oral finasteride may be more effective than using either of them alone.

00:17:20 Steve Small
 Now, minoxidil and finasteride tackle hair loss through two completely different mechanisms like we talked about before.

00:17:26 Steve Small
 So the thought is maybe using them together could create a synergistic effect.

00:17:30 Steve Small
 So remember, oral finasteride lowers that DHT hormone that causes follicle miniaturization, whereas minoxidil improves blood flow and prolongs the hair growth phase.

00:17:41 Steve Small
 Now, because they act on different pathways, maybe combining them boosts both follicle preservation and new growth here.

00:17:49 Steve Small
 And a randomized trial of about 400 men found that this combo of topical minoxidil 5% twice daily plus oral finasteride 1 milligram daily produced significant improvements in hair density, hair diameter, and overall photographic assessment, outperforming minoxidil or finasteride alone.

00:18:08 Steve Small
 So that's interesting.

00:18:09 Don Weinberger
 It is. It does make sense.

00:18:11 Don Weinberger
 You know, you're tackling, like you said, those two causes of hair loss.

00:18:15 Don Weinberger
 So what should patients be aware of when they're, when they're using these products, whether alone or as combination, as far as results or expectations.

00:18:27 Steve Small
 Right. Keep in mind, the data here is still pretty limited doing this combination, but the results seem promising.

00:18:33 Steve Small
 But we have to be real here.

00:18:34 Steve Small
 Hair growth with these products is only temporary and will return back to baseline in about three to six months after stopping these meds.

00:18:41 Steve Small
 And the only long-lasting treatment is a hair transplant.

00:18:45 Steve Small
 So taking follicles from the back of the hair and then moving them to the thinning areas of the scalp.

00:18:51 Steve Small
 So it's pretty invasive.

00:18:52 Don Weinberger
 It sounds ouch too, but adds meaning to the phrase, beauty comes with pain, right?

00:19:00 Steve Small
 Yes, that's a very true phrase.

00:19:02 Steve Small
 So when it comes to this claim that combining topical minoxidil with oral finasteride may be more effective than using them alone, the verdict is…

00:19:14 Steve Small
 True.

00:19:15 Don Weinberger
 Yeah. So what about, I have patients that do ask using an oral and topical of the same active ingredient.

00:19:22 Don Weinberger
 So like an oral and topical finasteride, kind of get that DHT blocking at every angle.

00:19:28 Don Weinberger
 Like what's the advice there?

00:19:30 Steve Small
 Yeah, like dunking your whole head in finasteride there in a way.

00:19:35 Steve Small
 But using both at the same time may not really provide added benefit here.

00:19:39 Steve Small
 And instead, it may just increase the risk of side effects because really oral finasteride already saturates most of that 5-alpha reductase enzyme at low doses, such as the 1 milligram per day we're talking about.

00:19:51 Steve Small
 So adding topical finasteride may not meaningfully increase scalp DHT suppression and like we said, could just increase libido issues and other things we want to avoid.

00:20:00 Steve Small
 So keeping that in mind.

00:20:01 Don Weinberger
 Thanks for coming out of those good points.

00:20:02 Don Weinberger
 And we do cover this combo and other options in our treatment and prevention of hair loss chart.

00:20:08 Don Weinberger
 Definitely helps tackle those hairy questions about hair loss.

00:20:14 Steve Small
 Right.

00:20:14 Steve Small
 And take a look at the show notes or description.

00:20:16 Steve Small
 We've linked directly to that resource in Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights.

00:20:22 Don Weinberger
 If you aren't already a subscriber, don't miss out on these resources.

00:20:25 Don Weinberger
 Sign up today to stay ahead with trusted insights and tools.

00:20:30 Don Weinberger
 And for this next claim, we're trying to find out what works for hair loss if patients want to try the natural way.

00:20:39 Don Weinberger
 And the claim here is saw palmetto and rosemary oil are effective for hair loss.

00:20:43 Don Weinberger
 To help us out. Early this week, I spoke with Jeff Langford from our NatMed Pro to dig into this.

00:20:48 Don Weinberger
 Let's go to him now.

00:20:54 Don Weinberger
 Hey Jeff, glad to pull you away from your own natural medicine podcast to help give us the assist here.

00:21:01 Don Weinberger
 I saw that rosemary oil and saw palmetto were the more common ones to use for hair loss as natural medicines.

00:21:09 Don Weinberger
 Can you help us untangle this claim?

00:21:11 Jeff Langford
 Hey there, Don.

00:21:12 Jeff Langford
 Yeah, let's start by tackling saw palmetto first.

00:21:16 Jeff Langford
 Think about how it works and what kind of data we have around that.

00:21:19 Jeff Langford
 It seems to work by inhibiting 5-alpha reductase and lowering DHT.

00:21:23 Jeff Langford
 So much like what you've talked about with finasteride.

00:21:26 Jeff Langford
 And in terms of the data, we have a small study that used saw palmetto in male and female patients.

00:21:32 Jeff Langford
 They had androgenic alopecia.

00:21:34 Jeff Langford
 And in the study, they found that taking saw palmetto oil capsules, 100 milligrams daily, or applying it as a lotion, like a 20% lotion, for over 4 months, reduced hair loss and increased hair density compared to placebo.

00:21:47 Jeff Langford
 So it sounds pretty good, right?

00:21:49 Jeff Langford
 But there are some limitations to the data.

00:21:51 Jeff Langford
 It didn't improve other parameters such as thickness of hair or subjective measures, like the patient's assessment of their appearance of hair or their appearance and assessment of their own hair thinning.

00:22:04 Jeff Langford
 Other data, used saw palmetto orally in a 320 milligram dose and did that over about two years.

00:22:11 Jeff Langford
 In this case, it was less effective than finasteride, 1 milligrams per day.

00:22:17 Jeff Langford
 And saw palmetto is out there in all kinds of combination formulations and has been studied with other plant extracts and micronutrients.

00:22:24 Jeff Langford
 And some of those studies, those combination therapies, including saw palmetto, increased hair density over six months.

00:22:30 Jeff Langford
 So we've got a little bit of a hodgepodge of data.

00:22:32 Jeff Langford
 I'd say the bottom line here is really that there are some limited data that saw palmetto can improve some assessments, such as hair density, but it may not improve the patient's own assessment.

00:22:43 Jeff Langford
 Which may give us some indication of how important or detectable those benefits really are at the patient level versus the dermatologist level.

00:22:51 Jeff Langford
 And it doesn't seem to work as well as finasteride in a direct comparison.

00:22:55 Don Weinberger
 That is interesting because it's the patient's kind of own assessment of how their hair is growing is the idea, right?

00:23:00 Don Weinberger
 The outward appearance, but that is kind of, that's interesting kind of observation and what came out of that.

00:23:08 Don Weinberger
 So what about the side effects though of saw palmetto? What can you tell us about those?

00:23:14 Jeff Langford
 Yeah, good question. So it's generally well tolerated.

00:23:16 Jeff Langford
 GI upset, not surprisingly, is among the most common side effect reported in these studies.

00:23:22 Jeff Langford
 But saw palmetto, because of how it works, can have sexual side effects such as erectile dysfunction or reduced libido.

00:23:29 Jeff Langford
 Some data have compared that.

00:23:31 Jeff Langford
 Again, we saw where it had been studied compared to finasteride.

00:23:34 Jeff Langford
 Seems like the side effects, although they are similar in type to finasteride, they may occur less frequently than finasteride.

00:23:42 Jeff Langford
 So maybe a little bit better, tollerated in terms of sexual side effects.

00:23:47 Jeff Langford
 GI upset is pretty common though.

00:23:49 Don Weinberger
 Got it. So it seems like whenever you inhibit that DHT, you kind of get those similar side effects that you're saying.

00:23:55 Don Weinberger
 Okay. So let's move on to the second natural product and part of that claim, which is rosemary oil.

00:24:02 Don Weinberger
 So what do you have for us on that?

00:24:04 Jeff Langford
 It sounds to me, Don, like you've been looking at some TikTok videos that talk about nature's Rogaine.

00:24:10 Jeff Langford
 And this does…

00:24:11 Don Weinberger
 Keep that between us.

00:24:12 Jeff Langford
 Yeah, exactly.

00:24:13 Jeff Langford
 This comes up from time to time and it's based on a study that was conducted in 2015.

00:24:18 Jeff Langford
 And it showed that a specific formulation of rosemary oil increased hair count in patients with androgenic alopecia.

00:24:25 Jeff Langford
 And it did that to a similar degree or a similar amount of increase in hair count as what was seen with a 2% minoxidil solution when these things were compared over a six month period.

00:24:35 Jeff Langford
 So that's where the nature's Rogaine bit comes from if you're seeing that or hearing that.

00:24:39 Jeff Langford
 But as I say, this evidence is pretty thin.

00:24:43 Jeff Langford
 Single study doesn't suggest that the patients, again, we don't have suggestion or confirmation that the patients perceived a difference in their hair results.

00:24:51 Jeff Langford
 In this case, these hair count results are like a photographic assessment of sections of hair where we can literally count that there are more hairs.

00:25:00 Jeff Langford
 Patients may or may not necessarily detect that or appreciate that difference.

00:25:06 Jeff Langford
 And again, if we want to think about patients may still want to try it.

00:25:09 Jeff Langford
 There are a lot of rosemary oil products that are marketed for hair growth.

00:25:13 Jeff Langford
 And if that's the case, I think some things I would keep in mind or counsel patients about is that well tolerated, but it can cause skin sensitivity or sun sensitivity in particular.

00:25:23 Jeff Langford
 So we need to know about that.

00:25:26 Jeff Langford
 And the question would generally come up about topical versus oral use.

00:25:31 Jeff Langford
 We know that rosemary is safe to eat in terms of as an herb or a seasoning, but we're talking here about essential oil from rosemary and people should not take that undiluted orally.

00:25:44 Jeff Langford
 In that case, it really can, has the potential to, cause serious side effects, including seizures.

00:25:49 Jeff Langford
 And there's no evidence for oral rosemary to help hair loss.

00:25:53 Jeff Langford
 So if people want to try it, guide them toward a topical product, explain the potential skin and sun sensitivity they may experience.

00:26:02 Don Weinberger
 Okay. So thank you very much, Jeff, for your sage advice, again, when it comes to tackling these hair loss claims.

00:26:10 Don Weinberger
 So I'll send you on back to your own Natural Medicines: Evidence in Practice podcast.

00:26:16 Don Weinberger
 So let's go kick it on back to Steve and get his thoughts on what you said and the verdict.

00:26:25 Don Weinberger
 Okay, Steve, what did you think about what Jeff had to say about those natural medicines?

00:26:29 Steve Small
 I always love to hear Jeff's natural takes to these things.

00:26:33 Steve Small
 You know, in the hospital, we don't deal with saw palmetto or rosemary oil.

00:26:36 Steve Small
 So this is really interesting.

00:26:38 Steve Small
 And I'm looking forward to listening to his upcoming premiere for his team's podcast.

00:26:42 Don Weinberger
 So do I. So going back to that claim is saw palmetto and rosemary oil are effective for hair loss.

00:26:47 Don Weinberger
 And the verdict is… 

00:26:51 Don Weinberger
 Evidence is mixed.

00:26:54 Steve Small
 Nice. You know, Don, for now, I'm going to keep my rosemary oil in my kitchen cupboard, not the medicine cabinet.

00:27:00 Steve Small
 But for patients trialing rosemary oil, it's recommended for a three-to-six-month time frame.

00:27:06 Steve Small
 And what about scalp irritation?

00:27:07 Steve Small
 And don't combine with oral finasteride without discussing with the provider first for more info.

00:27:13 Steve Small
 And you know, Don, I saw some interesting items used for hair loss, including cooling caps and microneedling.

00:27:19 Steve Small
 Can you pinpoint the reasoning here for me?

00:27:22 Don Weinberger
 Right, to kind of…I did see those as well.

00:27:25 Don Weinberger
 So cooling caps are thought to, they're more used with oncology patients when they're receiving chemotherapy.

00:27:32 Don Weinberger
 And the cooling actually causes scalp vasoconstriction and slows that hair follicle from uptaking that chemotherapy and impact of chemotherapy on that follicle.

00:27:43 Don Weinberger
 The results actually kind of depend on which kind of therapy was used in those patients.

00:27:48 Don Weinberger
 But keep in mind that approach was only studied really for oncology patients and not general patients with male, female pattern hair loss.

00:27:57 Don Weinberger
 I mentioned microneedles, right?

00:27:59 Don Weinberger
 So that's another interesting kind of, you know, device to use for hair loss.

00:28:06 Don Weinberger
 It's usually on a roller.

00:28:07 Don Weinberger
 I've seen some actually have like a motorized machine and they make these tiny skin punctures basically to increase blood flow and all those growth factors into those kind of micro wounds they make into the scalp, which nourishes new hair follicles or hair growth from existing follicles.

00:28:24 Don Weinberger
 But with that, studies are mixed.

00:28:28 Don Weinberger
 But microneedling actually might help topical medications absorb into the scalp better by letting them penetrate, you know, creating all those micro‑abrasions.

00:28:37 Don Weinberger
 But just keep in mind that no microneedling devices are FDA cleared specifically for hair loss, but some actually are cleared for things like wrinkles and scars.

00:28:48 Steve Small
 Yeah, that's already making my head itch, Don.

00:28:51 Steve Small
 Speaking of head scratcher, let's get to the bottom-line truth here, that treatments for hair loss aren't cut and dry.

00:28:57 Steve Small
 Ensure patients really get the facts with hair loss products so they can make informed decisions.

00:29:01 Don Weinberger
 Right, so we have tools available to patients can get all the facts they need from Pharmacist’s Letter and Prescriber Insights subscribers, to help guide decision-making and prevent dispensing mishaps if you see prescriptions in the pharmacy.

00:29:16 Steve Small
 Yeah, great.

00:29:17 Steve Small
 And with that, let's make like a hair and fall to our last segment here.

00:29:21 Steve Small
 It's time for the Rumor vs Truth mailbag.

00:29:25 Steve Small
 We have an audience question from the last episode about menopause treatments that came in through our rumorvstruth@trchealthcare.com e-mail address.

00:29:33 Don Weinberger
 All right, so our last episode was dispelling myths and applying facts about menopause treatments, right?

00:29:39 Don Weinberger
 So, this question did ask, does black cohosh increase estrogen levels?

00:29:46 Steve Small
 Well, can we get Jeff back in here? 

00:29:50 Don Weinberger
 He's probably long gone.

00:29:51 Steve Small
 He's already out the door.

00:29:53 Steve Small
 Thankfully, we did some of the homework on our own.

00:29:55 Steve Small
 And we looked this up in our NatMed Pro database.

00:29:58 Steve Small
 And research on black cohosh shows mixed results.

00:30:01 Steve Small
 A large review of 22 studies found that taking black cohosh from anywhere from 4 to 52 weeks can modestly improve overall menopausal symptoms, especially hot flashes and other physical complaints.

00:30:13 Steve Small
 But it didn't show clear benefits for things like mood symptoms, things like anxiety or depression.

00:30:19 Steve Small
 And an analysis of 20 clinical trials found that black cohosh isn't consistently better than a placebo and is less effective than hormone therapy for reducing hot flashes.

00:30:29 Steve Small
 So interesting pieces there.

00:30:30 Don Weinberger
 Yeah, that is interesting.

00:30:32 Don Weinberger
 Something to piggyback off that is, what's the idea of kind of how black cohosh works then?

00:30:38 Steve Small
 Yeah, that's a really good question.

00:30:40 Steve Small
 And its mechanism isn't really clearly understood at this point, but it seems to act more like a selective estrogen receptor modulator or SERM.

00:30:48 Steve Small
 By decreasing menopausal symptoms without increasing circulating estradiol levels.

00:30:53 Don Weinberger
 Interesting. So the next question is going to be any side effects with that?

00:30:58 Steve Small
 Yeah, you could say yes, SERM.

00:31:00 Steve Small
 Some common ones include breast tenderness, headache, and irritability, much like what you'd see from a prescription SERM like raloxifene.

00:31:08 Steve Small
 So overall, black cohosh may help some physical symptoms of menopause but it doesn’t seem to reliably improve mood and it doesn’t out-perform hormone therapy.

00:31:18 Steve Small
 So really important to keep in mind.

00:31:19 Don Weinberger
 Great for elaborating and glad we were to press play on that menopause question.

00:31:25 Don Weinberger
 So to our audience, don't brush off your burning questions.

00:31:28 Don Weinberger
 Please send them in, and we will tackle them next month about hair loss.

00:31:32 Steve Small
 Yeah, and we also use your suggestions to plan our episodes.

00:31:35 Steve Small
 So e-mail us at rumorvstruth@TRChealthcare.com or send us a text right from the podcast show notes.

00:31:41 Don Weinberger
 Right, before you go, claim CE credit and access evidence-based resources from Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights.

00:31:49 Steve Small
 And if you're not yet a subscriber or just want to upgrade, you can save 10% with our exclusive listener code, RVT1026 at checkout.

00:31:57 Steve Small
 And there's an easy link in the show notes.

00:31:59 Don Weinberger
 And are you a subscriber?

00:32:00 Don Weinberger
 Tap the claim credit link in the show notes or search your CE organizer for this episode.

00:32:06 Steve Small
 Yeah, definitely get that CE credit.

00:32:08 Steve Small
 And join us next time where we'll talk about artificial intelligence in practice.

00:32:12 Don Weinberger
 Sounds like fun.

00:32:13 Don Weinberger
 So, thanks again for joining us on Rumor vs. Truth, your trusted source for facts, where we dissect the evidence behind risky rumors and reveal clinical truths.

00:32:21 Don Weinberger
 See you next time.