- Reaction score
- 42
Over the last couple of years or so, I've had sort of a small, indirect "dialogue" with Dr. Sawaya on various issues, but mostly having to do with dutasteride. Many of you old-timers have seen the original set of questions I posed to her quite a while back about dutasteride, and her brief reply to me (which didn't satisfy me at the time).
More recently, a later post which I wrote comparing haircounts from various agents and which I've posted numerous times on several hairloss sites, so I'm sure many of you have seen that, too ("Topical minoxidil hair-counts vs. dutasteride hair-counts: a modest comparison...") was sent to her for comment, and here is her recent reply to that one:
---------------------------------------------------
"To me, this is like comparing apples to oranges...
You have to consider the quality of hair growth, such as thickness, pigmentation, and if it is cosmetically acceptable hair growth. In the minoxidil studies, very few men had cosmetically acceptable coverage, and the minoxidil studies were usually about 12 months. You really can't go on a per month basis, as the longer the studies go, the better the "quality" hair counts go and more time to initiate follicles into the growth phase. In minoxidil studies, which were a long time ago, they were counting alot of small, thin, nonpigmented hairs and these were very difficult to delineate into anagen vs vellus hairs. The finasteride and dutasteride studies were done with better techniques and imaging. I doubt anyone in dermatology would bet that minoxidil is a better hair growth agent than finasteride or dutasteride. Most do believe that you should use minoxidil in conjunction with either finasteride or dutasteride, since there are different mechanisms going on. None of the companies would do combined studies, but the animal studies did show more benefit when 2 products were used together.
regards
Marty"
--------------------------------------------------------------
In reply to Sawaya above, I wrote the following long response, and you'll notice that I was careful to document my position with references to the medical literature (the full citations appear at the end). However, at this point it looks like Dr. Sawaya has bailed-out of the discussion. She has most recently said something to the effect that she doesn't have the time to even READ, much less REPLY to what I wrote. I'm very disappointed by that, as all of you can imagine. I cannot help but suspect that in reality, she simply doesn't HAVE any good responses to the points I made. Without any further ado, here is my lengthy reply to the statement she made above:
-------------------------------------------------------------
Dr. Sawaya, I'd like to reply to your comments in some detail. I've put the appropriate numbered references for my own statements in parentheses, and the full citations appear at the end.
> To me, this is like comparing apples to oranges...
> You have to consider the quality of hair growth, such as thickness,
> pigmentation, and if it is cosmetically acceptable hair growth.
> In the minoxidil studies, very few men had cosmetically acceptable
> coverage, and the minoxidil studies were usually about 12 months.
> You really can't go on a per month basis, as the longer the studies
> go, the better the "quality" hair counts go and more time
> to initiate follicles into the growth phase.
In the earlier article I wrote which compared minoxidil haircounts with those of finasteride and dutasteride, I clearly acknowledged that I was drawing from a multitude of studies, lasting for varying lenghts of time: some were 12 months or longer, some were six months, and some were only three or four months. So how is one to compare studies that vary in length? Is there any reasonable way to do it?
In ALL such hairloss studies involving haircounts as a measure of efficacy, those counts obviously increase in a reasonably direct and somewhat linear fashion with the passage of time, at least up to the point where they tend to reach a plateau (usually about the 1-year mark). And hairs also tend to increase in "quality" with time, too, as you point out. But we don't really have all the data that we'd LIKE to have in every one of these studies, like average hair thickness, etc. We have to make do with what we DO have, and those are haircounts. And it seems to me that the simplest, most intuitive and best way to consider these varying studies is indeed to calculate the counts on a "per month" basis. Can you think of any better, more intuitive way to do it?
> In minoxidil studies, which were a long time ago, they were
> counting alot of small, thin, nonpigmented hairs and these were
> very difficult to delineate into anagen vs vellus hairs.
> The finasteride and dutasteride studies were done with better
> techniques and imaging.
Really? I've noticed that a lot of the topical minoxidil studies actually went to a lot more pains to differentiate between vellus, intermediate, and terminal hairs (studies 1-13), compared to all the finasteride/dutasteride studies I've seen. For example, the original large Propecia trial (14) merely said that the photographic transparencies "...were converted into dot maps of EACH VISIBLE HAIR by technicians..." (Emphasis is my own) It was the same in the so-called finasteride "frontal study" (15), too: "Macrophotographs were converted into dot maps of EACH VISIBLE HAIR by trained technicians..." (Emphasis is my own)
The haircounts for minoxidil still appear to me to be superior to those for finasteride and dutasteride! Consider Olsen's (1) count of 273.4 NONVELLUS hairs after 1 year! Compare that to dutasteride's haircount increase after six months of only 108 hairs (which is presumably a "total" haircount, not terminal hairs). And if you're still concerned about the validity of comparing a year-long study to one lasting only six months, then consider that Olsen's study was based on earlier work (3) which reported haircounts over much shorter durations of time. In that earlier study, 2% topical minoxidil was found to provide a TERMINAL haircount increase of 126 hairs, after only 4 months! So how would you explain higher terminal haircount increases for topical minoxidil, during both LONGER and SHORTER trials than the trial which tested dutasteride?
And notice Koperski's interesting statement in her own study (2) in the "Evaluation of Hair Growth" paragraph: "Hairs were initially classified as vellus, indeterminate, and terminal, but the total hair counts were found to be more reliable and are used in this analysis. Hair counts performed after 12 months, while presented as total hair counts, essentially represent the total number of nonvellus hairs (indeterminate plus terminal), since few vellus hairs were present (ten hairs)." (By the way, Koperski's results were: +188.5 hairs after 4 months, and +352.6 hairs after 12 months, again surpassing dutasteride's results of only +108 hairs after 6 months.)
> I doubt anyone in dermatology would bet that minoxidil is a better
> hair growth agent than finasteride or dutasteride.
Really? There was a study which made a direct, head-to-head comparison between topical minoxidil and oral finasteride (16). The researchers themselves concluded that "...minoxidil produced faster initial improvement in midfrontal/vertex AA....whereas finasteride produced marginally better results with increasing duration of treatment. Both agents were equally effective in stopping the progression of AA." But one very important thing to keep in mind here is that the topical minoxidil that was used in that study was only 2% Rogaine!
I want to make one final statement about all this. Oral 5a-reductase inhibitors obviously have an important advantage over topical minoxidil: they beneficially affect hair follicles over the entire scalp, whereas the effect of topical minoxidil is somewhat more limited to the area to which it's actually applied (there is some evidence that its effect does indeed spread out a little to other areas of the scalp, but mostly it's a "local" effect). Considering that fact, it's even more impressive that topical minoxidil could pretty well hold its own against oral finasteride in the study I cited above; moreover, my main concern here is not the OVERALL comparison of those two approaches, it's just the following statement that you made previously: "The dutasteride hair counts were pretty amazing. Glaxo presented the data about 4 years ago. Minoxidil hair counts were pretty dim." Given the evidence that I've cited in both this and my previous article, I fail to see how you could justify such a claim, or your characterization of dutasteride in the past as being a "WOW" drug.
I'd appreciate any further comments that you might have on all this.
Most cordially,
Bryan Shelton
1) "Five-year Follow-up of men with androgenetic alopecia treated with topical minoxidil", Olsen et al, J Am Acad Dermatol 1990;22:643-6.
2) "Topical minoxidil therapy for androgenetic alopecia", Koperski et al, Arch Dermatol Vol 123, Nov 1987.
3) "Topical minoxidil in early male pattern baldness", Olsen et al, J Am Acad Dermatol 13:185-192, 1985.
4) "A randomized clinical trial of 5% topical minoxidil versus 2% topical minoxidil and placebo in the treatment of androgenetic alopecia in men", Olsen et al, J Am Acad Dermatol 2002;47:377-85.
5) "Topical minoxidil in early androgenetic alopecia", Kreindler et al, J Am Acad Dermatol 1987;16: 718-24.
6) "Duration of minoxidil therapy to yield maximum benefit", Rietschel et al, (letter) Arch Dermatol Vol 124, Oct 1988.
7) "Dose-response study of topical minoxidil in male pattern baldness", Olsen et al, J Am Acad Dermatol 15:30-37, 1986.
8 ) "Dose-response study of topical minoxidil in male pattern baldness", Shupack et al, J Am Acad Dermatol 1987;16:673-6.
9) "Safety and efficacy of topical minoxidil in the management of androgenetic alopecia", Rietschel et al, J Am Acad Dermatol 1987;16:677-85.
10) "Long-term follow-up of men with male pattern baldness treated with topical minoxidil", Olsen et al, J Am Acad Dermatol 1987;16:688-95.
11) "Use of topical minoxidil in the treatment of male pattern baldness", Savin et al, J Am Acad Dermatol 1987;16:696-704.
12) "Androgenetic alopecia: Treatment results with topical minoxidil", Janet L. Roberts, J Am Acad Dermatol 1987;16: 705-10.
13) "Long-term efficacy of topical minoxidil in male pattern baldness", Katz et al, J Am Acad Dermatol 1987;16: 711-8.
14) "Finasteride in the treatment of men with androgenetic alopecia", Kaufman et al, J Am Acad Dermatol Volume 39 Number 4 1998.
15) "Finasteride in the treatment of men with frontal male pattern hair loss", Leyden et al, J Am Acad Dermatol 1999;40: 930-7.
16) "Minoxidil vs finasteride in the treatment of men with androgenetic alopecia", Saraswat et al, Arch Dermatol Vol 139, Sep 2003.
More recently, a later post which I wrote comparing haircounts from various agents and which I've posted numerous times on several hairloss sites, so I'm sure many of you have seen that, too ("Topical minoxidil hair-counts vs. dutasteride hair-counts: a modest comparison...") was sent to her for comment, and here is her recent reply to that one:
---------------------------------------------------
"To me, this is like comparing apples to oranges...
You have to consider the quality of hair growth, such as thickness, pigmentation, and if it is cosmetically acceptable hair growth. In the minoxidil studies, very few men had cosmetically acceptable coverage, and the minoxidil studies were usually about 12 months. You really can't go on a per month basis, as the longer the studies go, the better the "quality" hair counts go and more time to initiate follicles into the growth phase. In minoxidil studies, which were a long time ago, they were counting alot of small, thin, nonpigmented hairs and these were very difficult to delineate into anagen vs vellus hairs. The finasteride and dutasteride studies were done with better techniques and imaging. I doubt anyone in dermatology would bet that minoxidil is a better hair growth agent than finasteride or dutasteride. Most do believe that you should use minoxidil in conjunction with either finasteride or dutasteride, since there are different mechanisms going on. None of the companies would do combined studies, but the animal studies did show more benefit when 2 products were used together.
regards
Marty"
--------------------------------------------------------------
In reply to Sawaya above, I wrote the following long response, and you'll notice that I was careful to document my position with references to the medical literature (the full citations appear at the end). However, at this point it looks like Dr. Sawaya has bailed-out of the discussion. She has most recently said something to the effect that she doesn't have the time to even READ, much less REPLY to what I wrote. I'm very disappointed by that, as all of you can imagine. I cannot help but suspect that in reality, she simply doesn't HAVE any good responses to the points I made. Without any further ado, here is my lengthy reply to the statement she made above:
-------------------------------------------------------------
Dr. Sawaya, I'd like to reply to your comments in some detail. I've put the appropriate numbered references for my own statements in parentheses, and the full citations appear at the end.
> To me, this is like comparing apples to oranges...
> You have to consider the quality of hair growth, such as thickness,
> pigmentation, and if it is cosmetically acceptable hair growth.
> In the minoxidil studies, very few men had cosmetically acceptable
> coverage, and the minoxidil studies were usually about 12 months.
> You really can't go on a per month basis, as the longer the studies
> go, the better the "quality" hair counts go and more time
> to initiate follicles into the growth phase.
In the earlier article I wrote which compared minoxidil haircounts with those of finasteride and dutasteride, I clearly acknowledged that I was drawing from a multitude of studies, lasting for varying lenghts of time: some were 12 months or longer, some were six months, and some were only three or four months. So how is one to compare studies that vary in length? Is there any reasonable way to do it?
In ALL such hairloss studies involving haircounts as a measure of efficacy, those counts obviously increase in a reasonably direct and somewhat linear fashion with the passage of time, at least up to the point where they tend to reach a plateau (usually about the 1-year mark). And hairs also tend to increase in "quality" with time, too, as you point out. But we don't really have all the data that we'd LIKE to have in every one of these studies, like average hair thickness, etc. We have to make do with what we DO have, and those are haircounts. And it seems to me that the simplest, most intuitive and best way to consider these varying studies is indeed to calculate the counts on a "per month" basis. Can you think of any better, more intuitive way to do it?
> In minoxidil studies, which were a long time ago, they were
> counting alot of small, thin, nonpigmented hairs and these were
> very difficult to delineate into anagen vs vellus hairs.
> The finasteride and dutasteride studies were done with better
> techniques and imaging.
Really? I've noticed that a lot of the topical minoxidil studies actually went to a lot more pains to differentiate between vellus, intermediate, and terminal hairs (studies 1-13), compared to all the finasteride/dutasteride studies I've seen. For example, the original large Propecia trial (14) merely said that the photographic transparencies "...were converted into dot maps of EACH VISIBLE HAIR by technicians..." (Emphasis is my own) It was the same in the so-called finasteride "frontal study" (15), too: "Macrophotographs were converted into dot maps of EACH VISIBLE HAIR by trained technicians..." (Emphasis is my own)
The haircounts for minoxidil still appear to me to be superior to those for finasteride and dutasteride! Consider Olsen's (1) count of 273.4 NONVELLUS hairs after 1 year! Compare that to dutasteride's haircount increase after six months of only 108 hairs (which is presumably a "total" haircount, not terminal hairs). And if you're still concerned about the validity of comparing a year-long study to one lasting only six months, then consider that Olsen's study was based on earlier work (3) which reported haircounts over much shorter durations of time. In that earlier study, 2% topical minoxidil was found to provide a TERMINAL haircount increase of 126 hairs, after only 4 months! So how would you explain higher terminal haircount increases for topical minoxidil, during both LONGER and SHORTER trials than the trial which tested dutasteride?
And notice Koperski's interesting statement in her own study (2) in the "Evaluation of Hair Growth" paragraph: "Hairs were initially classified as vellus, indeterminate, and terminal, but the total hair counts were found to be more reliable and are used in this analysis. Hair counts performed after 12 months, while presented as total hair counts, essentially represent the total number of nonvellus hairs (indeterminate plus terminal), since few vellus hairs were present (ten hairs)." (By the way, Koperski's results were: +188.5 hairs after 4 months, and +352.6 hairs after 12 months, again surpassing dutasteride's results of only +108 hairs after 6 months.)
> I doubt anyone in dermatology would bet that minoxidil is a better
> hair growth agent than finasteride or dutasteride.
Really? There was a study which made a direct, head-to-head comparison between topical minoxidil and oral finasteride (16). The researchers themselves concluded that "...minoxidil produced faster initial improvement in midfrontal/vertex AA....whereas finasteride produced marginally better results with increasing duration of treatment. Both agents were equally effective in stopping the progression of AA." But one very important thing to keep in mind here is that the topical minoxidil that was used in that study was only 2% Rogaine!
I want to make one final statement about all this. Oral 5a-reductase inhibitors obviously have an important advantage over topical minoxidil: they beneficially affect hair follicles over the entire scalp, whereas the effect of topical minoxidil is somewhat more limited to the area to which it's actually applied (there is some evidence that its effect does indeed spread out a little to other areas of the scalp, but mostly it's a "local" effect). Considering that fact, it's even more impressive that topical minoxidil could pretty well hold its own against oral finasteride in the study I cited above; moreover, my main concern here is not the OVERALL comparison of those two approaches, it's just the following statement that you made previously: "The dutasteride hair counts were pretty amazing. Glaxo presented the data about 4 years ago. Minoxidil hair counts were pretty dim." Given the evidence that I've cited in both this and my previous article, I fail to see how you could justify such a claim, or your characterization of dutasteride in the past as being a "WOW" drug.
I'd appreciate any further comments that you might have on all this.
Most cordially,
Bryan Shelton
1) "Five-year Follow-up of men with androgenetic alopecia treated with topical minoxidil", Olsen et al, J Am Acad Dermatol 1990;22:643-6.
2) "Topical minoxidil therapy for androgenetic alopecia", Koperski et al, Arch Dermatol Vol 123, Nov 1987.
3) "Topical minoxidil in early male pattern baldness", Olsen et al, J Am Acad Dermatol 13:185-192, 1985.
4) "A randomized clinical trial of 5% topical minoxidil versus 2% topical minoxidil and placebo in the treatment of androgenetic alopecia in men", Olsen et al, J Am Acad Dermatol 2002;47:377-85.
5) "Topical minoxidil in early androgenetic alopecia", Kreindler et al, J Am Acad Dermatol 1987;16: 718-24.
6) "Duration of minoxidil therapy to yield maximum benefit", Rietschel et al, (letter) Arch Dermatol Vol 124, Oct 1988.
7) "Dose-response study of topical minoxidil in male pattern baldness", Olsen et al, J Am Acad Dermatol 15:30-37, 1986.
8 ) "Dose-response study of topical minoxidil in male pattern baldness", Shupack et al, J Am Acad Dermatol 1987;16:673-6.
9) "Safety and efficacy of topical minoxidil in the management of androgenetic alopecia", Rietschel et al, J Am Acad Dermatol 1987;16:677-85.
10) "Long-term follow-up of men with male pattern baldness treated with topical minoxidil", Olsen et al, J Am Acad Dermatol 1987;16:688-95.
11) "Use of topical minoxidil in the treatment of male pattern baldness", Savin et al, J Am Acad Dermatol 1987;16:696-704.
12) "Androgenetic alopecia: Treatment results with topical minoxidil", Janet L. Roberts, J Am Acad Dermatol 1987;16: 705-10.
13) "Long-term efficacy of topical minoxidil in male pattern baldness", Katz et al, J Am Acad Dermatol 1987;16: 711-8.
14) "Finasteride in the treatment of men with androgenetic alopecia", Kaufman et al, J Am Acad Dermatol Volume 39 Number 4 1998.
15) "Finasteride in the treatment of men with frontal male pattern hair loss", Leyden et al, J Am Acad Dermatol 1999;40: 930-7.
16) "Minoxidil vs finasteride in the treatment of men with androgenetic alopecia", Saraswat et al, Arch Dermatol Vol 139, Sep 2003.
