Finasteride vs Minoxidil for Hair Loss: What the Trials Show
Finasteride and minoxidil are the two hair-loss drugs with years of placebo-controlled trials behind them. Both work for many men with pattern hair loss, finasteride slightly better over a year, and they can be combined. Finasteride carries sexual and mood side-effect warnings you should read first. Supplements like biotin and saw palmetto are far weaker.
Written by Sift Nutrition Editorial Team, Research & Editorial
✓ Reviewed by the Sift Nutrition Editorial Team
Updated on 2026-09-29
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Finasteride and minoxidil are the two drugs with strong trial evidence for male pattern hair loss. Both beat placebo in large randomised trials and meta-analyses. Finasteride, a daily 1 mg pill, lowers the hormone DHT and mostly stops further loss; over a year it did slightly better than topical minoxidil in a network meta-analysis. Minoxidil, a foam or solution you apply (or a low-dose tablet used off-label), mostly helps hair regrow, and it is the one that works for women too. Neither cures anything: stop, and the benefit goes. Finasteride also has a real side-effect debate, with UK and US regulators warning about sexual problems and mood changes. Supplements such as biotin and saw palmetto are nowhere near either drug.
How each drug works
Male pattern hair loss (androgenetic alopecia) happens when DHT, a hormone made from testosterone, slowly shrinks hair follicles in people who are genetically prone to it. Finasteride blocks the enzyme that turns testosterone into DHT, so the shrinking slows or stops. Minoxidil was first a blood pressure tablet; people who took it grew extra hair, and it was turned into a scalp treatment. It works on the follicle directly, keeping hairs in their growth phase for longer. That difference is why they are often used together: one protects what is left, the other pushes regrowth.
What the trials found
| Treatment and study | Who and how many | What it found | Evidence grade |
|---|---|---|---|
| Finasteride 1 mg, two phase III trials, J Am Acad Dermatol 1998 (PMID 9777765) | 1,553 men aged 18 to 41, 2 years | 107 more hairs than placebo at 1 year and 138 more at 2 years in a 5.1 cm² patch on the crown (baseline about 876). Men on placebo kept losing hair | STRONGEST |
| Finasteride 1 mg, 5-year extension, Eur J Dermatol 2002 (PMID 11809594) | Same trials, 1,215 men continued | Improvements lasted over 5 years; placebo groups continued to lose hair | STRONGEST |
| Finasteride, systematic review, Arch Dermatol 2010 (PMID 20956649) | 12 trials, 3,927 men | One extra man felt his hair improved for every 5.6 treated in the short term and every 3.4 over 2 years or more. Hair count rose about 24% over placebo long term | STRONGEST |
| Topical minoxidil 5% vs 2% vs placebo, J Am Acad Dermatol 2002 (PMID 12196747) | 393 men, 48 weeks | 5% beat both 2% and placebo, with 45% more regrowth than 2%. More itching and irritation with 5% | STRONGEST |
| Minoxidil 5% foam vs placebo, J Am Acad Dermatol 2007 (PMID 17761356) | 352 men, 16 weeks | Significantly more hair than placebo; well tolerated over a 52-week safety follow-up | MODERATE (short efficacy phase) |
| Meta-analysis of treatments vs placebo, J Am Acad Dermatol 2017 (PMID 28396101) | Good and fair quality randomised trials | Finasteride 1 mg, minoxidil 2% and 5% in men, and minoxidil 2% in women all beat placebo | STRONGEST |
| Network meta-analysis of finasteride, dutasteride and minoxidil, JAMA Dermatol 2022 (PMID 35107565) | 23 studies | At 48 weeks, finasteride 1 mg added more terminal hairs than topical minoxidil 2% (about 32 per cm²) and 5% (about 26 per cm²). At 24 weeks, 5 mg oral minoxidil led on terminal hairs | MODERATE (indirect comparisons) |
| Finasteride plus topical minoxidil vs either alone, Aesthetic Plast Surg 2020 (PMID 32166351) | 5 randomised trials | Better photo scores and more men with marked improvement on the combination, similar side effects. No significant difference in hair density | MODERATE (small trials) |
Oral low-dose minoxidil: the newer option
Dermatologists increasingly prescribe minoxidil as a small daily tablet, usually 0.5 to 5 mg, instead of the foam. It is easier to stick with than a twice-daily scalp application. It is not FDA-approved for hair loss, so it is used off-label.
The best head-to-head evidence is one Brazilian trial of 90 men. After 24 weeks, 5 mg oral minoxidil a day was not significantly better than 5% topical minoxidil twice a day on hair density, though photos of the crown favoured the tablet (PMID 38598226). Almost half the men on the tablet (49%) grew unwanted hair on the face or body, and 14% had headaches. In a larger safety study of 1,404 patients on low-dose oral minoxidil, unwanted hair growth affected 15%, and 1.7% had lightheadedness, 1.3% fluid retention and 0.9% a fast heartbeat; 1.7% stopped because of side effects (PMID 33639244). That study had no comparison group. Oral minoxidil lowers blood pressure, so it needs a prescriber who checks your heart and blood pressure history.
Side effects, and the finasteride controversy
Topical minoxidil's main problem is an itchy or irritated scalp, and the 5% strength irritates more than 2% (PMID 12196747). Finasteride is where the real debate is.
| Source | What it found | Evidence grade |
|---|---|---|
| FDA label, pooled 1-year trials (945 men on finasteride, 934 on placebo) | 3.8% reported lower libido, erection problems or ejaculation changes vs 2.1% on placebo. These resolved in men who stopped and in most who continued | STRONGEST for short-term rates |
| Systematic review, Arch Dermatol 2010 (PMID 20956649) | Erectile dysfunction roughly doubled vs placebo (1 extra case per 82 men treated) | MODERATE |
| Review of safety reporting in 34 finasteride trials, JAMA Dermatol 2015 (PMID 25830296) | None of the 34 trials reported side effects adequately; most tracked safety for a year or less, and the pattern suggested sexual effects were under-detected | MODERATE (it questions the trial data) |
| Medical-record cohort, PeerJ 2017 (PMID 28289563) | Among 4,284 men aged 16 to 42 on finasteride 1.25 mg or less, 0.8% developed erectile dysfunction lasting at least 90 days after stopping; longer use raised the risk | LIMITED (observational, one health system) |
| Interviews with men reporting persistent effects, J Sex Med 2011 and J Clin Psychiatry 2012 (PMIDs 21418145, 22939118) | 71 men described low libido and erectile problems lasting a mean of 40 months after stopping; in a related group of 61, 44% reported suicidal thoughts vs 3% of controls | LIMITED (self-selected, no before-data) |
| WHO VigiBase reports, JAMA Dermatol 2021 (PMID 33175100) | A signal for suicidality and psychological side effects in finasteride reports, strongest in men under 45 using it for hair loss. Reports rose after 2012 publicity | LIMITED (reporting data cannot give rates) |
| Swedish national cohort, JAMA Netw Open 2022 (PMID 36547981), and Ontario cohort, JAMA Intern Med 2017 (PMID 28319231) | In mostly older men taking it for the prostate: more depression diagnoses, no significant rise in suicide | MODERATE (large, but not the hair-loss age group) |
Regulators have acted on this. The FDA label for Propecia (finasteride 1 mg) lists depression and suicidal ideation and behaviour among post-marketing reports. In April 2024 the UK's MHRA introduced a patient card in every finasteride pack, and in May 2026 it strengthened the warnings: finasteride is associated with depression, suicidal thoughts and sexual dysfunction that may persist after treatment is stopped, prescribers should ask about any history of depression, and men on 1 mg should stop and contact their doctor if they develop depression or suicidal thoughts. A 2025 review describes post-finasteride syndrome as real for some patients but still poorly understood and contested (PMID 39953145).
Two practical points. Finasteride lowers PSA, the prostate cancer blood test, so tell any doctor who orders one that you take it (FDA label). And it is not for women who are or may become pregnant: they should not even handle broken or crushed tablets.
How supplements compare
| Supplement | Evidence grade | What the studies show | The catch |
|---|---|---|---|
| Biotin | LIMITED | A review found 18 reported cases where biotin helped, all in people with an underlying deficiency or disorder (PMID 28879195) | No good evidence for healthy people, and deficiency is uncommon |
| Saw palmetto | LIMITED | In a two-year open-label comparison of 100 men, 38% improved on 320 mg saw palmetto vs 68% on finasteride (PMID 23298508). A systematic review found small positive studies but no high-quality data (PMID 33313047) | Weaker than finasteride in the only head-to-head study, and not blinded |
| Multi-ingredient hair supplements (Nutrafol, Viviscal and others) | MIXED | A 2023 systematic review found some small positive trials for several branded products (PMID 36449274). One 70-woman trial of Nutrafol's menopause formula reported more hairs than placebo at 6 months (PMID 33400421) | Small, short trials, none compared with minoxidil. Useful mainly if you want to avoid drugs and accept a smaller, less certain effect |
Where ketoconazole shampoo fits
Ketoconazole 2% is an antifungal dandruff shampoo that some hair-loss plans add on. The support for it in pattern hair loss is thin: one small study found hair density improved on ketoconazole about as much as on 2% minoxidil, and its authors said it needed larger controlled trials (PMID 9669136). It is reasonable if you also have dandruff or an oily, flaky scalp. It is not a substitute for either drug.
Getting them in the US and UK
- Minoxidil 5% foam and solution are sold without a prescription in both the US and the UK. Minoxidil tablets need a prescription.
- Finasteride 1 mg needs a prescription in both countries. In the US, a primary care doctor, a dermatologist or a telehealth service can prescribe it. Our review of Keeps covers one US telehealth option, its prices and its limits.
- In the UK, the NHS says finasteride and minoxidil are the main treatments for male pattern baldness but are not all available on the NHS, so most people pay privately, through a private prescriber or an online pharmacy with a UK-registered prescriber. US telehealth services do not ship to the UK.
- Whichever route you use, the prescriber should ask about depression and your sexual health before starting finasteride, and you should be told how to stop if side effects appear.
Who should skip these drugs, or see a doctor first
- Anyone whose hair loss does not look like the usual pattern: patches, sudden shedding, a sore or scaly scalp. That needs a diagnosis first.
- Anyone with a history of depression, anxiety or suicidal thoughts thinking about finasteride. The MHRA asks prescribers to check this and review you regularly.
- Women who are or could become pregnant: no finasteride. Minoxidil is the evidence-based option for female pattern hair loss.
- Anyone with heart disease, low blood pressure or fluid retention considering oral minoxidil. It needs a prescriber who knows your full history.
- Anyone expecting a cure. Both drugs work only while you use them, and regrowth is partial.
The bottom line
If your hair loss is typical male pattern loss, finasteride and minoxidil are the two treatments with decades of placebo-controlled evidence, and they do treat the condition for as long as you use them. Finasteride edges ahead over a year and protects what you have; minoxidil drives regrowth and is the safer first step for anyone worried about finasteride's side effects. Using both is common and has some trial support. Before finasteride, read the side-effect evidence above and tell the prescriber about any mood history. Biotin and saw palmetto are not substitutes.
Frequently Asked Questions
Which works better, finasteride or minoxidil?
Over a year, finasteride 1 mg did slightly better than topical minoxidil in a network meta-analysis of 23 studies: at 48 weeks it added about 26 more terminal hairs per square centimetre than 5% minoxidil (PMID 35107565). Both beat placebo clearly (PMID 28396101). Finasteride mainly stops further loss; minoxidil mainly regrows. Using both together is common.
Can you use finasteride and minoxidil together?
Yes, and it is common. A meta-analysis of five randomised trials found the combination gave better photo-assessed results than either drug alone, with no rise in side effects, though hair density changes were not significantly different (PMID 32166351). The trials were small, so the size of the extra benefit is uncertain.
How long does it take to see results?
Plan on at least 6 to 12 months. The finasteride trials measured results at 1 and 2 years (PMID 9777765), the main minoxidil trial at 48 weeks (PMID 12196747). If you stop either drug, the hair it kept or regrew is lost again over the following months.
What are the side effects of finasteride?
In the 1-year trials, 3.8% of men on finasteride reported a sexual side effect (lower libido, erection problems or less ejaculate) against 2.1% on placebo, per the FDA label. Most cleared up. Some men report sexual, mood and other symptoms that persist after stopping, sometimes called post-finasteride syndrome; how common that is remains disputed. The UK regulator says finasteride is associated with depression, suicidal thoughts and sexual dysfunction that may persist after treatment stops.
Is oral minoxidil better than the foam or solution?
Not clearly. In a 24-week randomised trial of 90 men, 5 mg oral minoxidil a day was not significantly better than 5% topical minoxidil twice a day, although photos of the crown favoured the tablet (PMID 38598226). Half the men on the tablet grew unwanted hair elsewhere. Oral minoxidil is not FDA-approved for hair loss and should be prescribed and monitored.
Do biotin or saw palmetto work for hair loss?
Biotin helps only people who are deficient in it, which is rare; a review found no good evidence for healthy people (PMID 28879195). Saw palmetto has small, mostly low-quality studies; in the one two-year comparison, 38% of men improved on saw palmetto against 68% on finasteride (PMID 23298508).
Can women use finasteride or minoxidil?
Minoxidil, yes: a Cochrane review found topical minoxidil helps female pattern hair loss, with 2% and 5% working about equally (PMID 27225981). Finasteride 1 mg did no better than placebo in women in that review, and it must not be used in pregnancy; women who are or may be pregnant should not handle crushed or broken tablets.
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