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Hair Transplant Forum International
November/December 2008
Cyclical medicine for hair loss management and improved
results in hair transplantation
Rajendrasingh J. Rajput, MS, MCh Powai, Mumbai, India
Apart from androgenetic changes, hair loss, especially in
Table 2. Formulas Used (over-the-counter)
women, has been attributed to internal factors such as nutri-
Day 1
Day 1
Day 3
tional deficiencies, hormonal imbalance, metabolic changes,
Antioxidant composition
Calcium tablet
Amino acids
and seborrheic scalp. External factors that might contribute
Eicosapentanoic acid 45mg
Calcium Carbonate 400mg
Alanine 11.9mg
Docosahexanoic acid 35mg
Calcitrol 0.25mcg
Arginine 23.5mg
to hair loss include dust, pollution, chemical treatments,
Vitamin E 25IU
Zinc 7.5mg
Aspartic acid 35.2mg
Zinc 7.5mg
Cystine 3.9mg
dyes, excess heat or cold, and poor hygiene. While minoxidil
Beta Carotene 5mg
Day 2
Glutamic Acid 61.8mg
and finasteride are useful for treating androgenetic hair loss,
Folic acid 5mg
Iron & Folic acid
Glycine 12.8mg,
our treatment philosophy is to treat all cases of hair loss
Vitamin B6 3mg
Carbonyl iron 100mg
Histidine 7.7mg
Manganese sulfate 4.5mg
Adenosylcobalamine 500 mcg
Isolucine 14.6mg
with the combination treatment described below.
Copper 1mg
Folic acid 1.5mg
Lucine 23.8mg
Chromium 200mcg
Zinc Sulfate 61.8mg
Lysine 19.6mg
In this study of 500 patients we combined the use of anti-
Selenium Dioxide 150mcg
Methionine 3.9mg
oxidants, iron, calcium, zinc, amino acids, and vitamins E, D,
Vitamin B12 15mcg.
Phenylalanine 16mg
Vitamin C 75mg
Serine 16mg
and C1-3 with minoxidil and finasteride4-6 to control hair loss,
Vitamin A 5000 IU
Threonine 11.3mg
reverse miniaturization, and achieve new hair growth within
Vitamins D2 & D3 400IU
Proline 16mg
Thiamine 5mg
Tryptophan 3.6mg
2-4 months. The patients were also followed clinically for 2
Riboflavin 5mg
Tyrosine 11.9mg
Nicotinamide 50mg
Valine 14mg
years and were observed to maintain their improvement. The
Calcium pentothenate 5mg
supplements and finasteride are used cyclically once every
Magnesium dioxide 30mg
3 days. We believe the cyclical approach helps to prevent
vitamin overdose and the side effects of finasteride.
The average improvement in caliber was 37% at 2 months
and 47% at 4 months (Figure 1, A and B; Chart 1). Patients
Material and Methods
with temporal angle receding and thinning in the crown
The study included 500 patients randomly selected ir-
area also responded well to 4 months of cyclical medicine.
respective of age, sex, and grade of hair loss who were
In control Group II, density improved by an average of 2% at
grouped as follows:
2 months and 3.6% at 4 months. Caliber was unchanged in
Group I: Male test group with 200 patients who followed
44% of the patients, it was improved by 1.4% at 2 months
cyclical medicine (Tables 1 and 2)
and 5.5% at 4 months, at which time 26% of patients still
Group II: Male control group with 200 patients of similar
had no improvement.
age and hair loss grades as Group I, but who followed
Group III, female patients on cyclical medicine, showed
conventional minoxidil 2% and finasteride 1mg daily
an average 31% improvement in density at 2 months and
Group III: Female test group with 50 patients who used
51% at 4 months. The improvement in caliber was 21% at 2
cyclical medicine; finasteride was not used
months and 53% at 4 months (Chart 2). Patients with Poly-
Group IV: Female control group with 50 patients of simi-
cystic Ovarian Disease (PCOD) also responded without the
lar age and hair loss as Group III, who used minoxidil
use of anti-androgens (Figure 2, A and B). Receding female
2% and B complex with biotin 260mg daily
hair also showed marginal correction. Control Group IV
Table 1. Cyclical Medicine Program
* Treatment repeats in 3-day cycles
* Day 1: Antioxidants, Calcium
* Day 2: Iron, Folic Acid & Vitamin C
* Day 3: Amino Acids & Finasteride 1mg (Biotin in females)
* Minoxidil 2% local application every day
* 2% Ketoconazole & Zinc Pyrithione Shampoo every 3 days
Figure 1. A: Miniaturization of hair; B: Miniaturization reversed with 4 months
All patients were clinically evaluated every 2 months
of cyclical medicine
using digital photographs7,8 and folliscopic analysis. Evalu-
ations were performed by four different assistants who were
Chart 1. Improved Hair Density and Caliber in Males
not aware of the patient profile and patient group. In male
groups, the serum DHT levels were studied every 4 months.
Male patients were asked to report any sexual side effects
or breast tenderness.6
Age varied from 15 to 73 years, with 79% of the patients
in the range of 21-40. Fifty-five percent of the patients were
Hamilton Grades III and IV.
In Group I, the average improvement in density with cycli-
cal medicine was 30% at 2 months and 52% at 4 months.

Hair Transplant Forum International
November/December 2008
Figure 2. A: PCOD hair loss; B: PCOD hair loss response after 4 months
Figure 3. A: Miiaturization appearing as Grade VII; B: Miniaturization
of cyclical medicine
Reversed with 4mths of Cyclical Medicine to Grade III
Chart 2. Improved Hair Density and Caliber in Females
patients had follicles of better caliber, which were easy to dis-
sect, easy to handle, and easy to implant. The transplanted
hair growth started at 21/2 instead of 4 months, and these
patients did not have shock loss.
An irritation to minoxidil 2% solution application was
seen in 0.8% patients. One percent of patients in the control
group using 1mg finasteride daily reported loss of libido or
decreased seminal volume in the first 8 weeks of therapy.
This required reassurance and the symptoms improved as
the treatment continued. No sexual side effects were, re-
ported by any of the patients taking 1mg finasteride once
every 3 days.
density improved by 4% at 2 months and 10% at 4 months;
56% of females had no improvement at 2 months. Caliber
improved by 5% at 2 months and 19% at 4 months in the
It has been suggested that promoting hair growth requires
control group.
supplementation of certain minerals, vitamins, amino acids,
Patients responded to a self-assessment questionnaire at
and antioxidants, as well as control of sebum secretion and
4 months. In control Groups II and IV, 74% of patients said
antidandruff treatment.
they looked the same. A few patients (3%) said that they had
There are drawbacks to using vitamins, minerals, and
become worse than before. All patients in test Groups I and
amino acids together. Excess of vitamin A and E lead to im-
III felt that they saw new hair growth, the affected area was
proper keratinization of hair and cause hair loss.2 Absorp-
smaller, or friends and family noticed the difference. Some
tion of minerals and vitamins is dependant on their relative
patients (1.5%) stopped treatment after noticing improve-
deficiency in the body; iron and calcium given together reduce
ment at 4 months; they then noticed worsening of their hair
the absorption of one another.9 We have addressed these
condition in the next 3-6 months, and restarted treatment.
problems by giving these components once every 3 days. A
Serum DHT levels were studied initially and after 4
combination of two different drugs per day was used on a
months. A daily dose of finasteride 1mg (Group II) induced
schedule that repeated every 3 days for one complete cycle of
a 12-54% DHT suppression (avg. 41%) after 4 months. Fin-
4 months (Table 1). Contents and composition of these readily
asteride 1mg once every 3 days (Group I) achieved a 7-46%
available over-the-counter preparations used are in Table 2.
suppression of DHT levels (avg. 21%). The initial grade of
In female patients the same regimen was followed with 2%
hair loss and the improvement after treatment was not seen
minoxidil but finasteride was omitted.11 The combinations
to be proportional to DHT levels. In our opinion, this may
were easy to remember and followed the days of the week.
indicate that hair loss is multifactoral and even male pattern
The same drug combinations repeated on Monday/Thursday,
baldness requires other supportive treatments in addition to
Tuesday/Friday, and Wednesday/Saturday, with no medicine
DHT suppression and minoxidil.
on Sundays. Minoxidil 2% was used every day12 and 2% Ke-
toconazole plus Zinc pyrithione shampoo twice a week.
Two-year Follow-up
Finasteride has good receptor binding and 0.2mg finas-
Two-year follow up showed that patients had further (24-
teride per day can achieve 60% suppression of DHT levels
63%) improvement in hair caliber over 2 years, and 39-156%
suggesting that every 3 day dosing may be effective.7
further improvement in hair density. Thirty-four percent of
the patients discontinued treatment for a short while and
noticed increased hair loss 8-10 weeks after discontinuing
Improvement in hair count, hair caliber, and control of
treatment. All restarted treatment and regained their hair
hair loss was better with cyclical medicine than in the con-
growth in the next 4 months. A small percentage (6%) of
trol groups. Improvement was noted in males and females
the group that restarted treatment felt the improvement was
in all age groups and grades of hair loss at 2 months and
5-10% less than what they had initially achieved.
continued at 4 months. No patients reported any side effects
Some Grades V and VI patients on cyclical therapy could
of finasteride using the cyclical regimen. Pre-conditioning
achieve reversal of miniaturization to an extent, in our opin-
the hair with cyclical medicine before hair transplantation
ion, of not requiring a hair transplant (Figure 3, A and B).
appeared to prevent shock loss, improve growth, and made
The transplant team reported anecdotal observations
the grafts easy to dissect and easy to implant.
about patients on cyclical medicine. They felt that these
page 210

Hair Transplant Forum International
November/December 2008
Cyclical medicine
7. Kaufman, K.D., R. Devillez, and J. Roberts. A 12-month
from page 209
pilot clinical study of the effects of finasteride on men
with male pattern baldness. Poster: Abstract number 550.
SID, 55th Annual Meeting, Baltimore, April 27, 1994.
1. Eisenberg, E. Hair Loss Unrelated to Androgenetic Alo-
8. Barry, E.D., and M.G. Gregory. Standardized Photogra-
pecia. In: Hair Transplant, 4th edition, Chapter 4. New
phy. In: Hair Transplant, 4th edition, Chapter 22. New
York: Marcel Dekker. 2004; 67.
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2. Spencer, D.K. The Hormonal Effects of Diet on Hair
9. Goodman & Gillman. The Pharmacological Basis of
Loss. In: The Bald Truth, Chapter 2. New York: Simon
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& Schuster Inc. 1998; 37-54.
10. Spencer, D.K. The power of herbal treatments. In: The
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Bald Truth, Chapter 3. New York: Simon & Schuster Inc.
to energy." The importance of the diet and nutritional
1998; 55-70.
supplements in metabolic process of the hair bulb before
11. Whiting, D.A., and C. Jacobson. Treatment of female
and after transplant. ESHRS Journal. 2003; 3(2):4-5.
androgenetic alopecia with minoxidil 2%. Int J Dermatol.
4. Olsen, E.A., E.R. DeLong, and M.S. Weiner. Long-term
1992; 31:800-804.
follow-up of men with male pattern baldness treated with
12. Diani, A.R., M.J. Mulholland, and K.L. Shull. Hair growth
topical minoxidil. J Am Acad Dermatol. 1987; 16:688-695.
effects of oral administration of finasteride, a steroid
5. DeGroot, A.C., J.P. Nater, and A. Herxheimer. Minoxidil:
5-alpha reductase inhibitor, alone and in combination
hope for the bald? Lancet. 1987; 2:1019-1022.
with topical minoxidil in the balding stump tail macaque.
6. Olsen, E.A., M.S. Weiner, and I.A. Amara. Five-year follow-
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