Androgenetic alopecia. Which is best: Ketoconazole, Miconazole nitrate or Topical Dutasteride? Looking for topical solution

Hello, Great question!Dutasteride theoretically has more potency for hair preservation than Finasteride but a higher side effect profile as well.  The use of dutasteride for hair loss is an off-label use according to the FDA.  Typically regrowth of both agents occurs in areas where the hair is miniaturized and not where slick baldness occurs.  Consider the use of regenerative techniques such as PRP and others and the use of nutraceuticals such as Nutrafol which have a much better side effect profile.Best, Dr. Anil Shah

Thank you for this question. I agree with many of the other answers to this question. Oral finasteride would be an excellent option at this point. If you are trying to avoid taking an oral medicine and want to stick to topicals I would add 2% ketoconazole. Based on an emerging evidence base I would also recommend a series of injections with platelet rich plasma (PRP). Another consideration would be to ask your treating dermatologist about compounding a higher percentage of topical minoxidil with the 0.1% finasteride. I hope this is helpful. 

In order of efficacy, dutasteride, then ketoconazole/miconazole.  However, you can use them together for a synergistic benefit.  Make sure that the ketoconazole you are using is in an organic shampoo.

Of the ones you have listed, namely Ketoconazole 2% shampoo, Miconazole nitrate (Monistat), Dutasteride (Avodart capsule using topical), CopperPeptide, Caffein, Melatonin, Tretinoin, Azelaic Acid, Fluoride - the best evidence is for ketoconazole. There is less to no evidence for many of the one's you have listed. Ketocaonzole is a an anti fungal medication and effective for the treatment of dandruff and closely related seborrheic dermatitis. But research over the past many years has suggested that they help hair loss as well. I often recommend that individuals with genetic hair loss consider use of anti-inflammatory shampoos.
What is the evidence of ketoconazole studies for hair loss?
A nearly two year long study  examined the use of topical minoxidil to ketoconazole 2 % shampoo. Study participants received the 2 % shampoo or an unmedicated shampoo with or without minoxidil 2 %. Interestingly, hair density and follicle size improvements were similar with both ketoconazole and minoxidil regimens. The exact way that topical ketoconazole increases hair density and hair growth is unclear, but may be due to is anti-inflammatory effects against immune system cells (particularly T lymphocytes) and the yeast of the scalp which create inflammation (called Malassezia). Ketoconaozle also inhibits steroidogenesis and reduces DHT levels.
References for Interest
Inui.  J dermatol Sci 2007; 45: 66-8.
Pierar Franchimont Dermatology 1998; 196: 474-7

There is a liposomal form of finasteride that is topical and can be used fairly effectively without the sexual side effects that worry many men