(CNN)A receding hairline. A bald spot spreading on the top of head. Painfully thin hair that is especially noticeable where the hair parts. Some 90% of men will suffer some form of hair loss during their lifetime, often leading to symptoms of low self-esteem, anxiety and depression.
Studies on which nonsurgical treatments work best for male-pattern baldness have been limited, leaving men at a loss as to the most effective solution.
Now a new meta-analysis of 23 studies sheds light on that issue. The study, published Wednesday in the journal JAMA Dermatology, analyzed research on the impact on thinning male hair of using various dosages of the three oral and topical medications -- minoxidil, dutasteride and finasteride -- for two to four months.
"This meta-analysis is important. We don't have randomized clinical trials that compare these medications for male pattern baldness against one another, which would be ideal," said dermatologist Dr. Anthony Rossi of Memorial Sloan Kettering Cancer Center in New York City, who was not involved in the study.
Top performer: The analysis found taking 5 milligrams a day of oral dutasteride had the highest probability of reducing male hair loss.
Dutasteride is a prescription drug approved by the US Food and Drug Administration for the treatment of enlarged prostate glands in men. It's also used to treat male-pattern baldness, but that use is considered "off-label" since dutasteride does not have FDA approval as a hair loss treatment.
Off-label use is quite common in medicine, Rossi said. "Many medications are used off label, but there's usually enough evidence out there to explain why we believe those drugs will work," he added.
Dutasteride does have more severe side effects than several of the treatments, however, including a loss of sexual drive and the ability to get and keep an erection.
Second place: Taking 5 milligrams a day of oral finasteride was second in effectiveness, the study found. Finasteride, another prescription drug in the same chemical family as dutasteride, is also used to treat enlarged prostate. It has received FDA approval as a treatment for hair loss.
Finasteride also produced the greatest increase in total hair count at 48 weeks. A total hair count is just what it sounds like -- a count of all the different types of hair on a head, including finer baby hairs or "peach fuzz."
Third place: The third most successful treatment for male pattern baldness was a pill containing 5 milligrams of oral minoxidil. That pill produced the greatest increase in terminal hair count at the end of two months, much stronger than the lower dose.
"Terminal" hairs are the more mature hairs on the head (as compared to new, fine baby hairs) and are more likely to create that 'full head of hair" effect that many strive for, Rossi said.
Fourth place: Taking a reduced dosage of finasteride, only a 1 milligram pill each day, came in fourth in the ability to reduce male hair loss, the study found. However, it did show the greatest increase in mature hair count at 48 weeks.
Fifth place and lower: Using a 5% topical solution of minoxidil on the scalp was fifth in effectiveness, followed by the 2% solution of topical minoxidil. Last place in effectiveness, according to the study, was a much smaller dosage of oral minoxidil -- only 0.25 milligrams a day.
One caveat: While the study did ultimately rank the treatments in descending order, each had different benefits at different times during the 24- and 48-week cycle, and each comes with its own unique set of problematic side effects.
"In general, topical medications are going to have less systemic side effects than oral drugs, but topical treatments can be more laborious to use," said Dr. Amy McMichael, a professor of dermatology at Atrium Health Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, who was not involved in the study.
"The best medication is the one that the patient will be compliant with, since we are still much better at keeping the hair they have than turning back the hands of time," she said via email.
Not enough effective treatments
Halting male hair loss in its tracks -- rather than replacing the hair with expensive hair plugs and other invasive surgical techniques -- is the holy grail of treatment goals. Unfortunately, no one best option exists, experts say.
Over-the-counter (and therefore nonprescription) minoxidil is the most well known treatment for both men and women, and is available in liquid, foam and shampoo forms. Minoxidil requires an application on the scalp both morning and night, and some complain it can leave hair feeling sticky and hard to style.
Side effects can include a itching or a burning feeling on the scalp, as well as dryness, scaling and flaking. It takes several months for the positive effects to appear, and hair loss returns quickly once use is stopped.
Dutasteride can have brutal side effects in some men, Rossi said, including a loss of libido, erectile dysfunction and a form of low pressure called orthostatic hypotension.
On rare occasions, there can be more severe reactions to dutasteride. Call the doctor or go to the emergency room if there is any skin peeling, swelling of the face, tongue, or throat, difficulty breathing or swallowing, or any changes to the breasts such as increased size, lumps, pain, or nipple discharge, experts say.
Older men should speak to their doctors about their prostate cancer risk before beginning dutasteride, experts say, as taking the medication may increase the risk of high-grade prostate cancer, which spreads and grows more quickly than other forms of prostate cancer.
Finasteride can also impact male sexual abilities, but it is less potent than its cousin dutasteride, so it might be a better choice for some men.
Consider consulting a dermatologist who specializes in hair loss treatment who can help you navigate the confusing thicket of hair loss options, Rossi said. Often, he said, your doctor will suggest you start small.
"Many people take a stepwise approach," he said. "They may start on finasteride and if they're not improving on finasteride, then go to dutasteride. Or they may start on topical minoxidil and If they're not doing well then progress to oral minoxidil."
Finally, a warning: None of the study's results should be applied to women with hair loss, McMichael stressed. Some 50% of women experience hair loss at some point in their lives.
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"The studies of all these medications in women have been much less extensive, and there is no basis to say that the efficacy would be the same," she said. "In clinical practice, many of these medications are used off label in women, but there are some very real concerns."
None of the oral medications are acceptable for women of child-bearing years, for example, due to the chance of pregnancy, McMichael said.
"The only medications evaluated here that have been approved for use in women are minoxidil 2% and 5%, and of the two, we know 5% works better than 2%," she said. "I would not extrapolate the findings discussed in this paper to women."
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