Updated: Mar 31
We can fly to the moon, we have self-driving cars, yet we still do not have a full proof treatments for hair loss.
To this day scientists are perplexed by hair loss, and although we know a lot about what causes it and how it works, we still have not cracked the code on how to fix it. Luckily, people much smarter than you or I have been able to create several different treatments that, although they aren’t full proof, can be very effective at helping stop, and even sometimes reverse, hair loss.
Most notably are finasteride, minoxidil, low-level laser therapy, and ketoconazole shampoo. These are by far the most commonly used treatments because they are widely available and (besides ketoconazole) are FDA approved for hair loss, which means they have been shown to be significantly effective in clinical trials. But what happens if you combine all three of them?
Well, many people have already done this, in fact the combination of finasteride, minoxidil, and ketoconazole shampoo became very popular throughout the hair loss community and earned the nickname the big three.
Many people claim that the big three is the most effective combination of treatments that is currently available. In this article, we are going to break down that claim to see if it has any legitimacy or not. We will be looking closely at the big three to determine whether or not it is, in fact, the most effective treatment plan that you can get your hands on, or if there is another combination of treatments that might yield better results.
First off: what makes the big three so effective?
There is a reason that the big three has become the standard for an effective hair loss regimen: it covers all three of the most important areas for overcoming it: blocking dihydrotestosterone (DHT), enhancing blood flow, and improving scalp health.
Finasteride: takes care of DHT
Finasteride is the most important treatment in the big three. It is a 5-alpha reductase (5-AR) inhibitor, meaning it blocks the enzyme 5-AR which is responsible for converting testosterone into DHT.
Blocking DHT should be at the forefront of any and every hair loss regimen. DHT binds to the hair follicles and causes miniaturization. In other words, if you don’t block DHT, regardless of if you use other treatments or not, hair loss will continue to worsen.
Minoxidil: blood flow? Check.
The second treatment in the big three, minoxidil, is highly effective at promoting blood flow. It is a vasodilator, meaning it opens (dilates) the blood vessels.
After you have DHT taken care of (which again, ensures hair loss does not worsen) you need to focus on re-growing the hair that you have lost, and that is exactly what minoxidil helps with.
Blood carries vital oxygen and nutrients that your hair follicles use to grow and complete healthy hair cycles. Therefore, by using minoxidil, you can promote blood flow to your dying hair follicles to help revitalize them.
Ketoconazole shampoo: the scalp savior
The last component of the big three is ketoconazole shampoo. The reason that it is included alongside finasteride and minoxidil is because it takes care of the last critical aspect of overcoming hair loss: maintaining a healthy scalp and hair.
Ketoconazole has antifungal properties. This allows it to reduce harmful microflora (i.e. fungus, bacteria, etc.), which is important because it can help reduce and/or prevent dandruff, seborrheic dermatitis, and more. These, along with several other scalp conditions, can cause oxidative stress and inflammation, both of which can cause damage to hair follicles.
Having a healthy scalp and hair will give other treatments a better chance at being effective, making ketoconazole a critical component of the big three, but…
Are there more effective options?
That’s the big question: are there other treatments that would work better than what is currently included in the big three?
For starters, let’s look at DHT blockers.
Again, blocking DHT is the most important aspect of an effective hair loss regimen. Studies show that finasteride blocks about 70% of DHT. While this may be enough for some people, there are many who don’t get the results they desire from finasteride, in which case they may want to switch to dutasteride.
Dutasteride is also classified as a 5-AR inhibitor, although it blocks type 1 and 2 5-AR, while finasteride only blocks type 2. This is what likely makes it much more effective than finasteride, in fact, studies have shown that dutasteride can block up to 90+% of DHT! So, why isn’t dutasteride the go-to option for people using the big three?
It’s because it isn’t FDA approved for hair loss (yet). Dutasteride is much harder to obtain a prescription for because it has to be prescribed for off-label use, which also usually makes it more expensive as well. But regardless, research shows that it is more effective and would likely yield better results than finasteride.
Now that we have covered DHT, what about blood flow?
Good news, minoxidil is likely the best option we have for improving blood flow. It is the only FDA approved treatment for hair loss that specifically targets blood flow. And although there are other treatments that have shown promise, for instance: rosemary and peppermint oil, nothing comes close to the conclusive body of evidence that minoxidil has.
I will say this though, based on my own personal experience using other treatments (scalp massages, laser helmet, inversion method, etc.) alongside minoxidil to improve blood flow may be able to compound your results. The more blood flow improves, the higher your chances of having successful regrowth are. In short, if you are currently using the big three, consider adding more treatments that target blood flow.
Last but not least we have ketoconazole.
Is there something that will work better than ketoconazole shampoo? The short answer is no, but the type of shampoo you use matters… a lot.
Many people use the popular ketoconazole shampoo Nizoral because it is cheap and widely available. But, Nizoral, amongst many other shampoo’s, contains harmful chemicals that can degrade hair quality and even counteract the effects of ketoconazole in some cases.
If you want to get the most out of your ketoconazole shampoo, you are going to want to use one with natural ingredients that are targeted towards hair loss (I prefer to use Lipogaine).
The big three is a solid start to a successful hair loss regimen because it covers the three most important aspects of overcoming hair loss: blocking DHT, increasing blood flow, and optimizing scalp and hair health.
Although, while it is a solid foundation, there are definite areas for improvement in the big three. Dutasteride is a stronger alternative to finasteride, adding more blood flow-inducing treatments could help create more successful regrowth, and making sure you use the right ketoconazole shampoo should be emphasized.
Is the big three an effective hair loss regimen? Yes, but I also strongly recommend using the big three as a base and building upon it.