Comment on Current Investigations into the Postfinasteride Syndrome

Few dermatologic problems carry as much emotional overtones as the complaint of hair loss, while the best way to alleviate the emotional distress related to the hair loss is to effectively treat it. With the advent of effective pharmacologic agents, the options for managing male pattern hair loss (MPHL) and alopecia-related distress have expanded. Oral finasteride represents a major breakthrough, based on an understanding of the underlying pathophysiology, and observations on the phenotype of the respective genetic defect of type 2 5-alpha reductase. Clinical studies have demonstrated both a high efficacy of treatment and a favorable safety profile establishing the drug as first-line treatment. And yet, after 15 years of successful prescription, the postfinasteride syndrome has emerged. By definition, the condition is characterized by sexual dysfunction, somatic symptoms, and psychological disorders that persist after cessation of treatment. As yet, the condition is not recognized by the medical community. In fact, the concept has emerged from neuroendocrinological research and rodent models, while hair experts have performed investigations into the plausibility of the syndrome based on a comprehensive review of the respective medical literature, and found that persistent sexual side effects were only documented in low-quality studies with strong bias selection, and a significant nocebo effect. In fact, there is more evidence that the condition may represent a psychiatric disorder. In favor of this hypothesis are a striking similarity to Koro with regard to genital symptoms; emergence of the condition with media coverage; a known significant nocebo effect in patients informed about adverse effects of finasteride; high prevalence of personality disorders among men seeking treatment for MPHL; so far no consistent endocrinological or organic abnormalities; and quality of centrality: No matter how unlikely it is that these strange things are happening, the patient accepts them relatively unquestioningly.