“I’ve spent a fortune on shampoos and supplements — just tell me what actually works”

Androgenetic alopecia (male-pattern hair loss) is a confident CLINICAL diagnosis — gradual patterned loss (bitemporal recession, vertex thinning) in a post-pubertal man, usually with family history and hair miniaturisation, needing little or no investigation when typical. Briefly exclude mimics: telogen effluvium (diffuse, often reversible post-stressor shedding), iron deficiency/thyroid disease (ferritin, TFTs if diffuse shedding), alopecia areata (smooth patches, exclamation-mark hairs), and SCARRING alopecia (erythema, scaling, lost follicular openings — irreversible, refer dermatology). The honest evidence: TOPICAL MINOXIDIL and ORAL FINASTERIDE are the two treatments that genuinely work — they slow loss and partially regrow but are slow (minoxidil judged after at least 6 and possibly 12 months, BAD 2016; finasteride a year or more, SPC), work best early, and only maintain benefit while continued; finasteride is more effective but carries sexual side-effects in a minority (about 2%, may persist after stopping), a depression/suicidal-ideation warning (MHRA Drug Safety Update April 2024, reinforced May 2026 — ask about mood history first, especially given his distress), lowers PSA, and is teratogenic/not for women, while minoxidil can cause irritation and initial shedding — and neither can be prescribed on an NHS FP10 (NHS Drug Tariff Part XVIIIA), so both are bought or obtained privately. Be straight that caffeine shampoos, biotin and most supplements (absent deficiency), and derma-rollers/laser, are largely marketing with little good evidence; mention transplant and cosmetic options neutrally. The real consultation, though, is the EMOTIONAL one: heavy spending and frustration signal genuine distress, as hair loss young can hit identity, confidence and mood — explore and validate the impact, screen low mood/body-image preoccupation, set realistic expectations, and support whatever informed choice he makes, neither trivialising ("it’s only hair") nor overselling a cure.