I don't think that diagram is sufficiently complex to allow for it to illustrate the "ultimate stack". That diagram is a marketing gimmick for seti. It doesn't remotely encompass how complex hair loss is.
But if you want to put together a nuclear "kitchen sink" approach, with the strongest agent from every class, while still controlling side effects to possibly tolerable levels, this would be it in my opinion...
ULTIMATE HAIR LOSS AGENTS BY CLASS
- Androgen Receptor Antagonist
- Mechanism: Blocks DHT and testosterone from binding to androgen receptors
- Agent: Topical Darolumatide
- Rationale: Strongest medication in the entire drug class, does not cross blood brain barrier, topical use focuses effect at the scalp and should reduce systemic side effects
- 5-AR Inhibitor
- Mechanism: Reduces DHT levels by blocking 5-AR enzyme
- Agent: Dutasteride
- Rationale: Reduces serum DHT by 95%
- Anti-Histamine
- Mechanism: Decreases PGD2 as well as many other downstream inflammatory mediators triggered by androgen binding, likely should help male pattern baldness itch
- Agent: Topical Desloratadine
- Rationale: Cetirizine has better evidence but has potential stability problems in ethanol based solutions
- PGD2 Inhibitor
- Mechanism: Blocks PGD2 which is one downstream mediator of inflammation triggered by androgen binding
- Agent: Oral Setipiprant
- Rationale: No published evidence for any drug in this class yet exists, but at least we have some field reports from people trying oral seti that have noticed benefits, and it seems to be safe so far.
- Estrogen
- Mechanism: ER-beta stimulation has many positive effects in the skin and can prolong anagen of hair follicles
- Agent: Topical Estriol
- Rationale: Estriol has the greatest ER-beta predominance of all natural estrogens. Topical administration avoids excessive liver metabolism, reducing risks, and allows the effect to be focused at the scalp.
- Prostaglandin Stimulant
- Mechanism: Manipulation of prostaglandin signalling, particularly towards PGE2 can promote hair growth through inflammation
- Agent: Oral Minoxidil
- Rationale: Minoxidil is the best proven growth stimulant on the planet. Topical concentrations are limited to 5% traditionally due to poor solubility. Oral dosing allows greater delivery to the follicles, but with more side effects and risks.
- Stem Cell Stimulant
- Mechanism: Wounding in combination with growth stimulants triggers a stem cell response which leads to follicle neogenesis.
- Agent: PRP
- Rationale: PRP combines traditional wounding with the injection of natural growth stimulants from your own centrifuged blood and has good published evidence
- Tension Reducer
- Mechanism: Therapies to reduce scalp tension reduce tension-mediated androgenic inflammation and improve blood flow to the scalp
- Agent: Botox
- Rationale: Two sessions of scalp muscle Botox spaced 6 months apart gave equal results to finasteride by 1 year in one published study
