Minoxidil (Rogaine/Regaine): Do I really need to use forever?

I'm often asked if a patient needs to use their minoxidil (Rogaine/Regaine, etc) "forever." The answer is sometimes yes and in other cases the answer is "no." It really depends on the diagnosis and a few details specific to each patient. Here are a few examples.

Androgenetic Alopecia

Use forever?: Yes

If the patient has androgenetic alopecia (male balding and female thinning), he or she will need to use minoxidil forever. If minoxidil is stopped, the hair will return to the way it once was and progressively get worse. In fact, all treatments for androgenetic alopecia are the same - use is forever. 

Telogen Effluvium

Use forever?: Usually not

Patients with telogen effluvium or "excessive" daily shedding from a trigger such as low iron, thyroid problems or a crash diet often don't even need minoxidil. (I’m not a big fan of getting people to use minoxidil in telogen effluvium is the cause is known).

But the patient will often use to encourage more rapid resolution of the hair loss. Once the "trigger" has been addressed and treated, hair shedding usually slows down and eventually stops. Minoxidil can be used until the shedding returns back to a normal rate and them for a few months after. A patient who uses minoxidil after a crash diet will find that shedding reduces to normal once the diet is improved. If minoxidil was used it can be stopped in 6-13 months without the patient experiencing a return of the shedding. In this case minoxidil use is not forever. There are some forms of shedding which continue on and on despite fixing any known "trigger." We call this chronic idiopathic telogen effluvium and in such cases minoxidil may be needed long term for many years (1-15 years… or more!). Generally though even in such cases of chronic idiopathic telogen effluvium the minoxidil can be stopped.

In summary, for most patients with telogen effluvium, use of minoxidil is NOT forever. The goal of treatment is to treat the cause of the shedding (like the low iron or the thyroid problem!)

Alopecia areata

Use forever? Usually not

Alopecia areata is an autoimmune condition which can cause hairloss anywhere on the body. Most patients with alopecia areata lose hairs in circles or patches in the scalp. The hair loss in these areas can grow back on its own (we say "spontaneously") or with treatments such as corticosteroids and minoxidil. In most cases, once the hair regrowth is underway, it is possible to stop the minoxidil without the patch of hair loss coming back. 

In summary, for most patients with alopecia areata, use of minoxidil is NOT forever.

Scarring alopecia

Use forever? Sometimes 

Although scarring alopecias are commonly seen in my clinic, overall they are relatively uncommon conditions. Most have an immune basis, meaning that some sort of inflammation is generally present underneath the scalp. Treatment with minoxidil alone (as a sole treatment) is never appropriate for patients with "active" scarring alopecia. Minxodil however can be a good add on treatment (adjuvant treatment) to cheer on hairs that are trying hard to push their way through scar tissue in the scalp. I often recommend patients who decided to start minoxidil) and who show some kind of benefit) for scarring alopecias continue to use long term. Scar tissue is permanent and it is helpful if many cases to have minoxidil on board to cheer the hair growth along.

In summary, the decision to use minoxidil forever in scarring alopecias is taken on a case by case basis. For many patients long term use is advised if there is evidence it is actually helping.