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Side Effects of Low Dose Minoxidil (1-2.5 mg)

Side Effects of Low Dose Minoxidil (1-2.5 mg)

low dose minoxidil.png

Oral minoxidil was a common treatment in the past for individuals with challenging to treat blood pressure. The drug is seeing increasing uses among hair specialists at low doses (0.25 to 2.5 mg). I have been using it in clinic since late 2015. The drug may have benefits in treating androgenetic alopecia, chronic telogen effluvium and alopecia areata. Other uses are increasingly studied.

Although the drug is approved for blood pressure control, any use in treating hair loss is “off label” and should only be prescribed by a physician knowledgable and experienced with its use and only on a case by case basis.

It is important to understand the differences between low dose oral minoxidil and standard dosing - especially when it comes to side effects.

The most common side effects of low dose oral minoxidil can be summarizes with the “HAIR” memory tool and include headaches, ankle edema (swelling), increased hair on the face (and body too), skin rashes and hives. A slight reduction in blood pressure can occur but is usually just a few points. As one approaches 2.5 mg a slight increase in heart rate may occur for some users.

The side effects of higher doses of oral minoxidil reflect the impact the drug has on the cardiovascular system and increases a higher chance of dizziness, lowered blood pressure, increased heart rate, swelling around the heart, and shortness of breath. Other side effects like breast tenderness can be seen. Scroll to slide 2 to see side effects of higher dosing.

Both doses are not permitted in women who wish to become pregnant.

DOWNLOAD ORAL MINOXIDIL HANDOUT


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Combining Oral Minoxidil and Oral Spironolactone for FPHL

New Potential Options for Female Pattern Hair Loss

Female Pattern Hair Loss (FPHL), also known as female hair thinning or female androgenetic alopecia is a common type of hair loss that affects about one-third of women. Most women affected by the condition start with slightly increased hair shedding.  Over time, the patient notices decreased hair density and a more see through appearance to the scalp.

Topical Minoxidil remains the only formally FDA and Health Canada approved treatment for FPHL. Application of minoxidil does have it's own unique set of challenges. Many patients give up after a period of time. Other options including oral anti-androgens, laser, PRP and hair transplantation (for some women).

Oral minoxidil has been around for many decades and was originally used as a blood pressure medication. It is known to increase hair growth on the body as a side effects. Recently there has been increased interest worldwide in understand the potential benefits of using low dose oral minoxidil to treat hair loss. Rather than using the 10-40 mg doses that were once used to treat blood pressure, low dose oral minoxidil for hair loss involves doses ranging from 0.25 mg to 2.5 mg. 

Rod Sinclair from Australia set out to study the potential benefits of using oral minoxidil and oral spironolactone together. The dose of minoxidil prescribed was 0.25 mg and the dose of spironolactone used was 25 mg.

100 women were included in this study. The mean age was 48.44 years and the mean duration of diagnosis was 6.5 years. Overall the drug combination reduced shedding and reduced hair loss. There was a slight reduction in mean blood pressure of 4.52 mmHg systolic and 6.48 mgHg diastolic.  8 % of patients in the study have side effects but they were deemed mild.   Only 2 of the 100 patients overall discontinued treatment and these were patients with hives (urticaria).

 

Conclusion

This is an interesting study. It has long been known that the combination of topical minoxidil and oral spirionlactone (at higher does) are beneficial to FPHL. In fact, it was Dr Sinclair who showed this many years ago as well. This study is interesting because of the safety and limited side effects that were observed. Only 2 % of patients dropped out of the study. In another study by Dr. Sinclair (of chronic telogen effluvium) which also involved study of oral minoxidil, there were no drop outs. Together, these studies speak to a relatively good safety profile of oral minoxidil. 

We have been using oral minoxidil in clinic for some time. I was first inspired to consider it by presentation by Dr SInclair a few years back. (Nobody in the world has more experience with oral minoxidil for hair loss than Dr. Sinclair). The most common side effects is the increased hair on the face (especially upper lip) and body that some patients get. Dizziness, headaches, hives, ankle swelling are among the other side effects. The most common side effect in practice is increased hair on the upper lip in 25- 35 % of women. Other less common side effects are typically headaches, ankle swelling, hives. Surprisingly, shedding does not tend to be very common when starting. The ease of taking oral minoxidil vs topical minoxidil does make it a important option for further study. 

More studies of oral minoxidil are needed but studied to date are promising.

DOWNLOAD ORAL MINOXIDIL HANDOUT

 

REFERENCE

Female pattern hair loss: a pilot study investigating combination therapy with low-dose oral minoxidil and spironolactone. Sinclair RD. Int J Dermatol. 2018.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Minoxidil lotion vs foam for oily scalps

Can minoxidil lotion make an oily scalp worse?

Minoxidil is approved for use in males and females with androgenetic alopecia. A variety of different products are available including the minoxidil solution/lotion and minoxidil foam. The minoxidil foam is particularly popular because it is less greasy. There is no evidence that one product is superior to another so it's completely left up to personal preference and cost. 

Individuals with oily scalps may bind the minoxidil foam preferably to the lotion. However, one must consider that the underlying oiliness could be due to seborrheic dermatitis and treatment of the seborrheic dermatitis may be necessary in such situations. Use of shampoos with ingredients such as ketoconazole, zinc pyrithione, ciclopirox and selenium sulphide can help to reduce oils. Appropriate treatment may allow the patient to use minoxidil lotion or foam - whichever they prefer. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Minoxidil Use in Children

Can minoxidil be used in Children?

Minoxidil is formally approved for adults with genetic hair loss. Minoxidil can be used as an 'off label' indication in children with several types of hair loss including alopecia areata and early onset androgenetic alopecia.  Its use should generally be monitored by a specialist. Children can be sensitive to minoxidil and side effects such as headaches, dizziness, poor concentration, swelling in the feet can occur. Rarely some children develop excess hair on the back or arms. 

 

Minoxidil Dosing

There is no standard dosing schedule for children and much of the dosing recommendations rely on the experience of the physician and the type of hair loss being treated.  Our typical dosing schedule for children who are prescribed minoxidil is shown below. Generally speaking, any child starting minoxidil should be followed by a physician.  These doses may be altered depending on a variety of factors such as the weight of the child, height, previous treatments used and extend of hair loss. These doses are generally regarded as maximal doses. 

minoxidil in children

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Minoxidil for Use in the Temples.

Does minoxidil help the temples?

Minoxidil is a topical medication that is FDA approved for treating androgenetic hair loss (male balding) in men. The initial studies that lead to its approval were performed in men with hair loss in the crown (top of the scalp) and this lead to labeling on packaging indicating that it helped the crown. The early studies were not conducted on the front of the scalp and temples and so manufacturers were therefore not permitted to label the product as helping the frontal scalp and temples.

 

Minoxidil can help temples and frontal hairline

Minoxidil can most certainly help the frontal hairline and temples - especially in younger men and especially in the earliest stages of balding. It may not restore it to the 'original' density. But it certainly can help a proportion of males.  Two studies in the past played a key role to nicely demonstrate that minoxidil helps the frontal hairline. 

 

STUDY 1:   Hillman and colleagues

IN 2015, Hillman K et al published a study that evaluated the efficacy of twice daily 5% minoxidil foam in the temples of male patients with genetic hair loss. The study was a 24 week study and compared outcomes to placebo treatment and to the vertex region.  Study results indicated that hair counts and hair caliber increased significantly compared to baseline in both the temples and vertex scalp.   Furthermore, patients actually using 5% minoxidil foam rated a significant improvement in scalp coverage for both the front  and top areas.

   

STUDY 2 -  Mirmirani and colleagues

In 2014, Mirmirani et al conducted  a double-blinded, placebo controlled study of minoxidil topical foam 5% (MTF) vs placebo in  16 men ages 18-49 years with androgenetic hair loss. Study participants applied treatment (active drug or placebo) to the scalp twice daily for eight weeks. Again, similar to the previous study, results showed that minoxidil improved frontal and vertex scalp hair growth of AGA patients.

 

Conclusion

There is no doubt now that minoxidil can help some men with hair loss in the frontal scalp and temples. It does not help everyone, and doesn't bring the hair back to the original density - but it certainly can help. 

 

REFERENCES

Hillman K et al. A Single-Centre, Randomized, Double-Blind, Placebo-Controlled Clinical Trial to Investigate the Efficacy and Safety of Minoxidil Topical Foam in Frontotemporal and Vertex Androgenetic Alopecia in Men. Skin Pharmacol Physiol. 2015;28:236-244.  

 

Mirmirani et al. Similar Response Patterns to 5%Topical Minoxidil Foam in Frontal and Vertex Scalp of Men with Androgenetic Alopecia: A Microarray Analysis. Br J Dermatol. 2014 Sep 10. 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Is it okay to use more minoxidil?

Using more minoxidil is not advised

The dosings of medications have been carefully worked out to balance efficacy with safety. If a patient feels he or she needs more, they should speak to their physician or pharmacist regarding how to apply minoxidil efficiently. If one feels this dose does not work, they might consider a variety of off label means... but only under supervision. This could include using a bit more than 1 mL, or using oral minoxidil at low doses.

 

Side effects of using too much minoxidil

The side effects of overdosing on minoxidil include worsening headaches, dizzininess, low blood pressure, heart palpitations, heart rhythm disturbances, ankle swelling, hair growth on the body. Rarely patients end up in the emergency department every year because they feel so unwell after using too much minoxidil. 

Minoxidil is a drug and use must be respected.

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Minoxidil Dread Shed: What is meant by this?

Shedding from Minoxidil

Minoxidil lotion and foam are FDA approved for treating androgenetic alopecia (AGA) in men and women. This type of hair loss is also called male pattern balding and female pattern hair loss. A common concern among individuals who are deciding whether or not to use minoxidil is the potential for them to develop an increased amount of daily hair shedding in the first 6-8 weeks of starting minoxidil. This is known in the public as the "dread shed." Medically, the term is "immediate telogen release." This type of shedding is not to be confused with the shedding that happens when people with androgenetic alopecia incorrectly stop using minoxidil. (One must never stop treatment if they have androgenetic alopecia or else new hair growth will be shed and all benefits will be lost).

The 'dread shed' can be frightening when it occurs but is generally mild for most. Understanding why this occurs is important to help individuals decide whether this treatment is right for them to start or not.

 

Immediate telogen release: Understanding shedding with minoxidil

The increased shedding that accompanies starting minoxidil needs to occur for most people. It's not something that is really all that abnormal - it just looks abnormal. When you look closely at the scalps of men and  women with androgenetic alopecia (especially early stages of AGA), one will notice that a higher than normal proportion of cells are in the shedding phase. These hairs are waiting their turn to shed. Hairs generally need to wait in line 2-3 months before they are shed. That's just the rule of the nature. That's what it means to be human.

When minoxidil is applied to the scalp, a signal is sent to all hairs that are waiting in line to be shed. The message that is relayed is that the hairs no longer need to wait 2-2 months in that line. Rather any hair that is waiting in line to be shed is welcome to shed now.  The mandatory 2-3 month waiting period has been temporarily waived. And so what the patient then experiences is an increased amount of hairs coming out on a daily basis once they start minoxidil. What is being shed is hairs that were destined to come out anyways:

Instead of coming out tomorrow, a hair comes out today

Instead of coming out in 2 weeks, a hair comes out in tomorrow

Instead of coming out in 4 weeks, a hair comes out in 1 week

Instead of coming out in 6 weeks, a hair comes out in 2 weeks

This is what the 'dread shed' or 'immediate telogen release is all about.

 

For more information on the dread shed, readers might consider reviewing other articles. 

Immediate shedding from minoxidil: An analogy

 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Minoxidil Use in Alopecia Areata: Useful or not?

Minoxidil in Alopecia Areata

AA

Alopecia areata ("AA" for short) is an autoimmune condition that will affect about 1.7% of the world's population at some point in their lives. Many patients with AA develop hair loss in round or oval shaped patches. The individual shown in the photos has a fairly typical presentation.

There are a variety of treatments for AA including topical steroids, steroid injections, diphencyprone, anthralin, prednisone, methotrexate, sulfasalazine, tofacitinib.

 

Minoxidil for Treating AA

I include topical minoxidil in a large proportion of the treatment plans that I recommend for my own patients. Minoxidil is a topical product that is available in both generic forms as well as popular trade names such as "Rogaine" in North America and "Regain" in part of Europe.  Studies dating back to the 1980s have shown very clearly that minoxidil is beneficial in patients with alopecia areata. My personal view is that it does not usually help on its own if one were to use it as the only treatment  (i.e. 'mono therapy) but can help when added to a treatment plan that involves any of the treatment agents listed above.  When I prescribe a plan that includes use of topical steroids or steroid injections, I frequently include minoxidil on the plan. Even with anthralin or DPCP, I frequently recommend my patients use minoxidil as well. 

 

Minoxidil in AA: Clearing up the Many Myths and Misconceptions. 

There are certain many myths, confusions and inaccurate information when it comes to using minoxidil for alopecia areata. Here I will review a few common myths.

 

Confusion 1: Do I need to use it forever? Everyone tells me I do!

The 'rule' that minoxidil needs to be used forever and that one will lose hair if they stop applies to the use of minoxidil for men and women with a hair loss condition known as andoagenetic alopecia (i.e. male and female balding). These so called rules do not necessary apply to alopecia areata. Once hair starts growing really well again in those with alopecia areata, it is frequently possible for many to stop the use of minoxidil and still keep their hair. OF course, minoxidil may be needed again in the future were a patch of hair loss to occur again. However, the purchase of one bottle of minoxidil does not necessarily commit one to a lifetime of use. 

 

Confusion 2: The bottle says not to use it if I have patches of hair loss! What am I to do?

It is important to understand that minoxidil is only FDA approved for treating genetic hair loss. It has not gone through the million dollar rigours of the FDA approval process to have it formally approved for treating alopecia areata. However, we know from very good studies one the last 30-40 years that minoxidil does help patients with alopecia areata. Therefore, any such use in alopecia areata is said to be 'off label.' Because minoxidil is formally approved only for androgenetic alopecia the companies can not advertise that it helps other hair loss conditions. It is illegal for companies to write on their packaging that this product can be used in alopecia areata, traction alopecia, some forms of scarring alopecia. As a physician however, I can recommend it to certain patients with these conditions if I feel it will be helpful. However, the only thing that can be advertised by the companies is that it can be used in androgenetic alopecia. 

 

Confusion 3: I've heard minoxidil can cause hair loss. I'm terrified to start.

It is very well known that men and women who use minoxidil for treating 'androgenetic alopecia' (male and female balding) can developed hair loss in the first two months of use. This is because minoxidil triggers hairs in the telogen phase to exist fairly quickly over a span of a few weeks. This phenomenon can also happen in alopecia areata but one must remember that what is actually happening in most individuals is that minoxidil is triggering older injured hairs to exist and helping to facilitate new stronger hairs to reemerge. Most of the time a patient with alopecia areata who says their hair is worsening and worries that it is the minoxidil that is causing the worsening is actually just experiencing a worsening of their disease. For these individuals the minoxidil is not causing the hair to fall out more - it is the disease itself that is causing this. This individual needs more aggressive treatment. 

 

Confusion 4: Should I use 2 % or 5 %? Should I use minoxidil drops or the foam?

There is no 'one answer' for all patients. The decision on what type of minoxidil to use should be reviewed on a case by case basis. In general, if one is going to use minoxidil, they should just get the product on the scalp consistency. There are situations where I recommend the 2 % lotion and there are situations where the  5 % foam is perfect. The benefit of the older lotion is that a patient can more carefully control the dosing. Instead of using 1/2 cap of the foam, a patient using the lotion is allowed to use up to 1 mL (25 drops). This frequently allows more of the product to be spread all around the scalp. In addition, if a patient is very sensitive to the effects of minoxidil and develops headaches or dizziness and there are worries about the effects of minoxidil on the heart, I may recommend 2 % minoxidil and start with 4-6 drops and slowly work up to 25. The key is to get the product on the scalp.

 

Conclusion

Minoxidil has been used as therapy for treating alopecia areata for over 3 decades. Its use is off label but given its generally good safety profile, it its an important consideration. I frequently combine it with many treatments I recommend for AA.

 

REFERENCE

Price VH. Double-blind, placebo-controlled evaluation of topical minoxidil in extensive alopecia areata. Clinical Trial. J Am Acad Dermatol. 1987.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Minoxidil and ​Shedding: Why does minoxidil cause shedding?

Why does minoxidil cause shedding?

Minoxidil commonly causes increased hair shedding in the first 6-8 weeks of use (and sometimes a bit longer).  

Every human has hairs on their scalp that are destined to come out next week, the week after and the week after that. When minxodil is applied to the scalp, many of those hairs simply come out earlier than they are supposed to. This is termed "immediate telogen release" and is the main mechanism by which minoxidil causes shedding in the first 2 months of use.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Erectile dysfunction in Minoxidil Users: What's the Naranjo Score?

Erectile dysfunction in minoxidil users

Anyone who reads online will see that there are reported links between topical minoxidil use and erectile dysfunction. But is it accurate ?  My opinion is that it's not impossible - but very unlikely for most users. Let's take a look at the data. 

One one study to date supports an association

To date, there are no really good clinical studies that support an associated between topical minoxidil use an worsening erectile dysfunction.  The original studies from the 1980s did not raise this issue. However a recent study did suggest that topical minoxidil was the cause of erectile dysfunction. 

MINOXIDIL ASSOCIATED WITH ERECTILE DYSFUNCTION

 

Blood pressure medications can cause impotence

Minoxidil is a blood pressure medication and was used orally in the 1980s as Loneten. It's certainly not out of the question for blood pressure medications to cause erectile dysfunction. Drugs like beta-blockers and diuretics like hydrochlorothiazide can sometimes cause erectile dysfunction. Blood pressure medications like ACE inhibitors, Angiotensin receptor blockers are less likely.  Minoxidil was FDA approved in 1979 as an oral medication to treat blood pressure problems. Topical minoxidil however, does not impact blood pressure to any significant degree in most users. Erectile dysfunction is not a side effect that has been raised in clinical trials to date.

 

The Naranjo Adverse Drug Reaction Probability Scale

When a patient asks me whether their minoxidil could be causing sexual dysfunction, my answer is first that it is possible and that we really need to consider something know as the Naranjo Adverse Drug Reaction Probability Score.

Anything applied to the skin or taken by mouth has the potential to cause a side effect. Some medications rarely cause side effects and others tend to cause frequent side effects. Occasionally a patient will report a side effect that perhaps has never been reported before. The question then becomes - is this a real side effect from the drug or is it happening from something else?

 

A Closer Look at the Naranjo Adverse Drug Probability Scale

The Naranjo Scale was created nearly 40 years ago to help standardize how clinicians to about assessing whether or not a drug could be implicated in an adverse drug reaction. It is used in controlled clinical trials. The scale is quite easy to use - and involves asking the patient 10 questions. Answers to the question are recorded as "yes", "no" or "don't know" and different points are assigned to each answer (-1, 0, +1, +2). 

Typical Questions in the Naranjo Scale (using minoxidil associated erectile dysfunction ("ED") as an example)

  1. Are there previous "conclusive" reports of minoxidil causing ED? (yes) 
  2. Did the ED (or worsening ED) appear after the drug was given or were their such issues before the patient started minoxidil?
  3. Did the ED improve when the drug was discontinued or a specific antagonist was given?
  4. Did the ED reappear upon readministering the minoxidil?
  5. Were there other possible causes for the ED that were explored by the family doctor?
  6. Did the ED occur again with administration of placebo?
  7. Was the minoxidil detected in the blood or other fluids in toxic concentrations?
  8. Was the ED worsened upon increasing the dose of minoxidil (from once to twice daily)? Or, was the reaction lessened upon decreasing the dose? (ie. does going to once daily minoxidil make sexual performance better?)
  9. Did the patient have a similar reaction to  minoxidil or a related  blood pressure drug in the past?
  10. Was the ED confirmed by any other objective evidence?

 

Determining the Naranjo Score

Scores can range from -4 to + 13. A score of 0 or less means the likelihood of the drug causing the side effect is doubtful, a score 1 to 4 indicates it is 'possible', a score 5 to 8 means it is 'probable' and a score 9 to 13 means it is 'definite'

 

 

Reference

Tanglertsampan C. Efficacy and safety of 3% minoxidil versus combined 3% minoxidil / 0.1% finasteride in male pattern hair loss: a randomized, double-blind, comparative study. J Med Assoc Thai. 2012.

Cecchi M, et al. Vacuum constriction device and topical minoxidil for management of impotence. Arch Esp Urol. 1995.

Radomski SB, et al. Topical minoxidil in the treatment of male erectile dysfunction. J Urol. 1994

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Can we predict if minoxidil will work or not?

Predicting the chance of benefit before starting

Minoxidil is the only topically approved agent that is approved but the FDA for treating androgenetic alopecia. The drug does not help everyone but does help 25-30 % of users. I've written in previous articles about the future of minoxidil pre-testing kits. It is well known that in order for minoxidil to have a chance to work, the body needs to convert the minoxidil to minoxidil sulphate. Some people have the enzyme (known as minoxidil sulphotransferase) to do this; other people simply do not. Those who lack the enzyme are more likely to be non-responders.

I was interested to read today in a press release that kits to test minoxidil sulphotransferase activity are moving forward in the FDA approval process.  The FDA journey can be lengthy, but the possibility exists that we might see these kits in the clinic in the near future. These will help physicians to predict if it's a good idea to prescribe minoxidil or not. 

Read the press release here: Press Release


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Has my minoxidil stopped working?

Has my minoxidil stopped working?

Minoxidil is FDA approved for the treatment of male balding and female thinning. After using it for a period of time, some patients find that it no longer seems to be working the way that it once did. This leads many to ask :

"Has my minoxidil stopped working?"

The most likely explanation is that the minoxidil is, in fact, still working but the machinery that controls balding is working harder. It is likely that more and more genes are being expressed inside the scalp and hair follicles that are accelerating the balding process forward. 

 

Genetic hair loss has many genes

A recent study from the UK, however, has shown that male balding is far more complicated and many hundreds of genes contribute to balding in men. It identified 287 genetic regions linked to male pattern baldness. This large study examined data from over 52,000 men.

Consider the 30 year old male who started noticing balding at 21 and started minoxidil. At age 16 - 18 he might have had 4-6 genes expressed at the start of balding (before he even noticed) and 21 there may have been a dozen or so distinct genes pushing the balding process. At age 30, there could be dozens and dozens of genes expressed. For many users of Minoxidil, it is usually working the same - and while it was pretty good at stopping 4 genes, it can't fully hold back the genetic changes associated with 60 or 70 genes. These numbers are different for everyone - but it illustrates an important point. The scalp environment and hair follicle milieu changes drastically over time.

 

Reference

Hagenaars SP, Hill WD, Harris SE, Ritchie SJ, Davies G, Liewald DC, et al. (2017) Genetic prediction of male pattern baldness. PLoS Genet 13(2): e1006594


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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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. 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 telogen effluvium and in such cases minoxidil may be needed long term for many years (1-15). Generally though even in such rare cases of chronic telogen effluvium the minoxidil can be stopped.

In summary, for most patients with telogen effluvium, use of minoxidil is NOT forever.

 

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.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Rogaine Foam for AGA

1/2 cap Twice Daily for Men; Once for Women

Minoxidil is the only FDA approved topical solution for treating androgenetic alopecia (AGA). In 1988 it was first approved for men and in 1992 for women. The early formulations contained propylene glycol which had a tendency to cause irritation. Although the propylene glycol based formulations are still widely available, the introduction of minoxidil foam as "Rogaine foam" in 2006 had many advantages as it was less irritating. Rogaine foam was approved for men in 2006 as a twice daily application of 1/2 cap each time. The FDA approved Rogaine foam in 2014 for women at a dose of 1/2 cap once daily.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Can minoxidil change hair texture?

Minoxidil is FDA approved for the treatment of androgenetic alopecia in men and women. The medication has several mechanisms of action including affecting potassium channels inside cells.

The main side effects are headaches, dizziness, heart palpitations, hair shedding and excessive hair growth. Another "side effect" that is not often discussed is the change in hair texture that some users notice. Such changes are varied but include mentions of hair becoming curlier, coarser, more wavy, drier, and straw-like. Sometimes this is attributable to the propylene glycol in the minoxidil lotion formulation but some of these changes also occur with minoxidil foam (which lacks propylene glycol). One needs to be aware of the possibility of hair texture changes when using minoxidil.
 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Minoxidil in FFA: Does it help?

I frequently get asked whether minoxidil has any benefit in treating frontal fibrosing alopecia (FFA). It seems that it could provide some benefit but it's not completely clear yet if it is truly helping the patient's FFA or their underlying androgenetic alopecia that many patients with FFA also have. Large scale studies are needed. 

I generally add minoxidil once I have some evidence that a patient is stabilizing with their main anti-inflammatory treatment. This typically includes one or more of topical steroids, steroid injections, doxycycline, hydroxychloroquine and anti-androgens such as finasteride or dutasteride. 

It’s interesting that 32 % of patients in one study had an improvement in their FFA with use of anti-androgens. When one looks at a larger group of 111 FFA patients of which 74.8 % were using minoxidil, one notes that 47 % of patients had an improvement with anti-androgens. So it does seem that patients using minoxidil had better outcomes. There is at least some suggestion here that minoxidil might help. 

 

Conclusion

Up to 40 % of patients with FFA have androgenetic alopecia so it’s difficult sometimes to decipher whether minoxidil is truly helping the patient’s FFA or whether it is helping their underlying androgenetic alopecia. More good studies are needed.

Reference

Vano-Galvan S et al. Frontal fibrosing alopecia: a multicentre review of 355 patients. J Am Acad Dermatol 2014; 70: 670-678


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Oral minoxidil for hair loss

Oral Minoxidil

Topical minoxidil was FDA approved in 1987 and we now have 30 years of experience with the drug. 

I'm increasingly asked about oral minoxidil. Does it work? Is it safe? What dose? 

Oral minoxidil is not FDA approved for treating hair loss. It was used in the 1980s for treating high blood pressure. When used at doses typical for treating blood pressure problems (5 mg twice daily), it can be associated with side effects - some quite serious. These include dizziness, low blood pressure, weight gain from fluid retention, high heart rate, heart rhythm problems. And of course hair growth can occur all over the body.

Lower doses of oral minoxidil may be safer and may still provide benefit. Doses ranging from 0.25 mg daily to up to 1 mg daily are generally well tolerated without a significantly increased risk of side effects. One does need to be closely monitored for blood pressure, weight changes, heart rate and excess hair growth on the body. For women, low dose minoxidil can be combined with spironolactone. In men low dose minoxidil can be combined with lower doses of finasteride.

 

Conclusion

Oral minoxidil is increasingly popular as men and women look for safer options for treating hair loss. Side effects of oral minoxidil must be respected and use of the medication must only be done in conjunction with a physician experienced in the use of oral minoxidil. Close monitoring is essential.

DOWNLOAD ORAL MINOXIDIL HANDOUT


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Immediate hair shedding from Minoxidil - is it really possible?

Minoxidil Shedding

It is normal to develop increased hair shedding within days of starting minoxidil. Hairs that are dormant and resting ( called "telogen hairs") are given a strong signal to leave the scalp immediately. This specific mechanism is called immediate telogen release.

Some people start minoxidil and then stop after a few days because they are either too worried about a side effect or they actually experience a side effect. They are surprised to find that they shed into week 2, 3,4 and sometimes even months - with just a few days of minoxidil use. The question they have is "how can this be possible."

The process has started and can't be stopped. Let's look at a few analogies I often share with my own patients.

If you started pushing a huge stone down a hill and then suddenly stopped pushing, you would see the stone keep rolling and rolling and rolling down the hill. You would not ask "Why is it still rolling? I stopped pushing." It makes sense to you that the process has been started and won't easily stop.

Or imagine a group of people at a party and suddenly someone pulls the fire alarm. Everyone gets up and starts running out of the building. It is soon realized that it is a false alarm and someone shouts "sorry false alarm - go back to enjoying the party!" Nobody can hear that it was a false alarm because of all the commotion. The process has started and can't be stopped.

It's the same with minoxidil. The dormant follicles are triggered to shed. The process has started. Some shedding will happen and may last a few months. It could be less than a few months for some people but for many it does last much longer than one might imagine. Eventually it will stop just like eventually the stone will stop (if the hill was not too steep) and eventually someone will realize it was a false alarm and come back to rejoin the party.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Scalp Dryness with Minoxidil

There are several reasons for one to experience scalp dryness with minoxidil. I always advise a full exam to determine the precise cause.

Common causes include: Irritant contact dermatitis, allergic contact dermatitis, seborrheic dermatitis as well as a coexisting scalp conditions (psoriasis, eczema) need to be ruled out. For many of my patients, use of oil based products along with anti-seborrheic shampoos containing ketoconazole or zinc pyrithione prove very helpful to treat the dryness.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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How long should minoxidil be left on the scalp? 

Minoxidil: 4 Hours Needed (8-12 hours better!)

Minoxidil needs to be left on the scalp at least 4 hours and 8 hours (or longer) is much better. 

This recommendation I give comes from a study done in 1990. In this particular research study, twenty-two male study participants completed a four-way, multiple-dose, randomized crossover study to investigate  the relationship between how long the drug was applied to the scalp and the amount of minoxidil absorption. A 2% topical solution was used in these studies.  The researchers compared how much minoxidil was absorbed at 1 hr, 4 hr compared to 11.5 hours. 

 

What were the results?

Relative to the amount absorbed after a contact time of 11.5 h, absorption was approximately 50% complete by 1 h and greater than 75% complete by 4 h.

 

Conclusion

Although minoxidil should ideally be left on 8 hours, a significang amount of benefit can still be achieved with 4 hour use. Even at 1 hour about one half is absorbed but clearly this is less than ideal. Understanding the absorption of minoxidil is important to help improve the ability of patients to 'stick with' the treatment. 

 

Reference

Ferry JJ et al. Relationship between contact time of applied dose and percutaneous absorption of minoxidil from a topical solution. J Pharm Sci 1990 Jun;79(6):483-6


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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