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QUESTION OF THE WEEK

Dr. Donovan's Articles

QUESTION OF HAIR BLOGS

Filtering by Category: Minoxidil


Can oral minoxidil be used in patients with allergy to topical minoxidil ?

Small study Suggests Oral Minoxidil Can be used in Patients with Topical Minoxidil Contact Allergy

Topical minoxidil is widely used in the treatment of female pattern hair loss. To date, it remains the only formally FDA and Health Canada approved treatment.

Skin Irritation can occur with topical minoxidil and is more common with minoxidil solution than the newer foam product. This is because the solution contains propylene glycol, a well known cause of irritation and sometimes contact allergy. The foam is devoid of propylene glycol. Rarely, patients can be allergic to the minoxidil component too.

Can patients who are allergic to topical minoxidil use oral minoxidil? According to a new study, the answer is yes.

Can patients who are allergic to topical minoxidil use oral minoxidil? According to a new study, the answer is yes.

Oral minoxidil is increasing used as an off label treatment for a variety of hair disorders. Doses used for treating hair loss range from 0.25 mg to 2.5 mg (or more) which are much lower doses than than the doses used in the past for treating high blood pressure (40 to 60 mg). . Side effects of oral minoxidil include shedding, hair growth on the face and body, hives, headaches, swelling in the feet/face and others.

See “10 Things You Need to Know about Oral Minoxidil for Hair Loss”

Therianou and colleagues recently reported 9 patients who demonstrated true patch test proven contact allergy to topical minoxidil but were able to tolerate oral minoxidil without any issues. Patients used oral minoxidil at low doses of 0.25 mg twice daily and follow up for these patients range from 7 to 33 months. None of the 9 patients reported side effects and all 9 patients were satisfied with results of their treatment.


Conclusion

The conclusion of this small study is that patients with patients with allergy to topical minoxidil may be able to use oral minoxidil at low doses without side effects. We don’t know if higher doses would cause problem and we don’t yet know the effects of treatments beyond 3 years. Presumably, the risk would be low.


Reference

Therianou et al. How Safe Is Prescribing Oral Minoxidil in Patients Allergic to Topical Minoxidil? Journal of the American Academy of Dermatology . 2020 Apr 11;S0190-9622(20)30567-3.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Topical tretnoin for Alopecia Areata: Is it still on the list?

Topical Tretinoin 0.05 % Cream May Help Some with Limited Alopecia Areata

Alopecia areata is an autoimmune disease that affects 2 % of patients. There are well over 2 dozen treatments available

More than Shots: The 30 Treatment Options for Alopecia Areata

Topical options are often viewed as safer than systemic options (pills) because the body gets exposed to less medication. Topical treatment options include: Topical steroids, Topical bimatoprost, Essential oils, Anthralin, Squaric acid, Diphencyprone, Minoxidil, Topical tofacitinib, Topical ruxolitinib, Onion juice, Garlic gels, Topical capsaicin and Topical retinoids

Treatments for alopecia are generally of three main types

1) those treatments that reduce inflammation around the hairs so the hairs can grow. Examples include topical steroids and topical tofacitinib.

2) those treatments that simply stimulate hair growth so that hairs can push through the skin and keep growing despite their inflammation. These options may also reduce inflammation as well. Examples include minoxidil and low level laser.

3) those treatments that cause inflammation somewhere else such as the surface of the skin layer so that inflammation gets slowly reduced from around the follicles. A variety of treatments fall into the third category include anthralin, Diphencyprone, squaric acid and tretinoin.

Use of Tretinoin in Treating AA

Today we’ll focus on the use of tretinoin in treating alopecia areata.

Tretinoin is a type of vitamin A. It is used as an acne treatment and as an anti-aging treatment and has been available to patients since the early 1970s. Several studies to date have suggested that tretinoin may have some benefit in the treatment of alopecia areata. It is not effective for everyone and is likely less effective than standard treatments like topical steroids, steroid injections and the oral immunosuppressants. But a small handful of studies suggest that it’s an option to be considered.

STUDY 1: Das and colleagues, 2010

In 2010, Das and colleagues published a study of 80 patients that sought to compare the benefits of 3 treatments, namely a strong topical steroid known as betamethasone diproprionate, tretinoin 0.05 % and anthralin paste 0.25% in the treatment of limited alopecia areata. A placebo group was also included in the study bringing the total number of study groups to four. Treatments were applied twice daily. Patients with alopecia areata in this study had more limited disease and could only be included in the study in their patches were less than 5 cm in diameter and if they had less than 5 patches in total. Results of the study showed that 70 % of patients received topical steroids had an improvement compared to 55 % with tretinoin, 35 % with anthralin and 20 % with placebo.

STUDY 2: Hussein 2020

In 2020, Hussein performed a study comparing the benefits of betamethsone diproprionate topical steroid to tretinoin 0.05% in 50 patients with limited alopecia areata. Treatments were applied twice daily. Similar to the 2010 Das study, patients could only be included in the study if they had less than 5 patches and if they had less than 25 % scalp involvement. After 12 weeks, 72 % of patients receiving the topical steroid had statistically significant clinical improvement compared to 36 % receiving tretinoin 0.05%.

STUDY 3: Kubeyinje and Mathur, 1997

A 1997 study showed that use of tretinoin in patients receiving steroid injections could have added benefit. The authors of the study evaluated the efficacy and safety of 0.05% tretinoin cream as an adjunctive therapy or ‘add on’ treatment with intralesional triamcinolone acetonide in aiopecia areata, by comparing the result of treatment with monthly intralesional triamcinolone acetone and daily application of 0.05% tretinoin cream in 28 patients with alopecia areata with 30 similar patients treated with only monthly intralesional triamcinolone acetonide as controls. Results at 4 months showed more than 90% regrowth in 85.7% of patients on triamcinolone acetonide and tretinoin cream, as compared with 66.7% of patients receiving only triamcinoione acetonide.

STUDY 4: Much, 1976

A 1976 study was among the first published studies to show benefits of tretinoin in treating alopecia areata.

Conclusion and Summary Points

With specific treatments like JAK inhibitors and others, the future of alopecia areata is bright. However, it is critically essential that we not forget our past and where we have come from over many decades of study. Physicians treating alopecia areata must appreciate that role of very simple and relatively inexpensive treatments and the large number of patients with limited alopecia areata they may potentially help. Tretinoin is on that list of simple treatments. Tretinoin is a topical treatment that certainly does not help everyone but may have a role in patients with more limited disease. In patients of mine with a few patches who can not tolerate minoxidil or who can not tolerate steroids, tretinoin remains an option.

 

We use tretinoin with several treatment including 1) tretinoin with topical minoxidil, 2) tretinoin with topical steroids, 3) tretinoin with steroid injections and 4) tretinoin with diphenyprone or squaric acid. 

Side effects including redness and irritation and that is in fact the reason that typically use it in alopecia areata. In other words, it is a side effect but not a concerning one as that is in fact that desired effect. We ask patients to keep close follow up with our office so that we can assist them in finding the right dose that works for them. Some need use daily, some twice weekly and some just 2-3 times per week. Tretinoin must not be used during pregnancy. 

When used alone, I may prescribe tretinoin daily to start  and then increase to twice daily. When used in conjunction with other treatments, we often start tretinoin 2-3 times weekly for a few weeks and then increase to 4 times weekly and then five times weekly and then six times weekly and finally using it daily. 

REFERENCE

Baird KA. Alopecia areata. Arch Dermatol. 1971;104:562-3.

Das et al. COMPARATIVE ASSESSMENT OF TOPICAL STEROIDS, TOPICAL TRETENOIN (0.05%) AND DITHRANOL PASTE IN ALOPECIA AREATA. Indian J Dermatol. 2010 Apr-Jun; 55(2): 148–149. 

Hussein AA. A comparative study of the outcomes of potent topical steroids versus topical tretinoin in patchy alopecia areata of scalp. Int J Res Dermatol. 2020 Jan;6(1):111-114

Kubeyinje EP, C'Mathur M. Topical Tretinoin as an Adjunctive Therapy With Intralesional Triamcinolone Acetonide for Alopecia Areata. Clinical Experience in Northern Saudi Arabia. Int J DermatolJ Dermatol. 1997 Apr;36(4):320

Much T. Treatment of alopecia areata with vitamin A acid. Z Hautkr, 51 (1976), pp. 993-998

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This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Can I Use Minoxidil When My Lichen Planopilaris (LPP) is Active?

Using Minoxidil in Cases of Active Lichen Planopilaris (LPP)

I’m often asked if minoxidil can be used for patients who have active scarring alopecia. The answer really depends on the patient and other specific details. Before we tackle the question, we need to take a look at what constitutes ‘active’ scarring alopecia.

What is active scarring alopecia?

Active scarring alopecia refers to hair loss caused by an overactive immune system process. The patient may have scalp itching, have increased scalp burning and may be shedding more and more hair. All of these things point to active scarring alopecia. What do we do when scarring alopecia is deemed active? Well, we increased the amount of immunosuppressive and immunomodulatory treatments we are using.

Here are just come examples of how we change treatment is we feel LPP is active

Example 1: instead of using steroid injections, we might use steroid injections AND topical steroids.

Example 2: Instead of using topical steroids, we might ADD oral doxycycline.

Example 3: Instead of using oral doxycycline, and topical steroids, a patient might be started on oral doxycycline PLUS oral hydroxychoroquine

In other words, once the LPP is determined to be active (or still active) we are going to make some pretty important decisions about increasing treatment. These are indeed big decisions because treatments have potential side effects, cost money

What is are the potential side effects of minoxidil?

Now , let’s focus on minoxidil and the potential side effects. In addition to side effects like headaches, dizziness and heart palpitations and hair growth on the face, minoxidil can cause two important side effects for patients with scarring alopecia: 1) Minoxidil can cause increased hair shedding and 2) Minoxidil can cause scalp itching for some people. These two side effects can make it difficult to figure out if the itching and shedding are coming from the active LPP or coming from the minoxidil.

So can I use minoxidil if I have LPP or not?

I always advise that patients review use of any medication with their dermatologist. In general, if a patient was using minoxidil for a very long time (without any problem) before the LPP even started, it’s usually fine to continue. In these situations, it’s unlikely any increased shedding or scalp symptoms the patient experiences is going to be attributable to the minoxidil. But starting up or initiating the use of minoxidil when one has active LPP is active is not usually a good idea. If the patient gets more shedding or more scalp symptoms, it will impossible to tell if they are coming from active LPP or coming from the minoxidil. In the worse case scenario, one can imagine a situation where the doctor increases the dose of medications thinking that the change in clinical symptoms or signs was due to increased activity of the LPP when really it was just the minoxidil. Imagine if the patient developed a side effect of the new mediation - and it never needed to be started in the first place.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Delivering More Minoxidil to Hair Follicles: What's possible and what possibly helps?

How can I deliver more minoxidil to my hair follicles?

Topical 2 and 5 % Minoxidil are FDA approved and Health Canada approved for treating androgenetic alopecia. The drug does not help everyone but certainly helps a proportion of users. Given the benefits of minoxidil, there is a tremendous interest in understanding how best to delivery the minoxidil down into the scalp so that hair follicles can use it to stimulate their growth.

In this article, we’ll take a look at 5 methods to deliver more minoxidil to follicles as well as the challenges and limitations associated with these methods.

1. Use the same amount and same concentration of minoxidil and use it with the same frequency…. but apply it properly. 

There’s a bit of a learning curve to applying minoxidil and some people just don’t apply it correctly. Minoxidil probably absorbs better when applied after the scalp is washed and is still a bit warm. But clearly this is impractical for everyone as many do not shampoo daily and many who do like to apply minoxidil at night and shampoo the hair clean in the morning.  Despite this, it’s probably more important to remember to apply the minoxidil every day that fuss about when to apply it and how clean the hair is.

Regardless of how it’s applied, the minoxidil needs to get on the skin of the scalp so it can begin its journey into the scalp. Getting minoxidil on the hair shafts does not help. Similarly, if there is a great deal of gunk blocking the scalp surface, it becomes more difficult for minoxidil to penetrate the scalp. Gunk includes excessive amounts of gel, oils and hair fibers.

2. Use the same concentration of minoxidil, but use more of it... or use it more often.

For some patients, using more minoxidil allows more to get into the scalp. This is especially true for males using minoxidil and may be true for some women as well. It’s clear that using 5 % minoxidil twice daily is better when treating male pattern balding than using 5 % minoxidil once daily. For some women - but not all - this may be true too. The downside of using more minoxidil is a greater chance of side effects. The chance of headaches, dizziness, and hair on the face all increase as the amount of minoxidil increases.

3. Expose the hairs to higher concentrations of topical minoxidil

Theoretically, using higher concentrations of minoxidil may help more get into the scalp. Studies that support the ideal minoxidil concentration are few and far between. In fact, one study suggested surprisingly that 5 % minoxidil was more effective than 10 %. Researchers from Egypt set out to compare the efficacy and safety of 5% topical minoxidil with 10% topical minoxidil and placebo in 90 males with balding. Surprisingly, after the 9 months, partipcants in the 5 % minoxidil group had higher vertex and frontal hair counts compared to study participants in the 10 % minoxidil group and the placebo group. Clearly, we still have a lot to learn and a long way to go. Higher concentrations of minoxidil are not necessarily better.

minoxidil

4. Compound the minoxidil with different topical agents or via other drug delivery strategies to allow minoxidil to penetrate the scalp better.

There is a major interest in the hair research community to figure out how best to get minoxidil into the scalp. Different vehicles, use of so called nanoparticles as well as other techniques are the focus of many studies. 

It’s also clear that use of adjuvants like retinoids can help make minoxidil more effective. Before we look at this concept further, it’s important to understand a few concepts. In order for minoxidil to do it’s job, it needs to be converted to minoxidil sulphate. Hair follicles have the machinery to help with this but some people’s hair follicles are not really that good at it. Scientifically, we say that some people’s hair follicles lack high levels of an enzyme known as “sulfotransferase” and so they cannot convert minoxidil into the active form that actually does all the work.  (The public does not yet have minoxidil sulfotransferase testing kits available to them but this technology may be coming at some point in the near future.) For year now, it has been known that mixing retinoids with minoxidil makes minoxidil work better. It has long been thought that retinoids irritate the scalp and somehow by doing so allow minoxidil to get into the scalp. Now, based on interesting work published by Sharma and colleagues in 2019 it’s realized that retinoids upregulate the minoxidil sulfotransferase enzyme and by doing so help generate greater amounts of active minoxidil sulphate in the scalp.

The use of derma rolling may be yet another strategy to get more minoxidil into the scalp. Scalp Micro-needling" (dermrolling) is a technique whereby a controlled injury is created in the scalp. Skin injury (at least in some situations) can stimulate the production of growth factors and inflammatory cytokines that promote skin healing and possibly hair growth. A "dermaroller" is one such device to cause controlled injury. A dermaroller consists of teeth of different lengths that are attached to a wheel. Dermarollers of 0.5 mm, 1 mm, 1.5 mm are common. These are "rolled" back and forth across the skin to create redness. A 2013 study of 100 patients supports benefit of dermarolling. The study set out to determine in patients who use topical minoxidil (Rogaine, etc) could achieve even further benefit by dermarolling. In the study, half the patients received daily minoxidil and the other half of the patients received weekly dermarolling sessions (using a 1.5 mm dermaroller) in addition to minoxidil treatment. Results showed that patients using a dermaroller achieved greater benefits than those using minoxidil alone. Specifically, 82 % of patients receiving dermarolling felt they achieved greater than a 50 % benefit in their hair compared to just 4.5 % receiving minoxidil alone. Physicians rated the improvements similarly. Hair counts (at an up close level) were increased in the dermarolling group compared to the minoxidil alone group (91.4 vs 22.2 respectively). These studies support the potential benefit of dermarolling - especially to increase the efficacy of minoxidil. More studies need to be done to verify or refute these results as well as to determine the optimal parameters for dermarolling. These include comparisons of daily vs weekly vs monthly treatment and comparisons of 0.5 mm needles, 1 mm or 1.5 mm needles. Studies are also needed to determine if any proportion of patient actually worsen with dermarolling.

5. Eat the minoxidil (or eat more).

If someone has androgenetic alopecia but is not able to achieve high enough concentrations of minoxidil deep under the scalp with use of topical minoxidil, switching from topical minoxidil to oral minoxidil could make sense.  As reviewed above, in order for minoxidil to do it’s job, it needs to be converted to minoxidil sulphate. Hair follicles have the machinery to help with this but some people’s hair follicles are not really that good at it. Scientifically, we say that some people’s hair follicles lack high levels of an enzyme known as “sulfotransferase” and so they cannot convert minoxidil into the active form that actually does all the work. When oral minoxidil is ingested, the liver does the job of converting the minoxidil to minoxidil sulphate - bypassing the need for the hair follicle to do this job.

Patients who don’t respond to topical minoxidil may respond to oral minoxdil. Similarly, patients who don’t respond to very low doses (like 0.25 mg to 0.5 mg) may respond to moderate doses (like 1-2-5 mg). Of course, increasing the dose may increase side effects like headaches, swelling, fluid retention, hives and excessive hair growth on the body.


References


Dhurat R, et al. A randomized evaluator blinded study of effect of microneedling in androgenetic alopecia: a pilot study. Int J Trichology. 2013.

Ghonemy S et al. Efficacy and safety of a new 10% topical minoxidil versus 5% topicalminoxidil and placebo in the treatment of male androgenetic alopecia: a trichoscopic evaluation. J Dermatolog Treat. 2019 Oct 21:1-6. doi: 10.1080/09546634.2019.1654070. [Epub ahead of print]

Jeong WY et al. Transdermal delivery of Minoxidil using HA-PLGA nanoparticles for the treatment in alopecia. Biomater Res. 2019 Oct 31;23:16. doi: 10.1186/s40824-019-0164-z. eCollection 2019.

Sharma A et al. Tretinoin enhances minoxidil response in androgenetic alopecia patients by upregulating follicular sulfotransferase enzymes. Dermatol Ther. 2019 May;32(3):e12915. doi: 10.1111/dth.12915. Epub 2019 Apr 23.





This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Higher Minoxidil Concentrations: Is More Always Better?

10 % Topical Minoxidil vs 5 % Topical Minoxidil: Which is better?

Minoxidil is FDA approved for treating androgenetic alopecia (male pattern balding and female pattern hair loss). It would seem logical to propose that if the drug minoxidil helps in the treatment of males and females with androgenetic alopecia that more minoxidil should help even more.

Researchers from Egypt set out to compare the efficacy and safety of 5% topical minoxidil with 10% topical minoxidil and placebo in 90 males with balding.  The study was a double-blind placebo controlled randomized trial over 36 weeks. The study comprised three treatment groups: 1) study participants receiving 5 % minoxidil 2) study participants receiving 10 % minoxidil and 3) study participants receiving placebo.

Surprisingly, after the 9 months, partipcants in the 5 % minoxidil group had higher vertex and frontal hair counts compared to study participants in the 10 % minoxidil group and the placebo group.

Conclusion

This was a nice study showing us that even after 40 years of studying minoxidil, we still have a lot to learn and a long way to go. Higher concentrations of minoxidil are not necessarily better - although more studies are clearly needed.

Reference

Ghonemy S et al. Efficacy and safety of a new 10% topical minoxidil versus 5% topicalminoxidil and placebo in the treatment of male androgenetic alopecia: a trichoscopic evaluation. J Dermatolog Treat. 2019 Oct 21:1-6. doi: 10.1080/09546634.2019.1654070. [Epub ahead of print]


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Managing Hair Loss During and After Pregnancy: Facts vs False Reassurance

Hair Loss During and After Pregnancy

Individuals with hair loss often ask what steps they should be taking to best help their hair during pregnancy and what steps they should take after delivery.

I have written on certain aspects of this topic before. Please consider reviewing my past articles on Hair Loss, Pregnancy & Breastfeeding:

July 23, 2019 - Stopping Medications in Pregnancy

May 6, 2018 - Pregnancy and Female Pattern Hair Loss

Mar 1, 2017 The Safety of Hair Loss medications in Pregnancy

May 19, 2012 - Which medications are safe during breastfeeding?

For many women who ask this question and are currently pregnant, I often say that there are two ways to help the hair while pregnant. The first is make sure that the individuals does not truly have any deficiencies by getting some basic blood tests if the individual or her doctor are worried about some type of deficiency. The second way to potentially help the hair is to consider reviewing the benefits of low level laser therapy (LLLT). Besides correcting a vitamin deficiency, administration of low level laser treatments is really the only treatment that can be safely used during pregnancy.

For women who were using minoxidil before pregnancy but needed to stop during the pregnancy, I strongly encourage them to see an expert to determine when minoxidil might best be restarted after delivery. Both the American Academy of Pediatrics and the American Academy of Dermatology have stated that Rogaine is reasonably safe for breastfeeding women (yes, despite the fact that all warning labels say otherwise). I can’t emphasize enough the importance of speaking to the dermatologist about this. in my opinion, we need to let years and years of medical research and years of observation help guide how we make tough decisions not simply outdated warning labels that protect companies from legal ramifications. These decisions are of course taken on a case by case basis.

False resurgence has no place in the management of any type of hair loss - and this is particularly true in managing hair loss around the time of pregnancy. It would be wonderful if I could reassure women that hair always grows back “fully” after delivery (i.e. to the same density as before pregnancy) - but this is not accurate. For most women who shed hair post partum, the shedding eventually slows down around month 6-9 post partum and shedding returns to normal and hair regrowth happens. However, hair density does not always grow back as full as it was before pregnancy if a woman has the genes for genetic hair loss instructing the hairs what to do.  For many women it does - but not all. This is far more than my professional medical opinion - it’s fact. For this reason, I encourage patients to have a solid treatment plan in place.

False reassurance that hair “always” grows back and not to worry leaves many women confused and disappointed. I sometimes advise a conservative approach and sometimes an aggressive approach to treatment after delivery. It all depends on the stage of the patient’s androgenetic alopecia, her current age and health and her family history of hair loss and other conditions. We don’t yet have tests available to set the known genes for genetic hair loss - so this is not part of the evaluation. The decision on what to use during pregnancy is easy as only laser is safe (and supplementing any deficiencies that are uncovered in the blood tests).  


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Is Androgenetic Alopecia (AGA) Caused Only by the Effects of DHT ?

Despite the Myth, Androgenetic Alopecia is Not Simply a Story of DHT

Androgenetic alopecia is a type of hair loss that affects men and women. In males, this condition is also referred to as male balding or male pattern hair loss and eventually affects some 80 to 90 % of males. In females, the condition is referred to as female pattern hair loss or simply hair thinning and affects 40% of women by age 50. The purpose of this article is to deal with some misconceptions, wrong information, errors and myths that many people have about the role of DHT in the balding process. DHT is certainly important - but other factors must be considered too.

The Evolution of the DHT Theory of Male Balding

Some of the earliest observations about the role of hormones in male balding happened in the time of Aristotle back in 300 BC. Aristotle showed that castrated males (eunuchs) did not develop balding. JB Hamilton in 1942 did additional pioneering work to understand male balding. He showed that male hormones are relevant to the balding process. Specifically, he confirmed observations by Aristotle and others that males that were castrated before puberty did not go on to develop balding. Hamilton took this further and showed that if testosterone was given back to castrated males, the males proceeded to develop male balding. This showed that male balding was an “androgen-dependent” process.

Hamilton

Further key work in understanding male balding was done in the 1970s and ultimately published in the New England Journal of Medicine. These were studies that showed that male pseudohermaphrodite living in the Dominican Republic with a genetic deficiency known as 5 alpha reductase deficiency did not produce dihydrotestosterone (DHT) and did not develop male balding. These findings lead ultimately to the rational development of drugs such as finasteride and dutasteride which block 5 alpha reductase and lower DHT levels.

story of MPB

The Story of Male Pattern Balding has a DHT Chapter but Don't Forget to Read the Others

From 300 BC to the 1990’s, the story of male balding seemed pretty clear. Male hormones, particularly the infamous DHT, seemed to be what male balding was all about. Blocking DHT was what treatments were all about.

Many people incorrectly assume that male balding is just a DHT story. Many people incorrectly assume that this DHT chapter is the only chapter they need to read when trying to understand male balding. While it’s true that DHT has a whole lot to do with male balding - the correct way to state it is “male balding is due in part to the effects DHT on hair follicles that are genetically sensitive to this hormone.”


DHT not the only chapter in the balding story

DHT not the only chapter in the balding story. One only need to consider a few other treatments that are used for balding to very quickly realize that male balding must be much more complex than just a DHT story. Minoxidil (Rogaine), for example, has nothing to do with DHT - and yet it helps some people with male balding. Granted I agree that finasteride and dutasteride are much much better treatments than minoxidil - but if DHT was the only thing we need to think about when it comes to treating male balding then minoxidil would not be expected to have any sort of benefit. Well, it does. Low level laser therapy also has nothing to do with DHT hormone levels - and yet it helps some males with their male balding. Platelet rich plasma (PRP) also has very little to do with DHT- and yet it helps some males with their male balding.

Drug Companies are Investing Large Sums with the Knowledge that Male Balding is Far Far More than A Simply DHT Story.

At least 12 pharmaceutical companies are investing millions upon millions of dollars with the clear understanding that DHT is not the only chapter in the balding storybook. These companies are hoping to the first to market with brand new types of drugs - again drugs that have nothing really to do with DHT. A brief summary of the drugs is below.

companies in race



If Male AGA is Far More than A Simply DHT Story, Female AGA is Far Far Far More than A DHT Story

If you have now come to realize that male balding is a bit more complex than simply a story about DHT, I’d like to point out that female androgenetic alopecia (i.e. female pattern hair loss) is even more complex. If you think for even a moment that you’re going to apply the same DHT story that you used in males to explain balding to the mechanisms operating in females with androgenetic alopecia, you’re going to come up short in terms of your ability to explain hair thinning in women.

Androgenetic alopecia in females is a far more complex story - and we still don’t know all of the mechanisms that govern how hairs thin in women. Of course, there is some aspects of the DHT story that relevant to female thinning. But finasteride and spironolactone and anti-androgens are far less consistently helpful in females than in males. Other treatments such as minoxidil and laser may be far more helpful in some women than in males. In other words, there are likely several different mechanisms that are contributory to androgenetic alopecia in females besides simply a DHT story. As further information for reflection to readers who still doubt this information, one must consider that some women with a genetic condition that completely makes them insensitive to the effects of androgens (called androgen insensitivity syndrome) can still develop androgenetic alopecia. Even women with low testosterone and low DHT levels can develop androgenetic alopecia. There are even some androgen deficient women who do not develop any balding whatsoever when you give them back supplemental androgens through various means of testosterone replacement therapy.

Conclusion

Is androgenetic alopecia simply due to the sensitivity of hair follicles to DHT? Well, it’s a good story, but it’s only part of the story. The DHT chapter is an important chapter to read in the story of male balding and female thinning, but be sure to read the remaining chapters of the story book. The DHT story is not the only story - and many pharmaceutical companies are banking on this concept.





This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Take Two Asprins and Call Me in the Morning (... to Discuss your Minoxidil)

Aspirin Potentially Reduces the Effectiveness of Minoxidil

Aspirin (acetylsalicylic acid) has always fascinated me. And it continues to fascinate people and researchers around the world. Apparently, some 58 billion doses of aspirin are taken every year. Researchers published over 1,000 scientific articles pertaining to aspirin last year alone. This just adds a bit more to the 23,000 studies that are already published in the scientific journals of the world.

We all know about aspirin. We take if for headaches. Some take it for preventing heart disease. Some take it for preventing strokes. Research now shows convincingly that taking an aspirin if you’ve had a heart attack can reduce your risk of having a second one. In addition, patients who take an aspirin after experiencing a mini-stroke (i.e. transient ischemic attack) have a reduced risk of having a stroke and a reduced risk of dying. Researchers are now trying to figure out how it can be used to prevent cancer and some dementias. This list of potential uses for aspirin is increasing - which means we could someday actually rise above the 58 billion doses yearly.

Aspirin has many effects in body and one is to inhibit an enzyme known as cyclooxygenase. By doing so, certain inflammatory pathways get shut down and the release of certain prostaglandins is inhibited in tissues.

Aspirin and Minoxidil: New Study Suggests Aspirin May Reduce Minoxidil Effectiveness

A new suggests that minoxidil could potentially reduce the effectiveness of minoxidil. To understand this further, it’s important to appreciate that minoxidil gets converted in the skin to minoxidil sulfate and it’s the minoxidil sulfate that actually does all the work for promote hair growth. The conversion of minoxidil to minoxidil sulfate occurs from enzymes known as sulfotransferases which are found the outer root sheath of hair follicles.

In the liver, it had been appreciated that derivatives of aspirin could inhibit sulfotransferase activity. In a new study, researchers found evidence that aspirin could inhibit sulfotransferase activity in hair follicles too. Using a kit that helps predict whether people respond to minoxidil or not, the researchers found that 14 days of continuous aspirin exposure reduced the number of minoxidil responders in half. Prior to aspirin use, 50 % of subjects in the study were predicted to respond to minoxidil treatment. After using aspirin, this was reduced to 27 %.

Conclusion

This is not definitive proof of aspirin’s ability to reduce the effectiveness of minoxidil, but it is certainly quite interesting and suggestive data. More research is needed to confirm this interesting finding.

Reference

Goren et al. Low-dose daily aspirin reduces topical minoxidil efficacy in androgenetic alopecia patients. Dermatol Ther. 2018 Nov;31(6):e12741. doi: 10.1111/dth.12741. Epub 2018 Oct 8.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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.

See Article “The Top 10 Things You need to Know About Oral Minoxidil”


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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.

See Article “The Top 10 Things You need to Know About Oral Minoxidil” 

REFERENCE

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


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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. 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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

 

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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. 

 

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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.

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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 2-3 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

 

 

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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

 

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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