The "Dread Shed" - Does it just apply to Rogaine?

The Dread Shed is Both Good and Bad

The term ‘dread shed’ refers to an increased shedding of hair that individuals notice within 1-3 months of starting a new treatment for androgenetic alopecia. Medically, the phenomenon is known to hair specialists by the term "immediate telogen release.” Most famously, the term ‘dread shed’ applies to the increased shedding some people experience with use of minoxidil. However, the term equally applies to other therapies. 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. Let’s take a look first at shedding from minoxidil.

Dread Shed from Minoxidil

Minoxidil lotion and Minoxidil 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 1-3 months of starting minoxidil. 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).

Immediate telogen release: Understanding shedding with minoxidil (Rogaine)

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 males and females with androgenetic alopecia (especially early stages of AGA), one will notice that a higher than normal proportion of cells are in the shedding phase of the hair growth cycle (i.e. the so called telogen 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.

Dread Shed from Spironolactone, Finasteride and Low Level Laser

As we reviewed together in the section above, a dread shed is expected. It’s not that it’s unexpected. It’s expected. If a patient does not get some little bit of increased shedding it’s probably a concern. Now, keep in mind that patients who wash their hair daily may not be able tell they are having increased shedding if the ‘dread shed’ is mild. It’s really only individuals with more marked shedding that will be able to tell they are having a dread shed. As well, people who wash their hair once per week are going to be able to appreciated subtle differences much easier than people who wash their hair daily. (I’m not saying to wash the hair weekly - I’m just say these are the individuals who can appreciate differences the easiest).

Any treatment for androgenetic alopecia that works has the potential to cause a dread shed. I think that’s worth repeating: Any treatment for androgenetic alopecia that works has the potential to cause a dread shed. Minoxidil, spironolactone, PRP, laser, finasteride, dutasteride, flutamide, bicalutamide - they all carry with them the potential to cause a dread shed.

Whenever a patient bring in a product and tells me they have a new wonderful product that does not cause a dread shed - I tell them simply that if the product they have in their hand has a zero percent chance of causing increased shedding then it probably does not help in the treatment of androgenetic alopecia.

Now as we finish our discussion of dread sheds and treatment related shedding in general, it’s important to keep in mind a few points:

1. Some treatments are more likely to cause marked shedding (i.e. a dread shed) than others. Minoxidil and spironolactone carry with them a greater risk than low level laser therapy.

2. Some treatments not only cause a dread shed but cause hairs that were not in the telogen phase to also be booted out of the scalp. This is called a drug induced telogen effluvium and can look similar to a dread shed and is challenging to differentiate from a simple dread shed phenomenon. Spironolactone can cause this phenomenon sometimes and so can minoxidil. In this case the shedding does not stop at month 3 -4. Expert advice is needed in these challenging cases.

3. Not all patients notice increased shedding after they start a treatment - especially patients who wash their hair daily.

4. The general advice for most patients with androgenetic alopecia who start minoxidil or an antiandrogen or laser therapy and experience increased shedding in the first 1-2 months is to keep going with therapy. Of course, each of these situations should be reviewed with the hair specialist on a case by case basis. But as we have seen above, increased shedding is expected with these therapies.

5. Not every single person who has shedding with treatment will find that the hair density improves at a time point 6 to 12 months into the future. For some patients with strong genes controlling the androgenetic alopecia, the increased shedding only serves to speed up the miniaturization process. This is not common but always needs to be considered. This is particularly true for those who experience a true drug induced prolonged telogen effluvium from use of these treatments. A small proportion of patients do have shedding when starting treatment and find one year later that the androgenetic alopecia has progressed and the hair density is worse. In some of these cases, the treatment did very little to help and the androgenetic alopecia simply pushed the hair thinning along its course. For others, the therapy accelerated the shedding process which further pushed the hair thinning along its course - ahead of where it would otherwise have been.

The Good and Bad of the Dread Shed

For patients with androgenetic alopecia who start treatment, increased hair shedding is generally viewed as a good thing. It’s something that we expect to occur rather than something are concerned with. The most likely scenario for patients who have shedding is that the shedding will eventfully stop and some amount of stabilization or improvement of the androgenetic alopecia will be seen. However, many variations are possible. In rare cases, shedding does not slow at the 3-4 month mark and hair density does not improve. These situations are rare but must always be considered.