Spironolactone in Female Pattern (Androgenetic Alopecia)

Spironolactone helps FPHL: 33 % have side effects, 3.8 % stop treatment

On Jan 21, 1960 Spironolactone received FDA approval as a diuretic. In dermatology, it’s commonly used “off label” in treating female pattern hair loss (also known as androgenetic alopecia). Women with acne and women with hirsutism (increased facial hair) commonly use this medication as well. It was increasingly used in dermatology for these indications starting in the late 1970s.

A recent study looked at benefits and side effects of spironolactone for female pattern hair loss, The study was a study of 79 patients. One half of patients were post menopausal. About 39 % had been on the treatment 6 months and 60 % had been on treatment a year or more. 53 % received just spironolactone (so called mono therapy) and 47 % were on combination treatments. 50 % were started on 100 mg doses (50 mg twice daily) and 33 % ultimately increased the dose. Side effects included dizziness (17%), nausea (2 %), spotting (2%) breast tenderness (1%), hyperkalemia (1%) and 7% had some other side effects. About 33 % of patients overall had some kind of side effects but these were significant enough side effects to prompt stopping the drug in about 3.8% of users.

Overall, the authors of this study reported that all women using spironolactone benefited and women with more advanced stages of hair loss saw the most significant changes. It took at least a year to have maximum benefits.

COMMENT/CONCLUSION

This was an interesting study for a number of reasons. First, the study reminds us that 100 mg of spironolactone probably does something positive in treating FPHL and the pressure to get to 200 mg need not apply to all women,. Second, the study reminds us that we really need to be patient when treating FPHL. Although results can be seen as early as 4-6 months, maximal results are not seen for about 1 year or more for most. Finally, good counselling is needed when prescribing this drug, About one third of patients are going to have side effects. Proper counselling will require only a small proportion to actually stop.

This study captures a specific population and the study is small at 79 patients. Irregular periods are very common on spironolactone. This was reviewed in this paper but 50% of patients in this study were post menopausal so the full scope is not explored. Fatigue can occur in some women and so can decreased libido. Some women have troublesome diuresis and need to use the washroom often. For most, these side effects are limited to the first 2-4 weeks of therapy but for some they continued and require dose adjustment.

The other side effects which was not fully touched upon here is hair shedding. Spironolactone in my experience causes shedding in some women. Fortunately for many this stops after a few months - but not in all. I have not seen spironolactone consistently and universally help all my patients.

What have other studies shown about spironolactone side effects?

In 2002, Shaw evaluated the frequency of side effects in women using spironolactone for acne. 91 patients were evaluated in his study and the treatment length was a mean of 28.5 months (range from 2 weeks to 10 years). Side effects in this study occurred in 59 % of users and 15 % of patients stopped therapy. The importance of this particular study was that patients were followed for at least 8 years.

Reference

Donovan J. Spironolactone vs Finasteride for Treating Female Pattern Hair Loss.

Burns et al. Spironolactone for treatment of female pattern hair loss. Journal of the American Academy of Dermatology.  VOLUME 83, ISSUE 1, P276-278, JULY 01, 2020

Shaw JC and White L. Long-term Safety of Spironolactone in Acne: Results of an 8-year Followup Study. J Cut Med Surg Nov-Dec 2002;6(6):541-5.

Goodfellow A, Alaghband-Zadeh J, Carter G, et al. Oral spirono lactone improves acne vulgaris and reduces sebum excretion. Br J Dermatol 1984; 111:209-214.

Lee 0 , Farquhar C, T oomath R, et al. Spironolactone versus placebo or in combination with steroids for hirsutism and/or acne. Cochrane Database Syst Rev 2000; (2):CD000194.