Deciding on Whether to Switch from Topical to Oral Minoxidil Because of Increased Hair Shedding. Does it help ?

Does switching to oral minoxidil cause shedding if topical minoxidil caused shedding?

I’m often asked if switching to oral minoxidil is a reasonable plan if someone has chronic shedding from topical minoxidil. The answer is maybe yes. Maybe no. I certainly see patients whose shedding does improve or stop with switching to oral minoxidil- but not everyone. It really comes down to why a person is shedding in the first place.

CONSIDERATION 1

If a person is irritated from one of the ingredients in topical minoxidil then switching to oral minoxidil which does not have these ingredients could help.

CONSIDERATION 2

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 to oral minoxidil could make sense. 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.

CONSIDERATION 3

If someone has androgenetic alopecia as well as seborrheic dermatitis, use of topical minoxidil sometimes worsens the underlying seborrheic dermatitis. This facilitates ongoing shedding. In this particular situation, switching to oral minoxidil can sometimes help. Of course, aggressively treating the seborrheic dermatitis is another option.

CONSIDERATION 4

Not everyone with chronic shedding from minoxidil finds it helpful to switch. If someone has an active scarring alopecia and finds they are shedding much more with topical minoxidil - switching to oral minoxidil might not change a thing. 

CONSIDERATION 5

If someone is not really a responder at all to topical minoxidil (only 20 -25 % of people are fairly good responders), switching may or may not help much. Certainly, for some people who are not good responders to topical minoxidil, switching to oral minoxidil makes no difference. For others there is a clear benefit even at tiny doses such as 0.25 to 0.625 mg. For others, there is no benefit at all at tiny doses and the benefits only come with use of higher doses such as 1.25 mg or 2.5 mg or rarely even 5 mg. So, when patients are deciding whether to switch to oral minoxidil they must understand that the first dose they try may or may not be helpful to them.

CONSIDERATION 6

When a patient switches from topical minoxidil to oral minoxidil and finds that their hair shedding lessens and their hair density improves, we generally assume the oral minoxidil helped. We give the credit to the oral minoxidil and praise its success. But we must alway keep in mind the possibility that the oral minoxidil actually did not help and instead all that simply happened was that some other disease settled down.