Shedding from Oral Minoxidil: Is there a dread shed?

Does oral minoxidil cause a dread shed?

 
I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in the use of oral minoxidil for women.

Question

Hi Dr. Donovan!

I am a 23 yr old female who has never had hair loss in my life until I had Covid in March of 2020. Since then, for two years I have had diffuse excessive shedding. It was originally considered a viral acute TE but after a biopsy my dermatologist is considering it chronic TE with possible mild AGA even though I have no history. I have tried supplements, and get blood work done every few months to check hair loss values and nothing is ever abnormal with no other obvious triggers. She put me on oral minoxidil 0.25mg I have been on it for 2 months (went up to 0.625mg on my 6th week of medications). I am still seeing consistent diffuse shedding which feels like it has increased specifically when i shower in the past few weeks.

My dermatologist is saying that oral minoxidil shedding is not common in patients and in the literature so now I feel like I should stop and it is not working for me! I know topical Rogaine dread shed is common.

Is oral minoxidil shedding common as well and for how long might I expect it?

Thanks!

Answer

Thanks for the question! This is so important! Thanks for taking the time to present your question.

Shedding on oral minoxidil is common yes - just not talked about much. In fact, it’s rarely talked about because many in the medical community and lay public have somehow come to view oral minoxidil as low risk and just decided to ignore any side effects. Not everyone of course - but a common view.

In fact, shedding issues are often not talked about in the medical community with many treatments. PRP shedding is not talked about much either!! Try to find studies on shedding with PRP and you won’t find much ! Not a day goes by that I’m not on the phone discussing post PRP shedding with someone somewhere in the world. Why don’t we talk about it? No idea.

So yes, oral minoxidil shedding is not talked about much. The attention is all put on the famous “Rogaine dread shed” which leaves people wondering “do these other treatments cause shedding?
They absolutely do.

I don’t know your reason for hair loss as I haven’t seen your scalp up close and don’t know the whole story AGA is quite likely with a story like this. CTE is pretty unlikely with a story like this. But of course the exact diagnosis comes with a full review of one’s medical information and proper review of the scalp.

Sanabria and collegues remind us about shedding, shedding shedding

Dr Sanabria and her colleagues from Brazil reminded us in 2021 that shedding from oral minoxidil is not really that uncommon. Give oral minoxidil to 2 female patients and guess what? One of them is going to get shedding? Is that rare? No. 1 in 2 people is not rare.

Here are some of the side effects that Sanabria taught us about in her study (see right column) and side effects Dr Vano taught us about in his study (see left column)

Summary

I appreciate your question. Oral minoxidil certainly does give shedding. It can last 3 months or so. It could be that you are not quite on the right dose (yet) so you and your dermatologist can decide if going up to 1.25 mg is right for you or not. If you are not having side effects (other than shedding), sometimes going up makes sense.

In addition, you’ll want to make sure all the other issues are addressed like seborrheic dermatitis, and any other triggers of telogen effluvium (stress, low iron, thyroid problems, medications, supplements, allergic contact dermatitis from shampoos and conditions and products you are using). By the sounds of it your blood tests are good so most causes in the list above seem unlikely. But seborrheic dermatitis always needs to be considered.

Everyone loses more hair on shampooing days so don’t gauge things too much by that. It’s normal to lose double or triple the hairs on a shampooing day especially if you are not shampooing all that often these days. Photos of the top of the scalp are going to be really important (in addition to the shedding patterns you are seeing).

At age 23, the key is to be patient with making adjustments - if possible. I don’t know the details of your hair enough to give much further but generally speaking sticking to a plan for a few months proves more helpful that jumping to another plan too quickly. Giving 0.625 mg a solid three months is not at all unreasonable (and you and your doctors may consider going up to 1.25 mg or even 0.625 mg alternating with 1.25 mg). Stopping minoxidil too quickly usually just creates more confusion than it helps.

You’ll want to review with your doctors if perhaps another COVID infection in Spring or Fall 2022 is contributing to any shedding now or whether seasonal shedding is throwing a bit of confusion into the picture. Any recent vaccinations add to the complexity. Any other medications you’ve used recently need to be factored in.

I thank you for the question and wish you the best.

REFERENCE

Sanabria B et al. Adverse effects of low dose oral minoxidil for androgenetic alopecia in 435 patients. JAAD 2021; 84: 1175-78