Do you love your hair the way it is? Many of us wish our hair were different–curlier, straighter, darker or lighter. But what people worry about most with their hair is when they lose it. Can you keep your hair from falling out? Why does hair loss affect some people, including women as well as men? Why do others seem relatively unaffected? What’s the latest update on low-dose oral minoxidil for hair loss?
While there is some familial component to male pattern baldness (despite the name, it affects women too), the exact genetics are unclear. Other causes of hair loss include autoimmune disease such as alopecia areata or hormone imbalance such as thyroid disorders. Pregnancy is a common cause of hair loss after delivery. That’s because the hair that has been in anagen phase (growing) shifts to telogen phase in which the hair follicle rests and the hair is no longer growing. Stress can also make hair fall out.
What Can You Do About Hair Loss?
Treating the conditions that trigger hair loss can be helpful. That’s why the first test might be for thyroid function. Once a thyroid imbalance is corrected, the hair loss will generally improve.
Infection and fever can also lead to hair loss.
According to the American Academy of Dermatology:
“Most people see noticeable hair shedding two to three months after having a fever or illness. Handfuls of hair can come out when you shower or brush your hair. This hair shedding can last for six to nine months before it stops. Most people then see their hair start to look normal again and stop shedding.”
Dermatologists call temporary hair loss due to stress or a shock to the system “telogen effluvium.” The word telogen means “resting.” Your hair goes through various cycles of growth. The “anagen” phase is active, when the follicle is working hard to create and grow a hair. It can last for years.
The “catagen” phase is a transition phase that just lasts a few weeks. It is followed by the “telogen” phase. Think of this stage a bit like resting or hibernation. The hair stays in the follicle, but is no longer growing. Eventually, the old hair falls out. That is called the “exogen” phase.
Effluvium is dermspeak for hair loss. So telogen effluvium means excessive hair shedding brought on by stress, infection, childbirth, weight loss, surgery, medications and a whole lot more.
Hair Loss From COVID-19?
We stumbled across an article in the journal of Medical Virology (Dec. 20, 2021) titled:
“A Systematic Review of Acute Telogen Effluvium, A Harrowing Post-COVID-19 Manifestation.”
The authors report that:
“The mean duration from COVID-19 symptom onset to the appearance of acute TE [telogen effluvium] was 74 days, which is earlier than classic acute TE. Most patients recovered from hair loss, while a few patients had persistent hair fall. Our results highlight the need to consider the possibility of post-COVID-19 acute TE in patients presenting with hair fall, with a history of COVID-19 infection, in the context of COVID-19 pandemic. Despite being a self-limiting condition, hair loss post-COVID-19 is a stressful manifestation. Identifying COVID-19 infection as a potential cause of acute TE will help the clinicians counsel the patients, relieving them from undue stress. “
Other authors have also reported hair loss after COVID infection.
Minoxidil To Keep Hair From Falling Out:
Perhaps you have heard of minoxidil (Rogaine) for hair loss. An oral version of minoxidil (Loniten) was first approved in 1979 to treat high blood pressure.
A “side effect” of excessive hair growth prompted the manufacturer to investigate the topical application against hair loss. The FDA approved prescription Rogaine in 1988. Later, the FDA allowed over-the-counter sale of this topical compound. It was never the kind of blockbuster success one might have anticipated. A drug that really keeps hair from falling out should be a billion dollar best seller!
But perhaps the problem was not with minoxidil itself. Maybe it was the topical application of the drug that led to disappointing results.
Here is a question from a reader:
Q. I am concerned about my thinning hair. I tried Rogaine and it worked well until I developed an allergic reaction.
I just read about low-dose oral minoxidil. What can you tell me about it?
A. Science writer Gina Kolata stirred up a lot of excitement in her New York Times article (Aug. 23, 2022). It was titled:
“An Old Medicine Grows New Hair for Pennies a Day, Doctors Say”
“Dermatologists who specialize in hair loss say that the key ingredient in a topical treatment worked even better when taken orally at a low dose.”
Gina describes the off-label use of low-dose oral minoxidil as an alternative to topical Rogaine (minoxidil). Several dermatologists have reported success prescribing very low doses of this blood pressure pill for people with hair loss.
The usual oral dose ranges from 5 to 40 mg per day for hypertension. However, at those doses people may experience serious side effects.
Some dermatologists are prescribing amounts that range from 0.25 to 1.25 mg (Journal of the American Academy of Dermatology, March, 2021). They often add the diuretic spironolactone (25 mg) to reduce fluid retention and counteract facial hair growth.
Topical Minoxidil Can Help Keep Hair From Falling Out:
One reader recently asked us:
Q. About two years ago, I was seriously considering a wig because I was losing so much hair above my forehead. My doctor suggested minoxidil.
The bottle says to use it twice a day for at least six months before you will see a difference. I was faithful about using it, and it does work. My hairdresser is amazed at the difference.
Now I have cut back to using it just once a day and it’s still working. I have heard that if I quit using it, I will lose my hair again. I am not willing to try that! Is there anything I should know about this OTC medicine?
A. While minoxidil does stimulate hair growth, there are some downsides. Skin irritation is one possible side effect.
An alternative to Rogaine is low-dose oral minoxidil.
The review described above concludes:
“Oral minoxidil was found to be an effective and well-tolerated treatment alternative for healthy patients having difficulty with topical formulations.”
This requires medical supervision because oral minoxidil, even in very low doses, may cause some side effects such as dizziness or fluid retention.
Another Option? Finasteride & Dutasteride:
Drugs that men use for enlarged prostate glands, finasteride and dutasteride, can also stop hair loss. They do have some sexual side effects, however, and they are inappropriate for pregnant women. How do these three oral medications stack up when it comes to preventing hair from falling out?
An article in the Journal of Dermatological Treatment (online, Aug. 15, 2022) is titled:
“Comparison of oral minoxidil, finasteride, and dutasteride for treating androgenetic alopecia”
The authors introduce their article this way:
“Androgenetic alopecia (AGA) is the most common cause of hair loss, often challenging to treat. While oral finasteride (1 mg/d) is an FDA-approved treatment for male AGA, oral minoxidil and oral dutasteride are not approved yet. However, clinicians have been increasingly using these two drugs off-label for hair loss. Recently, Japan and South Korea have approved oral dutasteride (0.5 mg/d) for male AGA.”
Under the heading Efficacy and Safety they state:
“A probable efficacy ranking, in decreasing order, is – dutasteride 0.5 mg/d, finasteride 5 mg/d, minoxidil 5 mg/d, finasteride 1 mg/d, followed by minoxidil 0.25 mg/d. Oral minoxidil predominantly causes hypertrichosis and cardiovascular system (CVS) symptoms/signs in a dose-dependent manner, whereas oral finasteride and dutasteride are associated with sexual dysfunction and neuropsychiatric side effects.”
A Drug for Eyelashes:
Ophthalmologists discovered some years ago that the bimatoprost eye drops they were prescribing to treat glaucoma could also make eyelashes grow thicker and fuller. The FDA subsequently approved this medication for eyelash growth under the brand name Latisse. The user applies it like eye liner and it works well for the lashes.
Drugs That Cause Hair Loss:
Certain medications may trigger hair loss, particularly in susceptible individuals. In most cases, the prescriber could find an alternative. For example, beta blockers such as metoprolol are known to cause this problem, but usually another medication could be used to control blood pressure or heart rhythm.
In the case of chemotherapy, the benefit of overcoming cancer is usually considered to far outweigh the distress of losing hair. Nonetheless, there is a new tactic that may help counteract the hair loss due to chemo. It is a type of close-fitting cooling cap that constricts blood vessels so less of the medication gets to the hair follicles.
One thing to avoid: using oil with heat processing. This can actually damage and scar the follicle, preventing recovery.
Keep Your Hair from Falling Out:
Keeping your body and skin healthy with good nutrition, adequate sleep and stress control is also a good way to maintain a healthy head of hair. Crash diets or extreme calorie restriction can lead to hair loss. Essential fatty acids, including omega 3 fats found in fish oil, can be helpful. Zinc supplements may also be useful to keep hair from falling out.
Reducing inflammation can be helpful to prevent hair from falling out. In general, prevention is more preferable to finding ways to rejuvenate growth. The supplements Dr. Adigun mentions as possibly helpful, although incompletely tested, are Viviscal and Nutrafol. They contain marine complexes and ashwagandha.
Our Radio Show Guest:
Chris G. Adigun, MD, FAAD, is a board-certified dermatologist who practices at the Dermatology and Laser Center of Chapel Hill, NC. In the picture, she is standing in the WUNC studio with Joe (seated) and Terry Graedon, hosts of The People’s Pharmacy.
Listen to the Podcast:
The podcast of this program will be available the Monday after the broadcast date. The show can be streamed online from this site and podcasts can be downloaded for free.
This interview with Dr. Adigun was recorded in 2019. We interviewed her and Dr. Warren Heymann on a live People’s Pharmacy broadcast. Dr. Heymann is Professor of Medicine and Pediatrics and Head of the Division of Dermatology, Cooper Medical School of Rowan University, Camden, New Jersey and Clinical Professor of Dermatology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania.
They were live in our studio on October 22, 2022. Dr. Heymann has written an article in the Journal of the American Academy of Dermatology (March, 2021) Titled:
“Coming full circle (almost): Low dose oral minoxidil for alopecia”
Download the free mp3 of our old interview with Dr. Adigun (Choose MP3 from the pulldown) or click on the arrow inside the green circle under the photo at the top of the page for the streaming audio.
The more recent interview with Dr. Adigun and Dr. Warren Heymann, focuses on oral minoxidil. You will want to lisiten to the streaming audio or download the free podcast at this link.
Alopecia Areata and Olumiant:
JAK (Janus kinase) inhibitors can be surprisingly effective for autoimmune hair loss. On June 13, 2022, the FDA announced the approval of baricitinib (Olumiant) for treating alopecia areata.
Here is how the FDA describes the new drug:
“Alopecia areata, commonly referred to as just alopecia, is an autoimmune disorder in which the body attacks its own hair follicles, causing hair to fall out, often in clumps. Olumiant is a Janus kinase (JAK) inhibitor which blocks the activity of one or more of a specific family of enzymes, interfering with the pathway that leads to inflammation.
“The efficacy and safety of Olumiant in alopecia areata was studied in two randomized, double-blind, placebo-controlled trials (Trial AA-1 and Trial AA-2) with patients who had at least 50% scalp hair loss as measured by the Severity of Alopecia Tool for more than six months. Patients in these trials received either a placebo, 2 milligrams of Olumiant, or 4 milligrams of Olumiant every day. The primary measurement of efficacy for both trials was the proportion of patients who achieved at least 80% scalp hair coverage at week 36.
“In Trial AA-1, 22% of the 184 patients who received 2 milligrams of Olumiant and 35% of the 281 patients who received 4 milligrams of Olumiant achieved adequate scalp hair coverage, compared to 5% of the 189 patients who received a placebo. In Trial AA-2, 17% of the 156 patients who received 2 milligrams of Olumiant and 32% of the 234 patients who received 4 milligrams of Olumiant achieved adequate scalp hair coverage, compared to 3% of the 156 patients who received a placebo.”
“The most common side effects associated with Olumiant include: upper respiratory tract infections, headache, acne, high cholesterol (hyperlipidemia), increase of an enzyme called creatinine phosphokinase, urinary tract infection, liver enzyme elevations, inflammation of hair follicles (folliculitis), fatigue, lower respiratory tract infections, nausea, genital yeast infections (Candida infections), anemia, low number of certain types of white blood cells (neutropenia), abdominal pain, shingles (herpes zoster) and weight increase.”
We cannot proclaim Olumiant a home run, given the number of side effects and the modest effectiveness of the drug. Nevertheless, it may be worth consideration given the challenges of alopecia areata.