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The Renaissance of Low Dose Minoxidil

When it comes to hair regrowth treatments that work, minoxidil was the first.

Imagine it’s the early 1970s. Bell bottoms are de rigueur, disco is king, and Star Wars is just a glint in George Lucas’s eye. Google, the internet and even cell phones are firmly in the realm of science fiction. 

You’re experiencing hair loss and there are no treatments available (save for snake oil and scams that prey on hope). Though surgical hair transplants have been around for about 20 years, they’re still in their infancy.

You’ve resigned yourself to coping with unwanted hair loss, and perhaps are even wasting money on purported treatments that only increase the growth of your credit card statement. 

Then, something miraculous happens. You participate in a trial for a new medication thought to lower blood pressure. Over the next three months, you could swear your hair is regrowing – and you’re not the only one. Everyone else in this study has also noticed hair growth. 

In the 1970s this accidental discovery would have felt like a bonified medical miracle. A pill taken once a day that reduces your blood pressure but also regrows hair predictably, something that has never been seen before. 

That thought exercise sets the stage for the renewed discussions we’re seeing in the New York Times and other news outlets on the benefits of low dose minoxidil as an inexpensive treatment for hair loss. Though many doctors (including Dr Linkov) have been prescribing low dose oral minoxidil for many years for the treatment of hair loss, it’s worth discussing why that first 1970s oral minoxidil preparation never took off. After all, it was the first medication that actually worked to regrow hair.  

And it has everything to do with the serious side effects experienced that came along with the original, much higher dose. 

Minoxidil hit the market in the early 1970s as hypertension (high blood pressure) medication, and though oral minoxidil’s FDA approval is still as a hypertension drug (meaning in the US it is prescribed off label as a hair loss treatment) it never really took off for that use. There were just much more effective blood pressure drugs available even then. Minoxidil’s unexpected side effect of promoting hair growth is what really got people’s attention. The caveat of early oral minoxidil was that the high doses needed to lower blood pressure (10-40 mg) caused some serious side effects, including fluid retention and pericardial effusion (fluid build-up around the heart). 

Topical minoxidil application had the advantage of promoting hair regrowth but with none of the serious side effects, so, in 1986, minoxidil was made readily available as a 2% topical solution to address hair loss in men. Safe and effective. 

So why the renewed interest?

It turns out that the side effects of taking oral minoxidil are dose dependent. Lower the dose, the risk of side effects decreases significantly. Also, a much lower dose of oral minoxidil (0.25 mg -1.25 mg for women, 1 mg- 5 mg for men) was found to be effective for treating both male and female patterned hair loss, as well as chronic telogen effluvium, traction alopecia, alopecia areata, chemotherapy induced hair loss, scarring alopecia, and eyebrow and beard regrowth. 

Oral minoxidil achieves this regrowth through a few mechanisms: it’s a vasodilator (increases oxygen available to hair follicles), promotes the anagen phase of the growth cycle, reduces inflammation (an underlying cause of scarring alopecia), stimulates the release of growth factors, and may have antiandrogenic effects. (For more in-depth discussion on the mechanism of oral minoxidil facilitated hair regrowth, see Dr. Linkov’s earlier video HERE). The result is hairs with increased length and diameter and more vellus hairs transitioning to a terminal state. 

Just like with topical minoxidil, results with low dose oral minoxidil take three months at least to see, it is a long-term commitment, and ceasing treatment will slowly diminish and walk back results. 

Low dose oral minoxidil versus topical minoxidil. 

Low dose oral minoxidil has a lot of advantages over topical minoxidil. First off it works better. Bioavailability is more potent in the bloodstream, meaning more minoxidil reaches the hair follicle. There is no scalp irritation, no unpleasant residue, a lower risk of temporary shedding, and it’s cheaper. Low dose oral minoxidil can also be used in conjunction with other hair loss treatments such as Finasteride, surgical hair transplant, and PRP therapy, so there’s no advantage to oral vs topical in that regard. 

There are also significant lifestyle advantages to low dose oral minoxidil over topical minoxidil, including application rigour. Topical minoxidil needs to be applied twice a day and the pill is taken once a day. Oral minoxidil is also more resilient to missed doses than topical minoxidil, which may be appealing to some users.  

Another less discussed lifestyle consideration when it comes to choosing between low dose oral minoxidil and topical minoxidil is whether you share a home with pets, as minoxidil is highly toxic to both cats and dogs (reference). Accidental exposure of pets to even small amounts, usually through stepping on spilt product, sleeping on pillows, licking after application, and garbage exploration, can be a set up for a very expensive veterinary bill. 

Of course, many pet owners safely use topical minoxidil by practising chemical safety, but the option to eliminate the risk of accidental exposure entirely could be considered yet another advantage. 

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Who is a candidate for low dose oral minoxidil?

Just because low dose minoxidil is safe and effective doesn’t mean it’s for everyone. Oral minoxidil is not for people who are pregnant, breastfeeding, or have pheochromocytoma (a rare benign tumor of the adrenal gland). Possible contraindications to taking low dose oral minoxidil include hypotension (low blood pressure), and any type of cardiac comorbidities, which need to be monitored by a cardiologist. Mild side effects that can still be experienced at a lower dose include hypertrichosis (extra hair growth typically on the face), headache, dizziness, light headedness, leg swelling, and increased heart rate. The more serious side effects seen with higher doses can still occur but are much rarer at the lower doses and can often be managed by lowering the dose further. Rarely does someone need to stop low dose oral minoxidil treatment due to side effects (less than 1%). 

Summary: Is low dose oral minoxidil better for hair loss treatment than topical minoxidil? 

Low dose oral minoxidil has some distinct advantages over topical minoxidil, provided you are a candidate. Whether you choose to explore oral minoxidil for your hair treatment journey depends on many factors, all of which are best discussed with your doctor or hair loss specialist. If you do decide to explore oral minoxidil, be aware it is a prescription medication and, due to its history, many doctors are still uncomfortable prescribing it.

Speaking of which, you can get prescription medication at feelconfident.com

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Written by

Kristi Charish

Edited by

Dr. Gary Linkov

The content of this newsletter is for entertainment and educational purposes only. This content is not meant to provide any medical advice or treat any medical conditions. Patients must be evaluated by an appropriate healthcare provider on an individual basis and treatment must be tailored to meet that patient’s needs. Results and particular outcomes are not guaranteed.

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