Several medical conditions cause hair loss. However, the most common is androgenetic alopecia (common male pattern baldness).[1] It is responsible for hair loss in as many as 50% of white men and women older than 40, and in a somewhat smaller proportion of Asians, blacks, and American Indians.[2]Pharmacists can recommend nonprescription minoxidil products that may help treat androgenetic alopecia. Before making any recommendations, it is important to differentiate androgenetic alopecia from other causes of hair loss.

Androgenetic alopecia is the only self-treatable member of a group of conditions known as nonscarring alopecias. Another nonscarring alopecia is alopecia areata, an inherited autoimmune condition of varying severity.[3,4] In some patients, hair loss is confined to one or more small oval patches; in others, the scalp is virtually denuded except for a few tufts of hair. Alopecia areata may extend to the entire scalp (alopecia totalis) or to the surface area of the whole body (alopecia universalis). The condition is marked by exacerbations and recoveries. When hair regrows, it may assume a white discoloration.

Another nonscarring alopecia is caused by trichotillomania, a psychiatric/psychological condition in which the patient is compelled to pull, tug, or yank at single strands or tufts of hair until they exit the follicle.[5] Patients describe a release of tension when the hair is pulled. Preadolescent and early adolescent girls are the most likely to suffer from trichotillomania, which may be related to obsessive-compulsive disorder, but it is seen in males and females of all ages. The bald area manifests as a bizarre geometric shape. The patient may leave only a small fringe around the head (known as the “Friar Tuck” sign). Hair also may be pulled from a secondary site, such as the eyelashes, eyebrows, underarms, body, or pubis. Patients who ask for help should be urged to seek counseling.

Some grooming methods may cause a nonscarring alopecia. Creating ponytails, braids, tight curls, or cornrows involves pulling hair in unnatural positions. Some of the hair is gathered tightly and secured with a ribbon, elastic band, or the braid itself. The continual outward pressure on hair causes many strands to be pulled from the scalp prematurely. This traction alopecia, which requires referral, often produces patterned hair loss on the temporal regions, periauricular zones, and frontal scalp.

Medications such as cytotoxic agents, colchicine, heparin, oral anticoagulants, vitamin A, and captopril can all induce nonscarring hair loss. A patient who suspects that he or she may have medication-induced hair loss should be directed to seek physician care.

Scarring alopecias may be induced by tinea capitis, discoid lupus erythematosus, cellulitis, burns, freezing, scleroderma, and the use of caustic chemicals such as hair relaxers or straighteners. If the scalp appears inflamed or scarred, the patient should be referred for appropriate care.

Androgenetic alopecia is a gradual thinning of the hair on a scalp otherwise free of scarring or inflammation.[7] Hair loss is pronounced over the crown in both men and women, and, in men, also on the front of the scalp.[8] In men, the onset is usually in the teens, while, in women, many usually notice the problem appearing or markedly worsening at menopause.

Before suggesting self-treatment, the pharmacist should ask whether the patient has a family history of androgenetic alopecia. For many years, common wisdom held that people inherited male pattern baldness from their mothers. Thus, a man was exhorted to look at his maternal grandfather and male cousins born to his mother’s sisters, who would be at identical risk if the inheritance were strictly matrilinear. However, inheritance is polygenic, so either or both parents can pass the tendency to a child, which explains why brothers may vary widely in their degree of hair loss.[9]Nevertheless, if a patient (male or female) contemplating self care has no history of hair loss in any family member, the labeling information on self-treatment products suggests a physician visit.

Topical minoxidil for androgenetic alopecia is unusual because it is the first FDA-approved medication used for cosmetic purposes. It is the only nonprescription ingredient proven to regrow hair, despite the numerous Web sites promoting unproven products.

The mechanism of minoxidil is uncertain, although it may work by increasing the cutaneous blood flow to the scalp. The manufacturer of the 2% solution provided regrowth statistics from a major efficacy study demonstrating that men ages 18 to 49 with moderate hair loss have a 26% chance of experiencing moderate to dense hair regrowth in four months and a 33% chance of minimal regrowth.[10] After eight months of use, women ages 18 to 45 with mild to moderate hair loss can expect moderate regrowth in 19% of cases and minimal regrowth in 40% of cases.[11] Those whose hair loss is recent and minor have the best chance for decent regrowth.

The patient should apply 1 mL of minoxidil twice daily. Packages contain several applicator options, including a dropper marked with a 1-mL calibration, a spray applicator, and an extended-spray applicator, which is ideal for long hair. Six pumps of the applicators release 1 mL of minoxidil. Because systemic absorption could affect blood pressure, the patient should not inhale the aerosol generated by the spray applicators.

After minoxidil reaches the scalp, it must remain in contact for at least four hours for full absorption. During this time, the patient must not swim, wash hair, allow rain to contact the head, or engage in heavy exercise that would cause sweat to wash away the minoxidil. The solution should be dry before other hair products are applied. Further, minoxidil should be used at least four hours before bedtime, or the solution might be rubbed off onto the pillow during presleep tossing and turning.

Several other precautions should be communicated to patients using minoxidil. For instance, patients should not apply more than 1 mL twice daily. Using more than the recommended dosage in a misguided attempt to speed hair growth is not only ineffective but also could lead to adverse reactions such as hypotension. If the patient uses his or her hands to more effectively spread minoxidil onto the scalp, they should be washed thoroughly. Minoxidil should not be used by anyone younger than 18 and is not known to prevent hair loss. Pregnant and breast-feeding women should not use – or even touch – the product, nor should anyone allergic to either minoxidil or the components of the formulation (eg, propylene glycol, alcohol).

Should the patient stop using minoxidil, regrown hair will likely be lost within three to four months’ time because it is effective only when it is being used. However, an interesting question arises regarding minoxidil’s mechanism of action and hair loss after its discontinuation. Suppose identical twins have androgenetic alopecia, each with a 1-inch diameter bald spot on the vertex. One uses topical minoxidil for a 10-year period and has moderate regrowth within the bald spot and no further hair loss.[12] The other twin does not use minoxidil and continues to lose hair during the same 10-year period, with the bald spot enlarging to 2 inches. At the end of the 10-year period, the minoxidil-using twin stops using the product. When his hair falls out, will his bald spot be 1 inch or 2 inches, like his twin’s? Unfortunately, minoxidil cannot stop the inexorable march of time and genetics, and the latter will be the case. Thus, long-time users may notice that halting use of minoxidil makes them look worse than before they first used it.

Users of minoxidil who experience an allergy to the ingredients should discontinue use. Others notice burning or irritation with use, more often with the 5% than the 2% products.[13] Local irritation of the scalp may induce pruritus or dryness. Patients may complain that their teenage dandruff seems to have returned in the form of flaking and scaling. Although these are mostly minor problems that do not necessitate discontinuation, patients should see a physician to rule out contact dermatitis. The patient can be urged to purchase a moisturizing shampoo.

Patients must not apply minoxidil to scalp areas that are inflamed, infected, irritated, erythematous, or eczematous. Women should not use the 5% product, since it can cause asymmetrical hypertrichosis, manifesting as de novo growth of dark hair on the face, hands, arms, legs, feet, chest, ear rim, and back.[14] Patients should be advised to discontinue use if they develop chest pain, tachycardia, faintness, dizziness, unexplained sudden weight gain, swelling of the hands or feet, and scaling and erythema of the scalp. Patients who have preexisting cardiac disease should not use minoxidil because of the potential for tachycardia and palpitations.

If a male patient has an inadequate response to minoxidil, the pharmacist can recommend that he see a physician to obtain a prescription for finasteride, an azasteroid that inhibits the enzyme responsible for androgenetic alopecia.[15,16] There are no prescription products for women.

Many people have hair loss beginning in their late teens. It is most often due to the effect of androgens – or male hormones – on hair follicles. Men may notice hair loss on the front of the scalp and on the crown, and women may notice a thinning along the top of the head. It is important to see a physician if you notice scarred areas or if the hair loss is patchy, due to compulsive pulling of the hair, hair grooming methods (eg, cornrowing), or the use of harsh chemicals on the scalp.

If your hair loss is due to androgens – a condition known as androgenetic alopecia – you may want to try minoxidil, a nonprescription product that is also known by the original trade name Rogaine. It is the only nonprescription ingredient proven to regrow hair.

Minoxidil does not produce instant results and does not work for everyone. Hair grows slowly, and the first hair to come in will be soft, downy, light in color, and barely noticeable. If you are using the regular-strength 2% minoxidil twice a day, it may take as long as four months before you notice a difference in the amount of hair you have. If you use the extra strength (5%) product for men, it may take two months to notice a difference. You may wish to ask someone to take a picture of the top of your head to use for comparison as time passes.

Hair may continue to fall out for the first two weeks of minoxidil use. Eventually, some people notice new hair that matches the color and thickness of the hair on the rest of the scalp. After about 12 months for men or eight for women, patients will have reached their maximum reaction to 2% minoxidil. Men taking the 5% product have their maximum response after about four months. If you have been using minoxidil for the time it takes to achieve maximum response and you have no real growth, you should stop using the product.

Topical minoxidil is proven effective for hair growth in men only on the crown of the head. It has not been proven to grow hair on the front of the scalp and should not be applied there. Hair regrowth will continue only as long as you keep applying minoxidil. If you stop using minoxidil, the regrown hair will gradually fall out within three to four months.

Male patients who experience inadequate hair regrowth with minoxidil may ask their physician about a prescription for Propecia. Many patients using the product experience a slow, steady filling in of thinning and balding areas on the crown and front to middle of their scalp. It is not effective on the temples. It is not indicated for use by women and could affect the genitals of developing male fetuses if taken by pregnant women.

A quick search through various Web sites exposes a plethora of products that promise to regrow hair, both directly and indirectly. One Web site advertises a product that contains a copper nutritional complex of unknown effectiveness. Another sells a book that promises to reveal 89 ingredients that cost $5 or less that cause hair growth (the book itself costs $14.99). Other than minoxidil and Propecia, no remedies have been proven to regrow hair. Instead of falling prey to these medical scams, Consult Your Pharmacist to learn whether minoxidil, Propecia, or a physician’s care would be most appropriate for treating your hair loss.

References

1. Pathomvanich D, Pongratananukul S, Thienthaworn P, Manoshi S. A random study of Asian male androgenetic alopecia in Bangkok, Thailand. Dermatol Surg. 2002;28:804-807.

2. Hoffman R, Happle R. Current understanding of androgenetic alopecia. Part II: clinical aspects and treatment. Eur J Dermatol. 2000;10:410-417.

3. Millar SE. Molecular mechanisms regulating hair follicle development. J Invest Dermatol. 2002;118:216-225.

4. Meidan VM, Touitou E. Treatments for androgenetic alopecia and alopecia areata: current options and future prospects.Drugs. 2001;61:53-69.

5. Penzel FI. Trichotillomania: recognition and treatment. Medscape General Medicine. 2000:2. Posted March 22, 2002. Available from: www.medscape.com/viewarticle/430540_print.

6. Mulinari-Brenner F, Bergfeld WF. Hair loss: an overview. Dermatol Nurs. 2001;13:269-272, 277-278.

7. Trüeb RM. Molecular mechanisms of androgenetic alopecia. Exp Gerontol. 2002;37:981-990.

8. Birch MP, Lalla SC, Messenger AG. Female pattern hair loss. Clin Exp Dermatol. 2002;27:383-388.

9. Hoffmann R. Male androgenetic alopecia. Clin Exp Dermatol. 2002;27:373-382.

10. Trade Package: Rogaine for Men, 2002.

11. Trade Package: Rogaine for Women, 2002.

12. Olsen EA, Dunlap FE, Funicella T, et al. A randomized clinical trial of 5% topical minoxidil versus 2% topical minoxidil and placebo in the treatment of androgenetic alopecia in men. J Am Acad Dermatol. 2002;47:377-385.

13. Friedman ES, Friedman PM, Cohen DE, Washenik K. Allergic contact dermatitis to topical minoxidil solution: etiology and treatment. J Am Acad Dermatol. 2002;46:309-312.

14. Trade Package: Rogaine Extra Strength for Men, 2002.

15. Shum KW, Cullen DR, Messenger AG. Hair loss in women with hyperandrogenism: four cases responding to finasteride. J Am Acad Dermatol. 2002;47:733-739.

16. Price VH, Menefee E, Sanchez M, et al. Changes in hair weight and hair count in men with androgenetic alopecia after treatment with finasteride, 1 mg, daily. J Am Acad Dermatol. 2002;46:517-523.