SF Derm Society Annual Meeting Pearls

Hair Me Out—A Synopsis of Dr. Paradi Mirmirani’s ‘Hair Loss Updates’

Part II: Low Dose Oral Minoxidil

Authors: Chandler Johnson, Paradi Mirmirani, MD

At the San Francisco Dermatological Society Annual Conference hosted in Half-Moon Bay, California on July 27, 2024, Dr. Paradi Mirmirani, MD led an informative lecture titled “Hair Loss Updates.” Dr. Mirmirani is a dermatologist and world renowned hair loss expert, serving as a scientific advisor for the Cicatricial Alopecia Research Foundation as well as an active member of the North American Hair Research Society and National Alopecia Areata Foundation. In Dr. Mirmirani’s lecture, she discussed three main topics of interest:

  • Alopecia Areata and JAK-inhibitors
  • Hair Loss and Low-Dose Oral Minoxidil
  • Scarring Alopecia and Environmental Triggers

The following writing outlines clinical pearls as well as updates to topics related to hair loss—relevant to dermatologists, patients, and their advocates.

Hair Loss and Low-Dose Oral Minoxidil

Hair miniaturization, is always thought of as hallmark of androgenetic alopecia. However, hair miniaturization can also be seen with alopecia areata, traction alopecia, and sometimes with scarring alopecia, and telogen effluvium. For individuals living with any of these beforementioned conditions, the use of low dose oral minoxidil makes for an effective treatment. Dr. Mirmirani is a believer in a “triad of treatment” for hair loss—no matter what a patient may have:

  1. Treat the inflammation
  2. Address hair miniaturization
  3. Remove any triggers

As Dr. Mirmirani did for the before-mentioned topic of JAK-inhibitors, she again compiled a list of top questions from colleagues she has received on the topic:

  1. What age group can you use low dose oral minoxidil in?

Anyone who is 12 years and above is eligible to use low dose oral minoxidil if its use is indicated clinically.

2. What can you use low dose oral minoxidil for?

Dr. Mirmirani notes that you may use low dose oral minoxidil for a wide variety of conditions: androgenetic alopecia, age-related hair thinning, or alopecia areata, traction alopecia, scarring alopecia, telogen effluvium.

3. What are the typical starting doses of low dose oral minoxidil?

Choice of dose will vary based on both age and sex, but generally, doses are:

  • Women: 1.25mg (1/2 of a pill) and then going up to 5mg
  • Men: 2.5mg (full pill) and then going up to 5mg

4. Are there any instances when you would NOT want to start low dose oral minoxidil?

The are a handful of absolute contraindications for the use of low dose oral minoxidil including having either a past or current history of the following: pericarditis, congestive heart failure (CHF), pheochromocytoma, or a current, or planned pregnancy. Though not an absolute contraindication, caution should be used in patients with comorbid renal impairment or cardiac disease.

5. Do you need to monitor a patient’s blood pressure during treatment?

No routine blood pressure testing is needed, unless there has been a specific precaution identified. Of course, minoxidil is an antihypertensive, a patient may exhibit a vasodilatory or even fluid retention effect. Best practice would be to instruct a patient to monitor for light headedness or fast heartbeat or leg swelling, and discontinue the medication and reach out if they experienced either.

6. How do you deal with hirsutism that may occur during treatment?

Hirsutism may be a cause of concern w taking low dose oral minoxidil. In these case, Dr. Mirmirani oftentimes instructs patients to decrease their current dose to 0/625mg (¼ of a pill), and potentially:

  • Recommend a depilatory
  • Recommend laser treatment
  • Add spironolactone
  • Add finasteride (preferred for Dr. Mirmirani over spironolactone, because it is better for hair growth)
  • For the above two combination treatment options, the choice may be guided by a patient’s future plans for pregnancy:
  • minoxidil + spironolactone (if desirous of pregnancy)
  • minoxidil + finasteride (if not desirous of pregnancy)

"Hair miniaturization, is always thought of as hallmark of androgenetic alopecia. However, hair miniaturization can also be seen with alopecia areata, traction alopecia, and sometimes with scarring alopecia, and telogen effluvium. For individuals living with any of these before mentioned conditions, the use of low dose oral minoxidil makes for an effective treatment."

A Reference of Organizations:

  • National Alopecia Areata Foundation: https://www.naaf.org/
  • Scarring Alopecia Foundation (SAF): https://scarringalopecia.org/
  • American Hair Research Society: https://americanhairresearchsociety.org/

ORCiDs

CEJ, https://orcid.org/0009-0000-5818-8710

PM, https://orcid.org/0000-0001-8627-2995