The Pros and Cons of Minoxidil

Can the Topical Treatment Minoxidil Solve Your Hair Loss?

Minoxidil works as a hair loss treatment, but not as easily as people think it does.

The smart brand marketing of Rogaine (minoxidil) when it was approved for over-the-counter sales led millions to expect to regain hair with ease. But 14 years later, have real experiences with the product lived up to hype?

Not for everyone. It works for only about 50 percent of patients who try it. Generally speaking, they are under the age of 40 and in an early phase of hair loss (i.e., thinning began less than five years ago). In other words, start using it as soon as you begin to notice a bald spot.

Note: the second pharmaceutical product available for hair loss treatment, Propecia (finasteride), is reviewed in separate articles on HairLoss.com.

Minoxidil works, but only to a certain extent

Minoxidil (brand names include Rogaine, Women's Rogaine, Rogaine for Men Extra Strength, Regaine, Apo-Gain, Gen-Minoxidol, Hairgro, Minox, Med Minoxidil, Hair Regrowth Treatment) works only on individuals, male and female, with androgenic alopecia (also known as male pattern baldness). For reasons unknown, minoxidil is slightly more effective for women than for men.

The location of where you are losing your hair seems to matter a lot as well. The crown of the head, the vertex, is much more responsive to minoxidil than is frontal or hairline loss. One study (D. S. Walsh, C. L. Dunn and W. D. James, "Improvement in Androgenetic Alopecia (Stage V) Using Topical Minoxidil in a Retinoid Vehicle and Oral Finasteride" [Arch Dermatol, 1995]) found that 36 percent of users experienced sufficient results over 30 months of use such that they felt compelled to spend time and money on the product. Of study participants, 32 percent said new hair growth was long enough that it had to be cut (often the regrowth is more of a peach fuzz than strands of hair).

Not so surprisingly, formula strength matters -- it's a situation where more is more. Regular Rogaine, a 2 percent concentration formula, and Rogaine for Men Extra Strength, a 5 percent solution, have been compared side by side in a couple of studies. One (V. H. Price and E. Menefee, "Quantitative Estimation of Hair Growth: Comparative Changes in Weight and Hair Count with 5 percent and 2 percent Minoxidil, Placebo, and No Treatment" [Elsevier, 1996]) compared hair mass, which is the weight of hair in a defined area of the scalp, in both products to find that the extra-strength formula indeed produced a 55 percent increase, compared with a 25 percent increase in the lower-concentration formula, after five months of use. Importantly, that mass-effect declined with both products after five years' use, to 25 percent and 15 percent increases, respectively.

The second study looked at actual hair counts, finding that the higher-strength formula does result in more hair shafts per square centimeter: 25 additional hair follicles per square centimeter from the 5 percent solution, versus 21 follicles in the 2 percent solution and 9 follicles in a placebo group, after a 48-week period (R. J. Trancik, "Update on Topical Minoxidil in Hair Loss" [Proceeding of the annual meeting of the American Academy of Dermatology, 1998]).

One effective application is for hair loss due to chemotherapy. Research sponsored by Rogaine's manufacturer, the Upjohn Company (now Pharmacia), on 22 women undergoing treatment for breast cancer found that the 2 percent topical solution decreased the duration of alopecia caused by chemotherapy, with no significant side effects (Duvic, Lemak et al., Division of Medicine, University of Texas, M.D. Anderson Cancer Center, 1996).

How does minoxidil work?

How minoxidil reduces hair loss is actually a mystery, since it was discovered by accident when use of the anti-hypertension drug Loniten was found to increase and darken fine body hairs. One imagines the scientists working on this had their eureka moment within one or two nanoseconds of coming upon this fact.

But two decades later, no one knows for sure how it works. It may be due to the way the medication dilates blood vessels, which on the scalp might stimulate hair growth. Minoxidil is a potassium channel opener, which causes hyperpolarization of cell membranes, possibly another reason it works.

To stem hair loss, minoxidil is applied topically (as a cream or foam). In pill form the medication is in a higher concentration and only approved for treating hypertension.

There are side effects to minoxidil

For the person first using minoxidil, there is often an initial period of paradoxical increased hair loss. Disturbing as that may be, this seems to be the scalp's way of ridding itself of weaker hair follicles to make way for stronger shafts. Other known side effects and issues are:

• Scalp irritation, likely because of the product's alcohol content
• Itchy scalp and dandruff
• Dizziness or rapid heartbeat (rare)
• Not recommended when the scalp is already irritated, injured or sunburned, which would allow the medication to be absorbed by the body at a higher and potentially dangerous level
• Formulated for scalp application and not recommended for use elsewhere on the body
• Effects on a fetus in women who are pregnant are unknown; however, women who are nursing are warned to not use it
• Rogaine users with severe, refractory high blood pressure might experience hypertrichosis, which is hair growth on the face or other bodily areas. The incidence of this occurs in about 3-5 percent of women who use the 2 percent solution and higher among women using the 5 percent solution.

Note that no animal or human studies indicate cause for concern regarding cancer and minoxidil.

Costs of minoxidil (and beware the snake oil salespeople)

According to online stores selling Rogaine, a three-month supply of the foam product is about $50, which is much lower than when the medication was first released (and protected by its original manufacturer by its patent, which expired in 1996).

But at least one company that operated clinics and treatment centers for hair loss, Avacor (Global Vision Product, Inc.), falsely claimed superior treatments that amounted to nothing more than a minoxidil solution repackaged as a shampoo (sold alongside herbal supplements that lacked clinical studies to support claims of efficacy). A class action lawsuit was successful in driving the clinics out of business. This case serves as a reminder that any medical solutions should be investigated closely for legitimacy -- and how hair regrowth charlatans are always looking to make money from people who are experiencing hair loss.

Minoxidil: The bottom line

To summarize, minoxidil will be most effective if you

• Use it as soon as you start to notice a thinning
• Are under age 40
• Are a woman; women get better results than men
• Use the stronger solution, as it will yield more results
• Are attentive to potential side effects, particularly if your scalp is irritated by sun or the medication itself
• Stay out of the sun or always wear a hat when outdoors
• Accept the fact the results in five years won't be as good as in one year
• Plan to continue using it to realize any beneficial effect