Last month, the New York Times published an article that painted small oral doses of minoxidil — an old cheap medication better known as Rogaine — as an antidote to medium-grade hair loss. It was a piece that seemed destined to be among the most-read of 2022 — and to inspire many a trip to the doctor’s office among the middle-aged. But is minoxidil all it’s cracked up to be? And how could a drug that might solve one of the world’s most vexing medical conditions have been so under-the-radar for so long? I spoke with Dr. Arash Mostaghimi, an assistant professor of dermatology and director of the dermatology inpatient service at Brigham and Women’s Hospital in Boston, about the drug’s level of effectiveness and why solving hair loss is such a guessing game.
First of all, I’m wondering what the reaction to the Times piece has been in your experience as a dermatologist. I was imagining a stampede of guys in their 30s and 40s booking appointments after reading it and demanding they get on minoxidil immediately. Has that happened?
You’re not the first person I’ve talked to about it over the last couple weeks, let’s put it that way. The tone of the article was interesting in that it presented minoxidil as a hidden secret, which maybe it is among some circles. But among those of us who take care of patients with hair loss, it’s a common drug we’ve been using for years and years. The one thing about minoxidil is — and this was clear from the article — is that because it lacks drug-industry backing, you don’t have commercials on TV, you don’t have that direct-to-consumer advertising. So I think the recognition of it, and how much people know about it in the general community, is certainly lower than perhaps it should be. But it’s definitely something that is well-known in the dermatology community.
Topical minoxidil has been available since the late 1980s. The origin story is that it grew hair on people who took the oral form in high doses for cardiac conditions, and it grew hair everywhere if given in high enough doses. What has come more into play over the last maybe 15 years is that physicians are recognizing the risk versus benefit — the risk being the adverse cardiovascular and other potential impacts of minoxidil orally, versus the benefit, which is the hair regrowth. If you give lower doses — 2.5 to five milligrams for males, or around that range, but usually slightly lower for women — you can get a lot of the hair regrowth, but the safety is in a good place as well with those doses. I think, as such, we’ve gotten more comfortable with it and are using it more frequently. If there’s been any revelation, it hasn’t been that this grows hair, but that it’s a safe thing to use.
The article really made it seem like a wonder cure. Does this thing actually live up to the hype?
It is highly efficacious, and the more you take of the medication, the better it works. The funny thing about minoxidil is that, although it grows hair, we don’t quite understand why it does. Other drugs that we have for hair regrowth have a specific mechanism of action that we can point to. With this one, there’s some thinking that it may work directly on the cell cycle of hair, there’s some thinking that it may have a vascular impact on hair. There’s a lot of other theories, but it hasn’t quite been worked out the way some of the other medications have been worked out.
And it works across many different types of hair loss. If I use finasteride, which has the brand name Propecia, that drug blocks conversion of testosterone to a high-potency form of testosterone, which is specifically designed for people with hormonal hair loss. So that’s for men with male-pattern baldness, and then there’s some off-label use for women with female-pattern baldness. In contrast, minoxidil will not only work for those patients, but will work for patients with other types of hair loss as well. The best data we have shows that head to head, minoxidil works equally well if not better than a lot of the other therapeutics that we have, and that the oral form works better than the topical form. So the claims made with regards to efficacy are supported by both my clinical practice and the published evidence.
I really thought you were going to say the Times oversold it …
Does it work uniformly for everybody? No. Is it a cure for everybody? No. There are some patients who can’t tolerate the medication. Some people get swelling of their lower extremities or they may get lightheaded on the medication. Other patients, particularly women, may suffer from hair growth that is exaggerated in places they don’t want and is not as good in the places they do want. So if you’re a woman taking this medication and all of a sudden you find you’re growing hairs on your chin, the impact that it has on your scalp may or may not be worth it.
There haven’t been any randomized controlled trials for this drug. Does it matter that the data is preliminary or incomplete?
As physicians and particularly as dermatologists, we use many, many drugs off label and the medications that we most commonly use off labels are older medications like minoxidil. These are medications that have been around a long time. They’re off patent, they’re usually very cheap, but there’s no desire by pharmaceutical companies to do randomized controlled trials, which is a typical way we get them in the United States for medications like this. It would be wonderful if NIH or a similar organization would fund a non-industry funded clinical trial that could give specific data and information for patients trying to make decisions about this.
But the absence of the data doesn’t necessarily mean that the drug doesn’t work. As I said, we have a lot of observational data. Certainly those of us that take care of patients with these conditions have seen a lot of success stories. Where we’re limited, though, is we can’t give you exact statistics or exact risk-benefit ratios or things along those lines. So in thinking about the article like the one in the Times — its tone and the wonder-drug aspect could have been toned down a little bit. But it’s nice that patients who may have not known that this was an option have learned about it, and are encouraged to engage in a conversation with a physician about — “Does this drug make sense for me? What could I expect from it? And is it safe for me to take?”
We’ve all learned the hard way recently, with COVID and then monkeypox, that our public-health infrastructure can be dangerously sluggish. What does it say about those agencies that everyone’s using this thing and they seem to be MIA on this?
Dermatology has two ends to it. One is we have the newest and most fancy and cutting-edge biologic therapies, which are highly understood and studied and regulated. And then on the other end, we have these old medications, which are often repurposed. From a public-health standpoint, I think there’s a lack of acknowledgement of diseases like hair loss. Recently, at least we’ve had the approval of a new drug, Oluminant, for alopecia areata. But until then there had been a dismissal of hair loss as largely cosmetic. Whereas in real life, both from any of us who have lost hair or know people who have — it has a profound impact on your psychosocial health and your ability to choose how you reflect yourself to others in this world. Things don’t necessarily have to be life or death for them to have value.
Ultimately, I think the hard problem that we have with minoxidil and with these other off-label indications in dermatology is the American reliance on industry to fund clinical trials. If we had a mechanism in general where trials weren’t funded by industry, you could not only design clinical trials differently to make sure they got the information the FDA needed, instead of an industry funding a trial and then taking it to the FDA for approval, but you could also do things like compare new drugs against old medications. If there’s a new medication for male pattern hair loss, why not compare it to minoxidil in a randomized clinical trial? So you can say, what’s the benefit of a potentially expensive new medication that’s coming out, compared to something that is known and we’ve used and has been around for a while?. When we leave that to industry, they’re never enticed to do it because we don’t require it for approval in the United States. But if we had a different mechanism, we could ask questions that are a little bit more clinically applicable to physicians of all types.
When should people start taking this? Should you get going on this when you notice any hair loss?
In general, there’s two things to think about when you’re starting minoxidil or any other systemic agent for hair loss. First is that the earlier you start, the better it is. That’s actually more important for the finasteride and the other drugs that work on the hormonal access, because a lot of those drugs are a little bit better at maintaining the hair you have than growing new hair. Minoxidil is different in that it actually helps you grow new hair and improves the quality of the hair you have, so you have a little bit more of a grace period when you start it. So if you’re concerned about hair loss, earlier is better, but it’s never too late to have that conversation.
The trade you’re making, however, is that these are not medications you take for two weeks, like antibiotics. They only work while you take them. So they’ll grow new hair or they’ll keep the hair that you have. If you stop the medications, the new hair that you grew will fall out. You don’t become worse — It doesn’t potentiate additional hair loss. But you can’t be lackadaisical. You have to have a strong sense of commitment. Also, it takes about six to nine months before you can really see a difference. These are slow-moving drugs. If you’re willing to make that commitment, earlier is better, but even if it takes a while to get there, even if you’re a bit delayed in showing up to the doctor, you may still benefit.
Why has hair loss been such a difficult problem to solve?
It comes down to the science of it. There’s been a lot of research into the molecular mechanisms, the inflammatory mechanisms, the hormonal impact, the stem cells involved in follicular biology. We have thousands of these hairs on our body and we take them for granted. But each one is its own organ system, with its own stem cell and its own immune protection and its own cholesterol coating, and all these types of things that make your hair know when to start growing, and determine what color it’s going to be.
When we shave our faces every day or cut our hair every month, we don’t even think about it because it’s just a part of our lives. But in fact, hair is an incredibly complex organ that has its own rules and mechanisms of action. People have been working at this and making progress, and they understand the basic biology. But it’s not as simple as one key thing that you can block or one simple thing that you can do to fix it. My feeling is that a lot of these problems seem intractable, but someday we will have a very effective, successful, broad based treatment, even more than minoxidil, and it’ll feel like an overnight success but will have been 40 years in the making.
This interview has been edited for length and clarity.
