An Old Drug Grows New Hair For Pennies A Day Doctors Say

The ads are everywhere — and so are the inflated claims: Special shampoos and treatments, sometimes costing thousands of dollars, will make hair grow. But many dermatologists who specialize in hair loss say most of these products don’t work. “There is an endless array of useless hair growth drugs,” often at “significant cost,” said Dr. Brett King, a dermatologist at Yale School of Medicine. However, he added, “because people are desperate, such hair growth treatments continue to abound.” But there is an inexpensive treatment, he and other dermatologists say, costing pennies a day, that restores hair in many patients. It is minoxidil, an old and well-known drug for the treatment of hair loss that is used in a very different way. Instead of being applied directly to the scalp, it is prescribed in very low-dose pills. Subscribe to The Morning newsletter from The New York Times Although a growing group of dermatologists offer low-dose minoxidil pills, the treatment remains relatively unknown to most patients and many doctors. It has not been approved by the Food and Drug Administration for this purpose and is therefore prescribed off-label—a common practice in dermatology. “I call us off-label bandits — a title I’m proud to carry,” said Dr. Adam Friedman, professor and chair of dermatology at George Washington University. He explained that dermatologists are trained to understand how drugs work, which allows them to try drugs off-label. In dermatology, it is often clear whether a treatment is helping. Does a rash fade or not? Dr. Robert Swerlick, professor and chairman of the department of dermatology at Emory University School of Medicine, agreed. “I tell people that most of the stuff we do is off-label because there’s nothing on-label,” he said. He provided a long list of conditions, including skin pigment disorders, skin inflammatory disorders and relentless pruritus, for which standard treatments are off-label. Minoxidil, the active ingredient in Rogaine, a lotion or foam rubbed into the scalp, was first approved for men in 1988, then for women in 1992, and is now generic. The use of the drug as a hair growth treatment was discovered by accident decades ago. High-dose minoxidil pills were used to treat high blood pressure, but patients often noticed that the pills encouraged hair growth all over their bodies. So its manufacturer developed a minoxidil lotion—eventually named Rogaine—and received approval to grow hair on bald heads. The story continues But dermatologists say the lotion or foam isn’t particularly effective for some patients, perhaps because they stop taking it. It has to get into the scalp itself – and the hair gets in the way. Many, especially women, stop using it because they don’t like leaving the sticky substance in their hair. Johnson and Johnson, Rogaine’s current owner, did not respond to requests for comment. Others find it just doesn’t work for them. Minoxidil must be converted to its active form by sulfotransferase enzymes that may or may not be present in sufficient amounts in the hair roots. When the drug is taken orally, it is automatically converted into an active form. But that’s not why low-dose pills were invented. Instead, the discovery was also made by accident 20 years ago. Dr. Rodney Sinclair, professor of dermatology at the University of Melbourne in Australia, had a patient with female pattern baldness. The hair on the top of her head was thinning and she hated the way it looked. Unlike what happened with most of his patients, Rogaine worked for her, but she developed an allergic rash on her scalp from the drug. However, if she stopped taking it, her hair would thin out again. “So I was hooked,” Sinclair said. “The patient was very motivated, and the only thing we knew was that if a patient is allergic to a topical drug, one way to desensitization is to give very low doses orally.” To do this, Sinclair tried cutting minoxidil pills into quarters. To his surprise, the low dose made her hair grow but did not affect her blood pressure, the original purpose of the higher dose drug. He then reduced the dose more and more until he reached effective doses of one fortieth of a pill and began to prescribe the drug regularly. This first patient is still taking it. At a meeting in Miami in 2015, Sinclair reported that low doses of minoxidil caused hair growth in 100 consecutive women. He published these results in 2017, noting that rigorous studies were needed, in which some patients would be randomly assigned to receive minoxidil and others a sugar pill. But this has not happened. He said he has now treated more than 10,000 patients. Recently, a growing number of hair loss dermatologists are prescribing low-dose pills to patients with male and female pattern hair loss, a normal phenomenon with age. “We are just starting to see an increase in popularity,” said Dr. Crystal Aku, a dermatologist at the Johns Hopkins School of Medicine. “Increasingly at conferences, we share our success stories.” Doctors who don’t specialize in hair loss, he added, “wouldn’t be familiar with oral minoxidil,” except as a rarely used treatment for high blood pressure that comes with a black box warning that it can cause heart problems. But, she and others say, the caveat is for much higher doses. If the hair loss is very severe, minoxidil won’t help, Aguh said. “It won’t work, for example, if a man is mostly bald, with a shiny scalp. There is nothing to restore.” He added that the ideal patient is not completely bald, but has lost enough hair that even a casual observer would notice. Without a rigorous trial leading to FDA approval, however, the use of minoxidil pills for hair loss remains off-label. And, dermatologists say, it’s likely to stay that way. “Oral minoxidil costs pennies a day,” King said. “There is no incentive to spend tens of millions of dollars to test it in a clinical trial. This study is really never, ever going to happen.” Some patients taking low-dose minoxidil, however, notice that stray hairs grow on their face and chin. So some dermatologists, including Sinclair, added another drug — very low doses of spironolactone, a blood pressure drug that also blocks certain sex hormones called androgens — to try to prevent unwanted hair growth. Patients who don’t want to go the off-label route are left with what some dermatologists say are useless over-the-counter treatments or one of two FDA-approved hair growth products. They include Rogaine and finasteride, a generic drug used in higher doses in men to treat a benign enlarged prostate. As an anti-hair loss drug, it is only approved for men. It has also been linked to sexual dysfunction. Then there is word of mouth about minoxidil in pill form. “I have seen miracles happen,” Aguh said. One involved Brandy Gray, 44, who lives in Monkton, Maryland. “Over time I was losing my hair,” she said. “Then I started getting circular patches” without hair. “They just got worse and worse.” She had seen another dermatologist who gave her shampoo and supplements, to no avail. Finally, she said her dermatologist told her, “There’s nothing else I can try for you, nothing more I can do.” She went to Aguh, who gave her a low dose of minoxidil. Ten months later, her hair was thick and abundant. “I can part my hair in different ways,” she said. “I don’t wear wigs anymore.” It’s like this hair loss never happened. © 2022 The New York Times Company

An Old Drug Grows New Hair For Pennies A Day Doctors Say

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