Very-low-dose oral minoxidil in reported positive outcomes with a much lower dose

male androgenetic alopecia: A of OM in women (OM 0.25 mg combined with

study with quantitative
trichoscopic documentation
To the Editor: Androgenetic alopecia (AGA) is the
most common type of alopecia in men and may have
a negative effect on quality of life.1,2 Currently, oral
finasteride and topical minoxidil are the only drugs
approved for treatment of male AGA. Therefore, we
read with great interest the publication by Jimenez-
Cauhe et al3 reporting successful use of low-dose
oral minoxidil (OM) (2.5-5 mg/d) in men with AGA.
As stated by the authors, the optimum dose of
OM still needs to be delineated. Recently, Sinclair4
spironolactone 25 mg). In this letter, we would like
to share our results using this very low dose of OM
(0.25 mg/d) as monotherapy in the treatment of 25
male patients with AGA.
We performed a retrospective review (2017-
2018) of medical records from patients with male
AGA using formulated capsules of OM (0.25 mg/d).
Patients included had at least 24 weeks of follow-up
and records of clinical and trichoscopic images.
Patients with recent (\6 months) or concomitant
use of other therapies for AGA were not included.
For evaluation of treatment response, analysis of
pretreatment and posttreatment (24 weeks)

Fig 1. Pretreatment and posttreatment (A) clinical and (B) trichoscopic pictures ( frontal region
of the scalp) of a 32-year-old man. B, Red indicates hairs present at baseline but lost at 24
weeks. Green indicates new hairs detected at 24 weeks of treatment.

J AM ACAD DERMATOL JANUARY 2020 e21

e22 Notes & Comments J AM ACAD DERMATOL
JANUARY 2020

Table I. Parameters studied before and after 24 weeks of treatment

Before 24 Weeks After 24 weeks
Parameters N Median IQR Min Max N Median IQR Min Max P value
Vertex
Total hair density/cm2 25 184 130 to 223 52 259 25 176 141 to 213 53 252 .26
Density of terminal hair/cm2 25 114 74 to 173 34 209 25 100 68 to 151 23 213 .088
New hairs/cm2 25 4.1 18.9 to 6.3 36.8 46.3
New terminal hairs/cm2 25 3.1 8.9 to 3.1 34.0 24.2
Frontal
Total hair density/cm2 25 200 143 to 221 93 255 25 194 155 to 225 109 267 .19
Density of terminal hair/cm2 25 130 104 to 167 57 216 25 115 96 to 165 55 212 .24
New hairs/cm2 25 4.1 9.0 to 13.5 22.7 24.7
New terminal hairs/cm2 25 1.020 3.281 to 5.725 11.3 14.1

IQR, Interquartile range (quartile 1-quartile 3); Max, maximum; Min, minimum.

trichoscopic images from the frontal scalp (midline)
and vertex was carried out by using FotoFinder
TrichoLAB Snap software (TrichoLAB, Bad
Birnbach, Germany) with Hair-to-Hair Matching
technology. Parameters examined were total hair
density (THD)/cm2, density of terminal hair (DTH)/
cm2, new hairs/cm2 (NH/cm2), and new terminal
hairs/cm2 (NTH/cm2) (Fig 1).
The sample included 25 patients with a mean age
of 36.7 years (range, 23-53 years). Ten (40%) had
mild-moderate AGA (II-III vertex by the Hamilton-
Norwood scale) and 15 (60%) severe AGA (IV-VI).
Improvement or stabilization after 24 weeks was
observed in a percentage of individual patients for all
parameters analyzed ( frontal scalp: NTH, 48%; NH,
52%; DTH, 40%; THD, 60%; vertex: NTH, 44%; NH,
40%; DTH, 44%; THD, 40%). However, statistical
analysis did not show a significant variation in the
group as a whole (Table I). A statistical trend toward
better response was detected for patients with mild-
moderate AGA in DTH/cm2 (P ¼ .075). Adverse
effects reported were pedal edema in 1 (4%), hair
shedding in 4 (16%) and body hypertrichosis in 5
(20%) patients. Interestingly, 13 patients (52%)
reported perception of increased hair density in the
beard. There was no difference in mean arterial
pressure and no reports of fainting or dizziness. No
patient discontinued treatment.
The small sample size and high percentage of
patients with advanced AGA in our study are
possible explanations for the lack of statistical
significance; for those reasons, we cannot exclude
a type II error. As shown with topical administration,
OM might have lower efficacy in advanced AGA.5
Additionally, we speculate that higher doses of OM,
as used by Jimenez-Cauhe et al,3 might be necessary
to produce significant effects in men. Different
methods for assessing treatment response prevent
comparison with our results. Despite the higher
dosage, their profile of adverse effects was similar
to ours.
Rodrigo Pirmez, MD, and Corina-Isabel Salas-
Callo, MD
From the Department of Dermatology, Instituto de
Dermatologia Professor Rubem David Azulay,
Santa Casa da Misericordia do Rio de Janeiro,
RJ, Brazil.
Funding sources: None.
Conflicts of interest: None disclosed.
Reprints not available from the authors.
Correspondence to: Rodrigo Pirmez, MD, Rua
Visconde de Piraj
a 330, sala 712, Rio de Janeiro,
RJ, Brazil, 22410-000
E-mail: rodrigopirmez@gmail.com
REFERENCES
1. Kelly Y, Blanco A, Tosti A. Androgenetic alopecia: an update of
treatment options. Drugs. 2016;76(14):1349-1364.
2. Han SH, Byun JW, Lee WS, et al. Quality of life assessment in
male patients with androgenetic alopecia: result of a pro-
spective, multicenter study. Ann Dermatol. 2012;24(3):
311-318.
3. Jimenez-Cauhe J, Saceda-Corralo D, Rodrigues-Barata R, et al.
Effectiveness and safety of low-dose oral minoxidil in male
androgenetic alopecia. J Am Acad Dermatol. 2019;81(2):
648-649.
4. Sinclair RD. Female pattern hair loss: a pilot study investigating
combination therapy with low-dose oral minoxidil and spi-
ronolactone. Int J Dermatol. 2018;57(1):104-109.
5. De Villez RL. Topical minoxidil therapy in hereditary androge-
netic alopecia. Arch Dermatol. 1985;121(2):197-202.
https://doi.org/10.1016/j.jaad.2019.08.084