I think that topical minoxidil is not working

/by William Rassman, M.D./0 /

I’ve been using topical minoxidil and oral finasteride for around 6 months. My loss has pretty much stabilized but no regrowth so far. I’m thinking about switching to oral minoxidil. Is this a good idea after 6 months or should I wait longer like with finasteride? Also, I have a lot of body hair, basically all over (shoulders, back, chest, stomach, you name it). I guess this can’t even get much worse with oral minoxidil, just wondering if anyone else who already had a lot of body hair here started using oral minoxidil and what their experience was.

What do you think? Switch now or wait longer?

if you feel that minoxidil is not working, then you probably do not have Sulfotransferases, an enzyme that enhances the conversion of Minoxidil to Minoxidil Sulfate, the active form of minoxidil for hair growth.  Sulfotransferases are found both in the liver and in the ‘outer root hair sheath’ of the hair follicle. When present in the hair follicle, the person will respond well to minoxidil.  Only about 40% of people are responders to minoxidil in the scalp. Because it is also present in the liver, the conversion of oral minoxidil to minoxidil sulfate in the liver with the oral minoxidil may help people who do not have this enzyme in the scalp hair follicles, making them more responsive to oral minoxidil than to topical minoxidil. That becomes a decision that only you know if the topical minoxidil is working, if not, then the switch may be a reasonable decision.

Rare case of heart complication from taking low dose oral minoxidil

/by William Rassman, M.D./0 /

The following is the introduction of the article titled: Pericardial, pleural effusion and anasarca: A rare complication of low-dose oral minoxidil for hair loss

Authors: Ncoza C. Dlova, MBChB, PhD, Tarryn Jacobs, MBChB, and Satish Singh, MBChB

“INTRODUCTION
Topical minoxidil has been used for many years in the treatment of androgenic alopecia and other hair disorders. Although the mechanism of action of topical minoxidil is poorly understood, animal studies have shown that it affects the hair growth cycle by shortening the telogen phase and prolonging the anagen phase.1,2 Lately, there has been growing evidence to support successful use of low-dose oral minoxidil (LDOM) in the treatment of various types of alopecia. The dosing regimens range from 0.25 to 5 mg daily to twice daily, with side effects reported to be dose dependent.”

The presented Pericardial Effusion occurred 3 weeks after starting the low-dose oral minoxidil.  The woman presented with significant swelling in her feet and eventually elsewhere. A Pericardial Effusion is a condition where fluid accumulates around the heart, inside the sac (pericardium) that surrounds the heart. Fluid in this space will restrict blood flow to the heart and fluid back up in the body. Significant swelling of the feet and anasarca (a generalized swelling of many body parts) was clearly a warning that brought this woman to a doctor. She was admitted to the hospital, treated with diuretics, and stopped the oral minoxidil, all of which normalized her state of health, so she was discharged from the hospital on the 5th day. 

WARNING: People taking oral minoxidil or even high-dose topical minoxidil might develop the symptoms described above.  Always seek medical attention when a change in your health to this magnitude appears, especially if you are taking oral minoxidil. 

Ref: JAAD Case Reports 2022;28:94-6., 2352-5126, 2022 by the American Academy of Dermatology, Inc. Published, by Elsevier, Inc. This is an open-access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). https://doi.org/10.1016/j.jdcr.2022.07.044

Exosomes

/by William Rassman, M.D./0 /

Hello dr. Rassman, I was wondering if its a good idea to treat thinning crown hair with exosomes and 1mg fin ED? I have no hairloss anywhere else and the crown thinning started like 1 year ago.

The problem with exosomes is that there needs to be clinical scientific evidence that expsomes work in treating hair loss. Currently, there is none. You end up paying a lot of money for it. Indeed, the doctor makes money, but you may get nothing from the treatment.  Recognize that it may not work. 

What are exosomes: Google defines it as: “extracellular vesicles generated by all cells and they carry nucleic acids, proteins, lipids, and metabolites. They are mediators of near and long-distance intercellular communication in health and disease and affect various aspects of cell biology.”  Every cell in the human body secretes about 20,000 exosomes each day. These exosomes ‘chemically’ communicate information from one area of the body to another. Even cancer cells secrete exosomes and, as such, contain the genetic codes for the cancers. 

Sweting after hair transplant, is it safe?

/by William Rassman, M.D./0 /

I’m 9 weeks into my hair transplant journey. Resumed going to the gym at the 8 week mark. I’ve noticed my donor area start to get itchy. I sweat profusely while working out. My heart rate during a HIIT session can also climb to ~200bpm. Should I be worried that this will negatively impact my hair transplant at this stage? Side-question: sometimes I don’t get the chance to wash my head after a workout until at least some hours later. Is that an issue? Is it possible that the itching on my donor area is completely unrelated to the exercise and has more to do with my minoxidil/finasteride use? I’ve only been on topical min- oral fin for 20-ish days so far.

Feeling really panicky and paranoid so any answers help!

9 weeks after a hair transplant means that you are now normal. Do whatever you did before the transplant. The transplant should be undetectable at this stage. Any medical health issues should bring you to see your primary doctor, not your hair transplant doctor. At this time (actually 3 weeks out), you can wash your hair normally and sweat all you want without worrying about the hair transplant.

Does Finasteride impact a man’s semen

/by William Rassman, M.D./0 /

What has been reported to me in addition to what I read are the following impacts on men’s semen: 1- change in consistency, 2- decreased volume, and 3- reduced sperm count.

Men wishing to have a baby should check their sperm count. If they find that they have a problem impregnating their partner they may consider stopping the drug with a risk of losing the hair you gained from it. I have seen some scattered reports that some men have seen such a radical reduction in sperm count that they would be considered sterile; however, stopping the drug supposedly increases the sperm count over time. 

Does it matter at what age you start losing hair?

/by William Rassman, M.D./0 /

I started noticing diffuse thinning when I was around 14 and four years later it has gotten more noticeable. I have been taking finasteride and minoxidil for 3 months and still waiting for progress. As I started thinning very early on, I’m curious to know if that affects my potential to see growth or my chances of responding. Anyone else have a similar case?

It is rare for significant balding in the form of recession and the development of a Norwood Class 3 pattern of balding or greater to be seen in a man under 18. Then, if you are on-top of it, you have a good chance at stopping the balding in its tracks.

Dutasteride and length of side effects

/by William Rassman, M.D./0 /

I recently discovered that Dutasteride has a half life of 4-5 weeks. I am considering getting off of Dutasteride (daily usage for about 3 years) completely because I feel like it is heavily contributing to my anxiety (timing is very similar). I am on no other hair loss remedies currently but have had one temporal area hair transplant. If I discontinue Dutasteride or take it less frequently, what therapies seem to be working for people nowadays? With such a long half-life, couldn’t Dutasteride hypothetically be taken once a week or potentially less and maybe still have similar results?

In theory, you are correct; with a long half-life, one would expect that a once-a-week dosing might be enough, but for reasons I personally don’t understand, dosage recommendations have been more frequent.  As the FDA has not cleared dutasteride for hair loss use, this is a real problem for doctors, i.e. to find the correct approved dose.  The blood levels may have a half-life of 4-5 weeks, but the tissues in which the dutasteride is embedded have a much longer presence in your body that could go up to a 1/2 year or more. That means if you get side effects, it may be a long time to get rid of them because dutasteride is in your tissues 6 or more months. 

I take finasteride 1mg every other day

/by William Rassman, M.D./0 /

I take finasteride 1mg every other day for a year and just recently noticed that the hairline is thining.  What you would think it the best thing I can do now?

I would increase your dose to daily rather than every other day.  See if that makes a difference with the finasteride. You could add microneedling weekly.   

Complications of minoxidil

/by William Rassman, M.D./0 /

Dr. Rassman in your practice have you ever had a patient with an adverse reaction to oral min? Thanks so much!

Yes, some people can’t tolerate this medication for one of many reasons, and the blood pressure effects can be disabling for a few people, with lightheaded and rapid heart beat. Here is a list of some of the side effects of minoxidil.  Some of these side effects only relate to the topical application of minoxidil.  

  • Fluid retention
  • Facial hair growth
  • Fast heartbeat
  • Hair shedding
  • Irritation
  • Nausea
  • Acne
  • Burning of scalp
  • Chest pain
  • Fainting
  • Headaches
  • Application site redness
  • Difficulty breathing
  • Hypertrichosis
  • Redness
  • Swelling of face
  • Breast tenderness
  • Burning
  • Low blood pressureReddened skin
  • Weight gain
  • Hair texture changes
  • Heart palpitations
  • Cardiac Tamponade (very rare with a lot of early signs of it but potentially deadly)

Finasteride tissue levels

/by William Rassman, M.D./0 /

So if tissue levels remain for 6 days, would topical application every 4/5 days be theoretically still somewhat effective?

Some amount of finasteride stays in the tissues for more than two weeks after stopping the pill. Daily dosing is the ideal way to build appropriate tissue levels.

I had 5500 grafts in two sessions total?

/by William Rassman, M.D./0 /

My hair is medium-coarse. I had two sessions totaling 5500 grafts.  Do you think that it too many grafts from my donor area? 

The men who most tolerate 5500 grafts excised from the back of the head are men with a coarser hair. That puts you in this category, so I would worry less, assuming that the FUE was done correctly with good spacing and no donor area shock loss.