An old medicine makes new hair grow for pennies a day, according to doctors

In an undated photo by Crystal Aguh/Johns Hopkins, Dr. Crystal Aguh saw Brandy Gray, 44, before and after oral minoxidil treatment. (Crystal Aguh/Johns Hopkins via The New York Times)

Advertisements are everywhere, as are inflated claims: special shampoos and treatments, sometimes costing thousands of dollars, will make your hair grow. But many dermatologists who specialize in hair loss say that most of these products don’t work.

“There are countless useless remedies for hair growth,” often at “significant cost,” said Dr. Brett King, a dermatologist at the Yale School of Medicine. However, he added, “because people are desperate, these hair growth remedies continue to abound.”

But there is an inexpensive treatment, he and other dermatologists say, that costs pennies a day, that restores hair in many patients. It is minoxidil, an old and well-known drug for the treatment of hair loss used in a very different way. Instead of being applied directly to the scalp, it is prescribed in very low-dose pills.

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Although a growing group of dermatologists offer low-dose minoxidil tablets, 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 the off-label bandits, a title I’m proud to wear,” said Dr. Adam Friedman, professor and chair of dermatology at George Washington University. He explained that dermatologists have been 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 go away 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 things we do are off-label because there’s nothing on the label,” he said. He provided a long list of conditions, including skin pigment disorders, inflammatory skin disorders, and unrelenting itching, for which standard treatments are off-label.

Minoxidil, the active ingredient in Rogaine, a lotion or foam that is 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 being used to treat high blood pressure, but patients often noticed that the pills caused hair growth all over their bodies. So its manufacturer developed a minoxidil lotion, eventually named Rogaine, and won approval to grow hair on bald heads.

But dermatologists say the lotion or foam isn’t particularly effective for some patients, perhaps because they stop taking it. It has to get on 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 on their hair.

Johnson and Johnson, the current owner of Rogaine, did not respond to requests for comment.

Others find it just doesn’t work for them. Minoxidil must be converted to an 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 wasn’t why low-dose pills were invented. Instead, the discovery also happened 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 his head had thinned and he hated the way it looked. Unlike most of her patients, Rogaine worked for her, but she developed an allergic scalp rash from the drug. However, if he stopped taking it, his hair would thin again.

“So I was stuck,” Sinclair said. “The patient was very motivated, and the only thing we knew was that if a patient is allergic to a topically applied drug, one way to desensitize is to give very low doses orally.”

To do this, Sinclair tried cutting minoxidil pills into quarters. To his surprise, the low dose made his hair grow but did not affect his blood pressure, the original purpose of the higher dose drug.

He subsequently lowered the dose further and further until he reached effective doses of one fortieth of a pill and began prescribing the drug routinely. That first patient still takes it.

At a meeting in Miami in 2015, Sinclair reported that low doses of minoxidil led to hair growth in 100 successive women.

He published these results in 2017, noting that rigorous studies were needed, in which some patients would be randomly assigned to take minoxidil and others a sugar pill. But that hasn’t happened. He said he has now treated more than 10,000 patients.

Recently, an increasing number of hair loss dermatologists have been giving the low-dose pills to patients with male and female hair loss, which is normal with age.

“We’re starting to see an increase in popularity,” said Dr. Crystal Aguh, a dermatologist at the Johns Hopkins School of Medicine. “Increasingly at conferences, we are sharing our success stories.”

Doctors who don’t specialize in hair loss, he added, “wouldn’t be familiar with oral minoxidil,” except as a little-used treatment for high blood pressure that comes with a black box warning that it can cause problems cardiac But, she and others say, the caveat is for much higher doses.

If the hair loss is too severe, minoxidil won’t help, Aguh said. “It won’t work, for example, if a man is mostly bald, with a shiny scalp. There’s 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.

However, without a rigorous trial leading to FDA approval, 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’s no incentive to spend tens of millions of dollars to test it in a clinical trial. That study is really never, ever going to be done.”

Some patients taking low-dose minoxidil, however, notice that stray hairs grow on their face and chin. So some dermatologists, including Sinclair, have 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 remedies or one of only two FDA-approved hair regrowth 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’s word of mouth about minoxidil in pill form.

“I’ve seen miracles happen,” Aguh said.

One of them involved Brandy Gray, 44, who lives in Monkton, Maryland.

“I had been losing my hair over time,” she said. “Then I start getting circular patches” with no hair. “They were worse and worse.”

She had seen another dermatologist who gave her shampoos and supplements, to no avail. Finally, she said her dermatologist told her, “There’s nothing left I can try for you, nothing else I can do.”

He went to Aguh, who gave him 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 as if this hair loss never happened.

© 2022 The New York Times Company

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