I want to thank Kate for emailing me this Case Report about the use of spironolactone and minoxidil in treating female pattern hair loss. The Case Report appeared in the Australasian Journal of Dermatology Volume 48 Issue 1 Page 43-45, February 2007
CASE REPORT
Treatment of female pattern hair loss with a combination of spironolactone and minoxidil
Carlijn Hoedemaker, Sylvia van Egmond and Rodney Sinclair
Department of Dermatology, St Vincent’s Hospital, University of Melbourne, and Department of Medicine and Skin and Cancer Foundation, Melbourne, Victoria, AustraliaSummary
A 53-year-old woman with clinical evidence of female pattern hair loss and histological evidence of androgenetic alopecia was initially treated with the oral antiandrogen spironolactone 200 mg daily. Serial scalp photography documented hair regrowth at 12 months; however, the hair regrowth plateaued, and at 24 months there had been no further improvement in hair density. Twice daily therapy with topical minoxidil 5% solution was then introduced and further regrowth documented, confirming the additive effect of combination therapy.
Introduction
Female pattern hair loss is a common, psychologically distressing, age-related, androgen-mediated condition that presents with increased hair shedding and reduction in hair volume over the mid-frontal scalp.1
Binding of dihydrotestosterone to cellular androgen receptors induces susceptible scalp hairs to undergo a progressive and orderly transition from terminal to vellus hairs to produce patterned baldness. Antiandrogen therapy with either spironolactone or cyproterone acetate is commonly used to treat FPHL, as is topical minoxidil.2 The mechanism of action of minoxidil is unknown, but does not involve androgen pathways.3 The use of topical minoxidil together with an oral antiandrogen might have an additive effect; however, combination therapy has not been previously reported.
Case Report
A 53-year-old woman, with a past history of hypertension for which she was treated with felodipine, presented with a 6-month history of increased hair shedding, combined with a noticeable reduction in hair volume over the mid-frontal scalp. On specific questioning she stated that the volume of her hair, when held back in a ponytail, had decreased by 30% over the past 6 months. No obvious trigger for the hair loss was identified on history. On examination she was noted to have minimal bi-temporal recession. Her hair pull test was negative. Her mid-frontal scalp hair density was estimated as Stage 3 on the clinical grading scale (Sinclair scale).
Screening biochemical investigations were normal. A horizontally sectioned punch biopsy from the mid-frontal scalp confirmed androgenetic alopecia with a terminal to vellus hair ratio of 3:1.
As spironolactone is known to be effective in the treatment of hypertension as well as FPHL, felodipine was replaced by oral antiandrogen therapy with spironolactone. She was commenced at an initial dose of 25 mg daily, which was incrementally increased to 200 mg daily over 6 weeks, carefully monitoring her blood pressure.
Serial scalp photography was used to document response to therapy at 6-monthly intervals. Compared with baseline (Fig. 1), the photograph taken at 12 months (Fig. 2) revealed noticeable improvement, particularly in the mid-frontal area of the scalp. Two years after commencing spironolactone, her hair regrowth plateaued (Fig. 3). The patient was instructed to apply 1 mL twice daily of minoxidil 5% solution. Follow up 1 year later revealed additional regrowth (Fig. 4), and the patient was instructed to continue with combination therapy indefinitely. Follow up over an additional 4 years shows that the regrowth seen with combination therapy has been maintained (Fig. 5).
Discussion
Spironolactone is an androgen receptor antagonist. In addition, it reduces the levels of the cytochrome P450-dependent enzymes 17?-hydroxylase and desmolase, both of which are required for androgen synthesis.4 Spironolactone has been reported to be effective in the treatment of FPHL at a dosage of 200 mg daily.5
In this patient, improvement in hair regrowth was seen after 12 months therapy with spironolactone 200 mg.
Hair regrowth with topical minoxidil is well documented in literature.6 Minoxidil prolongs anagen, shortens telogen and converts partially miniaturized (intermediate) to terminal hairs and results in at least partial normalization of the hair follicle morphology. Minoxidil has no antiandrogen properties.3
While spironolactone and minoxidil are established monotherapies for FPHL, the different modes of action of these two therapies make it logical to combine these two agents. However, we are not aware of any reports of combination therapy in the literature. The additive regrowth seen in this woman with FPHL and biopsy proven androgenetic alopecia suggest that combination therapy should be considered for women presenting with FPHL.
References
1. MessengerA, De BerkerD, SinclairR. Disorders of hair. In: BurnsT, BreathnachS, CoxN, GriffithsC (eds). Rook’s Textbook of Dermatology, Vol. 1, 7th edn.
Oxford: Blackwell Science, 2004; 1–120.
2. YipL, SinclairR. Antiandrogen therapy for androgenetic alopecia. Expert Rev. Dermatol. 2006; 1: 261–9. CrossRef
3. MessengerAG, RundegenJ. Minoxidil: mechanisms of action on hair growth. Br. J. Dermatol. 2004; 150: 186–94. Synergy, Medline, ISI
4. MenardRH, GuenthnerTM, KonH, GilletteJR. Studies on the destruction of adrenal and testicular cytochrome P450 by spironolactone. J. Biol. Chem. 1979; 254: 1726–33. Medline, ISI
5. SinclairR, WewerinkeM, JolleyD. Treatment of female pattern hair loss with oral antiandrogens. Br. J. Dermatol. 2005; 152: 466–73.Synergy, Medline, ISI
6. LuckyAW, PiacquadioDJ, DitreCM, DunlapF, CantorI, PandyaAG, SavinRC, TharpMD. A randomized placebo-controlled trial of 5% and 2% topical minoxidil solutions in the treatment of female pattern hair loss. J. Am. Acad. Dermatol. 2004; 50: 541–53. CrossRef, Medline, ISI
The PDF Has Images of The Woman
{ 19 comments… read them below or add one }
Hmm. Very interesting! This is my recommended treatment for androgenetic alopecia, but I’m beginning with the 5% minoxidil FOAM (so much better than the liquid) 2x daily, and then in 3 months will add on Spiro. My derm said that they work well in combination and I guess this case study proves it’s worked in at least one case. Thanks for posting this!
I am feel like how crazy am I for years i have been hiding this , I felt confuesed and I just resorted like let life take its toll and soon i will have no hair and i will get a wig ! But when i would see myself in pictures and my hair was gettin thinner and thinner I was completely in pain . What do i do where do i go from here jow do i make it stop. I went to the gyn and some blood work came back and they noticed that my hormone levels were not right and not ot mention I can’t get pregnant and thats when they told me pcos , now have an appointment to see an endiocronologist and i can now feel like knowledge is power and i konw that things are gonna get better for me . I have to begin my journey .
Hi Dee, Welcome to the site! I wish I had the absolute answer on how to make your hair loss stop, but unfortunately I don’t. If you’ve been diagnosed with PCOS then that can definitely either be causing or contributing to your hair loss. Since your hormonal blood test can back abnormal there is something there as well. You really need to make sure you are working with a caring and knowledgeable doctor, I really think that is the most important thing since both you and your doctor have to sort of be detectives in trying to pinpoint the cause of the hair loss and if it can be rectified. Have you been diagnosed with either telogen effluvium or androgenetic alopecia? Knowledge is power, and the more you know the more confident you are going to feel making decisions regarding treatment or anything else regarding your health issues. I’m glad you’ve found site, there are a lot of supportive women on this blog who are going through the same thing as you, so know you are not alone.
~Y
Hi, I am 30 years old and going through hair loss for the past one year. I will not go into detail regarding the emotional toll this has taken since I know everyone on this site has experienced the same thoughts of despair and hopelessness. I am posting this because currently I am on the combo spironolactone and minoxidil therapy and in the last couple months I have seen positive change. Even though the change is minimal its something!!! So I hope that anyone reading this gets some benefit and maybe the push to try it. The minoxidil is over the counter but you will need prescription for the spironolactone from your dermatologist. Knowledge is power and I wish I had the courage to seek this type of support long time ago.
-P
Thanks P for posting some positive results!
Bridget
P-
I am glad to you are getting some relief and seeing some change with the Minoxidil and Spironolactone. I completely understand the emotional toll it’s probably taken on you. I am 36 years old, and have been experiencing hair loss for the past 4-5 years. Just recently I saw how significant the loss has been, and have tumbled into a severe depression because of it. I’ve read nothing good about Minoxidil, but have read quite a lot of good things about Spironolactone. I myself have taken it in the past to treat acne, and know that it does work. I am curious–what strength minoxidil will you be trying?
Anyway, good luck to you!
E-
I’m 38 yrs young with high blood pressure. I’m currently taking Propranolol 60mg to lower my pressure. I started noticing thinning hair about 9mos ago.I’m so depressed!It seems like whenever I pass some one in the street with thin hair,I think about my own. I think about it EVERYDAY-ALL DAY! I get my hairdone every 2wks,that’s the 1st thing my stylist says “you’re thinning again”. It’s gotten so bad I spray black spray on my scalp to hide it. But I know its there.I don’t feel attractive anymore.It’s affecting every aspect of my life.I have a 3yr old son, who tells me I’m pretty.(my angel) What do you do?
Kendra, propranolol is a beta blocker and they cause hair loss.
Alopecia and drug eruption of the scalp associated with a new beta-blocker, nadolol.Shelley ED, Shelley WB.
Infiltrative dermatitis and marked alopecia of the scalp appeared shortly after a new beta-blocker, nadolol (Corgard), was prescribed for the treatment of a patient with hypertension. Cessation of the beta-blocker therapy, after four months of therapy, was followed by a dramatic involution of the eruption, and total regrowth of scalp hair occurred within three months. The associated eruption and rapid regrowth of hair upon discontinuation of nadolol distinguish this alopecia from the telogen effluvium previously associated with other beta-blocker drugs, such as propranolol (Inderal) and metoprolol (Lopressor).
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Propranolol and alopecia.Hilder RJ.
A case is presented herein of alopecia developing in a patient receiving propranolol. The literature is reviewed and this case compared to the first one reported. The two cases have similarities, and most importantly, both showed an effluvium of the telogen type. This may be important as a diagnostic aid, if substantiated in further cases. In a survey of several major textbooks this side effect of propranolol is not noted and it is hoped that this article will make practitioners aware of the possible complication.
PMID: 477381 [PubMed – indexed for MEDLINE]
Hi..I was prescribed Propranolol in December 2008. It is now May 2009, I have 2 large patches of alopecia (complete baldness) and have noticed significant hair reduction all over. I have (had) quite long blonde hair but it is now really straggly and thin. My Dr says its probably not connected yet that is the only thing that has changed for me in 6 months. I cannot believe it isn’t the propranolol. Can anyone help???
Hey I’m writing to ask anyone here about the pattern of your loss. I have aga and noticed it first thinning in the temples but now its affecting my hairline. Dr Redmond says its normal for women to have this pattern as well as when the hairline is in tact with thinning behind it. My question is does anyone here have my pattern? Does it become so obvious that you have to wear your hair over your forehead. Please help thanks!
I have been on spironolactone (200mg/day) and minoxidil(5%, twice/day) for 4 months. But my hair loss is not getting better. I don’t know what else I can do. If you’ve ever had the same experiences please let me know.
Petty I am also on 200 of spiro for almost 4 months and no slowing in shedding yet. This is making me very sad and nervous. By the way, what is the pattern of your hair loss and how long have you been experiencing this? I have for the past year and am only 22 years old. Also, mine is affecting my hairline slightly. Thank you
I hate to sound like the medical community isn’t doing enough because the help they can provide in a number of regards for various conditions/syndromes/illnesses, well it’s just amazing, however I feel like very few doctors are seriously looking into female hair loss, especially when associated with hormonal imbalances/illness. I have PCOS and every attempt to try to help halt and reverse my hairloss is met with site after site that says “although there’s no cure for PCOS…” blah blah blah, as if doctors think, well, it’s manageable as is, no real point to figure it out. I don’t mean to go off on a PCOS tangent, but really, the hair loss aspect of an illness that already makes me feel fat, zitty, and hairy everywhere else I’d rather not have hair (not to mention the irregular periods which really make it a wonderful condition to have…not), well, it’s just plain cruel. I like so many of you long for my former hair. Hair that to me wasn’t perfect because it was fine textured but I had a ton of it. Hair that was annoying because I had waves in it that would frizz up in humidity. But damn it, I miss my hair and I hate that I’m expected in my 20s to just deal with it. Well sorry, but I can’t deal with it. As I type now I have a lump in my throat trying to hold back tears. It’s not fair (no, life isn’t fair, but it’s just incredibly horrible to have lost something that makes you feel like a woman, that society views you as feminine for having, but when it’s lost, you’re treated like you’re shallow and vain for missing it) to lose your hair when you’re young. Ever really. I mean, if I was like 85 years old with thinning hair, I probably wouldn’t mind so much because odds are I’d be married with kids and grandkids. Who will date a girl who’s balding? I don’t have bald patches, but I have diffuse balding/thinning and it makes me sick to my stomach to shower and see my hair circle the drain or see it come out in clumps when I brush. The worst part is my doctor won’t give me Spiro because she only gives it for severe cases but I’m going to beg her to give it to me because as horrible as it sounds, I’d pretty much rather die than lose anymore hair. I can’t stand just maintaining what I have left either. I need some sort of regrowth. I guess the point of my post is to say, yes, I’m glad that we have some options even if they don’t help everyone, and I think Spironolactone and Nizoral and Minoxidil rock because if they helped any of our fellow female hair loss sufferers, then more power to them, but seriously, can the medical community, some niche group, please, please, please work on a cure for hair loss? Hair loss isn’t a joke. It’s not vanity. You’re not supposed to lose hair in your teens, 20s, 30s, 40s, or even 50s. Sure, a little is expected, but none of us on this site are just shedding the average amount. We all have noticeable hair loss and it’s debilitating. I know I should be positive, but it’s hard not to feel defeated when you can’t even look in a mirror anymore without wanting to just crumple up in the fetal position and cry because you can see your scalp through your hair. And it’s hard to have well-intentioned people telling you it’s not that noticeable when you know that it is. I just want a cure. I want to halt the loss and I want to regrow what was lost. No, not lost, what a medical condition has taken from me. I think I could be positive if I knew that in a year or two years or even three, that there’d be an end in sight and that this horror would be over. If science could go a little faster and pinpoint the causes of female hair loss for us and find out an effective way to fight it and reverse it, it’d be so much easier to face the hair loss today.
Hi everyone..
I think the biggest question I have is shouldn’t FPB be a gradual condition, wher year after year you notice more and more scalp? Not immense shedding with scalp showing overnight??? I saw a dermatologist and he looked at my hair and said: FPB. He did a blood test which appeared normal except for high platelet count. I am 45, I was 42 when I noticed see thru hair in the front of my scalp. I tried rogaine 2%, went on supplements, reduced sugar (got a really bas sweet tooth) and went on a low androgenic pill-yasmin. A year later my hair was strong and thick again..was it the rogaine?? Was it the supplements? Was it the pill?? Don’t know, maybe it was all of it combined. The last jan-feb, I noticed my new hairs falling out and thinning again..and I was on the pill and rogaine every second day (started daily but when my hair thickened I did it 1x/2days). So, it’s back to the drawing board. I got a saliva test to ck my estrogen and progest, going for a pre-diabetes test, added iron to my suppl again (had stopped) but last march it was 17, a bit low. I’m also going to monitor my basal temp for poss hypothyroid. Geez, so many differnt things may be affecting my hair, makes my head spin from all the info bouncing around in my brain. Hopefully something comes of these tests that help clarify things for me and give me a solution..just venting, thank goodness for this site..good luck to all of you on here. Hope you find answers and solutions and here’s to happy endings of the crazy shedding and to new beginnings with tons of new hairs!!!!!
I inherit female pattern baldness from my mom. My hair is thinnning and shedding every day. Hairs are all over the place. I am depressed. I am a Malaysian and there are abundance of hair saloons offering hair loss treatments over here in Malaysia. What they do is they give the customer a good hair wash and hair steaming thereafter, of cos in between they would apply tonic and all. Anyone heard of this treatment before? Anyone of you believe that by regular steamings to our hair will help to open up the follicles for better absorption of hair tonic?
Anyone else notice facial swelling with minoxidil? Just switched to 5% rogaine and face is all puffed up 🙁
I heard of this new drug prescribed by Sinclair dermatology. Its in a small capsule combining both minoxidil n spiranolactone. Yes – its a two in one oral dosage.
Will keep u all posted if i d results are gd.
Just started on spironolactone & hesitantly rogaine (I hate that is causes shed before possible growth, burning scalp all day, & indefinite use). After several doctors, they can’t be certain with me its either chronic TE or AGA. The suffering is all so real. And mass amounts of information on products & treatments. It’s confusing, scary & expensive. I’ve been trying supplements, herbs, topicals, diet changes, prescribed hormone cream, shampoos….. for the past 5+ yrs and it’s still getting worse, thinning moved to balding spots. I’m so disappointed that there’s no clear help. I’m fighting the depression of it all. Thank you for this site & to all who offer input.
Pharmacist just called about spironolactone and minoxidil foam for my scalp and she wanted to warn me that there is a strong spell to it—very strong. I asked if it goes away after a while and she could not say. Also, I wear a wig and wondered if the wig will pickup the smell and she could not say. Anybody have this problem and does the smell go away soon after it is rubbed into the scalp?