An 18-year-old male presents with a two-year history of thinning at the front and top of his scalp. His father displayed a similar pattern of thinning at this age and progressed to lose much more hair later in life. The patient is panicked that he will lose as much hair as his father and has begun collecting and counting his hair loss daily for the past few weeks. Today, he brings a small bag of hair to be examined. During his history, he is wringing his hands and is ruminating over how much worse his hair loss may become.
Q: What would be the best treatment for this patient to consider?
A: This patient should start treatment with topical Rogaine (minoxidil). With early hair loss, minoxidil is a reasonable first choice in young patients. One should hesitate to prescribe finasteride in patients that have significant anxiety or OCD-like symptoms.
Q: Which version of minoxidil is the strongest?
A: The most effective FDA formulation of minoxidil is the 5% solution, as it contains propylene glycol which acts as a penetrative agent to increase its strength. A 5% foam version, without propylene glycol, is less irritating, but is slightly less effective. The foam is also more difficult to apply directly to the scalp in areas of significant hair. It is generally best to begin with the solution and then switch to the foam if there is irritation or flaking. Proprietary products that contain higher concentrations of minoxidil and ingredients to increase absorption (such as retinoid acid) can be considered if they do not cause irritation.
Q: Where should minoxidil be applied and how often?
A: Contrary to the more restrictive package indications, minoxidil works in all areas of the scalp where there is thinning. It should be applied to all areas of thinning, not only the crown. Many patients find that evening application allows the full 4-6 hours of contact time necessary for absorption and that the product will dry overnight and no longer look greasy in the morning. It was long thought that minoxidil should be used twice a day, but using it once a day will also be effective and compliance will be much better. Stress to the patient that minoxidil should be used continually and should not be stopped and restarted.
Q: How much should I use?
A: The “dropper full” of solution or “cap full” of foam is one-size-fits-all and has little relevance to areas of balding larger than just the crown. It is best to tell the patient to apply enough medication to coat the entire area of thinning, regardless of what this amount may be.
Q: When can I expect to see results from minoxidil?
A: Full results can take up to one year, although some benefit may be noted in 2-3 months. Shedding often occurs during the first few months and is usually an indication that the medication is beginning to work. Unless one is having side effects, such as irritation, burning or flaking, the medication should not be stopped. It is important to stress this to the patient or they will stop the medication at the first sign of shedding.
Q: Can you use minoxidil with PRP?
A: Yes, but unless you add them sequentially (6-12 months apart) it will be impossible to tell which one is helping the patient. Often patients do not care and want to stop their hair loss as quick as possible, but the logic of sequential treatment should at least be explained.