A Comprehensive Guide to Hair Loss Medications and Side Effects

1. Introduction:

   Hair loss affects both men and women of all ages around the world and also affects their physical appearance which results in reduced self-confidence of individuals. The cause of hair loss varies according to the individual and hence treatment of hair loss may also vary from individual to individual.

   1.1 A Comprehensive Look At Hair Loss Treatments:

   There are majorly two hair loss medications minoxidil and finasteride that are currently FDA approved for the treatment of hair loss, other than this many other therapies such as laser therapy, platelet-rich plasma and micro-needling are available for the treatment of hair loss. However, their cost-effectiveness and efficacy remain uncertain till now which limits their use as a sole treatment for hair loss.

   Topical minoxidil is the only medication which is currently used in the treatment of male and female androgenetic alopecia. It is available in both 2% and 5% formulations and promotes hair regrowth by dilating blood vessels.^[5]

   1.2 The Truth About Side Effects of Hair Loss Medications

   Before using hair loss medications, we must be aware of the side effects associated with these medications. In this article, we have discussed the minor and major side effects associated with hair loss medication, such as sexual as well as post-finasteride syndrome are some side effects associated with oral finasteride while scalp itching and heart palpitations are the side effects associated with topical minoxidil.

2. Understanding Hair Loss Medications:

   Treatment: Treating hair fall is a major challenge among physicians as it requires careful consideration of multiple factors such as the cost of the treatment, the time taken to show results, the practicality of compliance and their effectiveness are some crucial factors. Meta studies of the available data suggest that the main factor in adopting any hair treatment is the change in anagen hair count.

   2.1. Types of Hair Loss Medications

   There are only a few medicines currently FDA-approved for the treatment of hair loss such as finasteride and minoxidil. This medicine offers a range of therapeutic effects and shows an increase in hair count and decreased hair fall in patients with androgenetic alopecia (AGA). However, ketoconazole and some corticosteroids are also used off-label for the treatment of hair disorders.

   2.2. Mechanism of Hair Loss Medications

   Minoxidil: Minoxidil is a potent vessel dilator, and it works by increasing blood flow to the hair follicle. The active metabolite of minoxidil sulfate is believed to cause vasodilation and improve blood flow. This increased blood flow may improve the delivery of nutrients and oxygen to hair follicles, promoting hair growth.^[3] Topical minoxidil has also been shown to stimulate hair growth by increasing the duration of the growth phase of hair and increasing the hair size of hair follicles.

   Finasteride: Finasteride works by blocking the action of enzyme 5-alpha reductase. This enzyme is necessary for the conversion of testosterone to dihydrotestosterone (DHT). DHT is supposed to be the hormone which causes miniaturization of the hair follicles so blocking the enzyme prevents miniaturization and hence stops hair fall and improves hair growth.

3. Common Side Effects of Hair Loss Medications

   3.1 Minoxidil: Topical minoxidil was approved in 1988 for the treatment of hair loss, it is one of the most important drug used currently in case of mild to moderate androgenetic alopecia (AGA).^[1] It is most effective at the vertex and frontal regions of the scalp, where it can slow down the rate of hair loss by prolonging the anagen phase and promote hair regrowth by increasing both hair diameter and density.^[1] Both minoxidil foam, as well as solution form, are available in the treatment of hair disorders but minoxidil foam is considered a more advanced formulation as it allows better delivery of the drug to the hair follicles. This is why the US Food and Drug Administration (FDA) has approved 5% MF for the treatment of AGA, as it is more effective than the solution.^[3]

   To get optimal results it should be applied once or twice daily. The patient may expect results in 4 to 8 months which stabilises after 12 months oral minoxidil is an effective treatment option for female pattern hair loss, although it is not as popular as oral finasteride and not FDA-approved for this use. The safe dose ranges from 0.625 mg to 1.25 mg daily, and it has been reported to have tolerable side effects. Sinclair also reported that when minoxidil is combined with spironolactone is a safe and effective option for treating female pattern hair loss.^[1]

   Stats: A group of 904 males suffering from androgenetic alopecia (AGA) were studied for a period of 1 year, revealing that 62% of the subjects witnessed a significant reduction in hair loss in the affected scalp area upon receiving treatment of 5% topical minoxidil twice a day. Furthermore, 84.3% of patients experienced hair regrowth to some extent.^[1]

   Why Does Minoxidil Have Fewer Side Effects?

   The conversion of minoxidil to its active metabolite minoxidil sulfate was higher in hair as compared to other body parts that’s why minoxidil has fewer side effects.^[1]

   Minoxidil has very low side effects, but its application may cause discomfort to patients. Some side effects of topical minoxidil use include irritant and allergic contact dermatitis, pruritus, scalp irritation, and facial hypertrichosis. These side effects are more commonly seen with the use of 5% solutions rather than 2%.^[1]

   3.1.1 Skin Irritation: Skin irritation is the major side effect associated with minoxidil, it involves a reddening of the skin, discomfort, and a burning sensation. Due to this side effect, patients may feel discomfort during its topical application.

   3.1.2 Scalp Itching: Minoxidil topical formulation may also cause scalp itching after its application to the affected area. Scalp itching is often associated with increased seborrheic dermatitis (this condition mainly affects the scalp, it causes scaly patches, inflamed skin, and stubborn dandruff).^[6]

   3.1.3 Chest Pain: Chest pain is also associated as a side effect with its oral dose when taken for a specific long period, this side effect may become life-threatening many times, and chest pain is often associated with a fast heartbeat also.^[7] Overall it causes heart problems to the patients who are taking this medication.

   A separate study involving 30 male patients who received a daily oral dose of 5 mg of minoxidil for 6 months showed comparable outcomes, with all patients displaying clinical improvement and 43% of them demonstrating significant improvement. the side effects ratio was, as 93% of patients developed hypertrichosis (excessive hair growth in any part of the body), 10% developed edema, and 10% developed heart-related abnormalities.^[5]

   3.2 Finasteride: It is the medication which is in currently used for the treatment of male pattern baldness since 1997. This drug may be purchased over the counter so it becomes cost-effective also.

   A large study conducted in Japan involving 3177 males with AGA found that finasteride use resulted in significant hair regrowth in 11.1% of the subjects, moderate growth in 36.5%, and only a moderate increase in hair growth in 39.5% over a period of 3 years. This study suggests that finasteride can be effective in treating male pattern baldness.^[1]

   There are some side effects which are associated with finasteride, including orthostatic hypotension (seen in about 9% of patients), dizziness (seen in 7%), erectile dysfunction (seen in 5-19%), ejaculatory dysfunction (seen in 1-7%), and a decreased libido (seen in 2-10%). However, the severity of these side effects may vary among individuals and some of these may improve or resolve over time.^[1]

   3.2.1 Depression: It is a post finasteride syndrome (PFS) which usually occurs after the discontinuation of the medication, it may affect a person’s mental health and is also associated with persistent sexual and neuropsychiatric side effects.^[8] However, this PFS is generally resolved in a patient after some time and after that, no psychiatric side effects are seen in the patient. To overcome this post finasteride syndrome, a foundation was developed to offer education and safety measures to patients who are suffering from this PFS.^[8] This foundation achieved success and is potentially able to educate the people regarding PFS its symptom and its treatment also.^[1]

   Irwig et al. conducted a study in 2012 which found that the rates of depression and suicidal thoughts were significantly higher among individuals who had previously used finasteride, compared to a control group.^[1]

   3.2.2 Swelling: Swelling of lips, tongue and face are the side effects associated with the oral use of finasteride. These side effects may develop tolerance after continuous use and may diminish after a specific period.

   3.2.3 Sexual side effects: In 2011, FDA issued a warning regarding the oral use of finasteride that oral use of finasteride may result in sexual side effects such as loss of libido, ejaculation disorder, erectile dysfunction, premature ejaculation, and breast enlargement.^[9]

   A retrospective study was conducted on over 400 men who were taking a daily dose of 1 mg of finasteride. The study found that 0.8% of the men developed persistent erectile dysfunction (PED) after a median of 4 years following discontinuation of treatment.^[1]

4. Less Common but Serious Side Effects

   4.1 Minoxidil:

   The serious side effects associated with minoxidil was mostly seen with its oral preparation, not the topical formulation, so it is advised that patient may take the oral medication under closed medical supervision because these side effects may even be proved fatal in some cases and lead to major consequences. However, side effects associated with it mostly are dose-dependent and can be reversed after the discontinuation of the drug. Side effects include pericardial effusion, congestive heart failure (CHF) and allergic reactions.

   4.1.1 Low blood pressure: Minoxidil is a potent vasodilator by dilating the blood vessel it may cause low blood pressure as a side effect, usually first-dose hypotension is seen with minoxidil. These side effects may diminish when we stop the use of this medicine.

   4.1.2 Heart palpitations: From a cardiovascular point of view, it acts as a systemic vasodilator [blood vessel dilator], which leads to reflex tachycardia [Increased heartbeat] that can provoke myocardial ischemia [low blood supply to the heart]. So due to these side effects, minoxidil is avoided in patients with angina or recent myocardial infarction (MI).

   4.2 Finasteride

   4.2.1 Allergic reactions: Allergic reactions such as redness of the skin, itching and skin rashes are the side effects associated with finasteride, but these side effects are very less common and seen only in less fraction of patients and if left untreated, may cause serious damage to the patient.^[11]

   4.2.2 Hormonal imbalances: Finasteride may cause hormonal imbalance as it increases the estragon level and decrease the DHT levels. The decreased level of DHT is its common pathway for achieving its therapeutic effects which is the reduction of hair fall. In some rare cases, it may cause gynecomastia (enlargement of the breast) and testicular pain in men which further leads to more side effects.

   Finasteride is usually contraindicated in case of pregnancy because its use may cause ambiguous genitalia (a rare condition in which an infant’s external genitalia doesn’t appear clearly) in a male foetus.^[1]

5. Conclusion

   In this article, we have read about the medicine that is used for the treatment of hair loss disorder such as finasteride and minoxidil. We also studied the potential side effects linked with this medication such as sexual side effects linked with the oral finasteride and the itching and skin-related side effects associated with the use of topical minoxidil. Some of these side effects are time-dependent and resolve after a specific period and some side effects may also continue even after the discontinuation of the drug such as post-finasteride syndrome. If someone is encountered side effects, he/she must be talked to his physician about the side effects especially the sexual side effects of finasteride.

   As we know the root cause of hair disorders may be different in different individuals, so the treatment is generally cause-based, in this way, it is very important to seek the medical advice of the physician before starting the hair loss medications because the physician can identify the cause of hair loss and suggest the treatment according to the patients need and root cause. Also, the physician is familiar with the side effects of the medications so the physician can prevent the side effects linked with the medicines. in this way, physicians play an important role in the treatment of hair loss disorder.

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