CASE 9

Hello Dr Donovan!

This is a case of a 35 year old female patient diagnosed with FPHL who is experiencing ongoing on and off shedding w/density loss despite treatment with topical finasteride 0.3%/6% minoxidil qAM, topical minoxidil 5% PM (no finasteride topically in evening) for about 1 yr.

Last summer the patient added oral finasteride 5mg once daily about 8 mo ago to this regimen in attempt to move to an oral regimen. The patient also uses Derm-a-roller sporadically and Low Level Laser treatment 3x wk.

She has been tentatively dx with PCOS in the past due to irregular periods but has no hirsutism nor obesity hx. Thus was prescribed Metformin 500mg qd Spironolactone 100mg once daily prior to becoming a patient. She does use Clobetasol every 2 wks as this helps with the inflammation from the topicals and helps with the feeling of her scalp "feeling tight".

This seems to be a stable regimen but patient would like to try adding oral minoxidil with the oral finasteride in attempt to get off of topicals for many reasons (irritation, time consuming, cost, difficulty covering the area precisely each time) but I do not know how to effectively do so. That is to say, should I add oral minoxidil to her regimen and have her overlap her topical regimen for a set number of weeks/months before stopping the topical fin/min combo? If she begins having shedding with the addition of oral minoxidil how would I know if this is due to the oral minoxidil not working or not being of a strong enough dose when in fact it was actually that I stopped the topicals and that is why she is having shedding?

Finally, she would like to have children and has asked about when she should stop the above medications as well as if topical cetirizine and also rosemary oil during pregnancy is useful.

Any advice here would be appreciated.

ANSWER

Thanks for the great question. To summarize first, we have a 35 year old female with AGA on topical minoxidil, topical minoxidil-finasteride, oral finasteride, spironolactone, laser, clobetasol, metformin and a dermaroller. She is stable and wants to transition to topical. Pregnancy is planned in the future.

Your patient is on the equivalent of 5 % minoxidil twice daily. We don’t have great data on what dose of oral minoxidil is equivalent but generally speaking 1 mg of oral minoxidil is slightly less effective than 5% minoxidil twice daily. Most likely, 1.25 mg or 1.5 mg of oral minoxidil is going to be pretty similar to 5 % minoxidil twice daily in women. Now, let’s not forget she is dermarolling. That means she’s probably getting a bit more minoxidil. So it’s probably safe to assume that 1.5 mg of oral minoxidil is going to be somewhat equivalent to what she is using now.

As we go about thinking about how to transition her, we need to keep in mind that we have no idea if she’ll tolerate this or not.

In a situation like this, I would tend to STOP the topical minoxidil-finasteride morning dose and STOP the dermarolling and stop the evening minoxidil and just start 1.25 mg oral minoxidil. I would do this for 3 months to make sure she is tolerating this and does not have side effects like headaches, fluid retention in the feet, fluid retention around the eyes, hair growth on the face and dizziness. Then after three months, if all is going well, and the feeling is that she is shedding more than expected I would increase the oral minoxidil to 1.25 mg five days per week and 1.875 mg 2 days per week (Tuesday/Thursday). But if she is tolerating everything well, I would just stick with 1.25 mg oral minoxidil and keep things simply.

What is the diagnosis of scalp tightness?

Now, before we leave this, let me say that we need a diagnosis about the scalp tightness. It sounds like an irritant contact dermatitis but we need a 100% confident diagnosis. It could be that dermarolling is harming not helping. Many think dermarolling is harmless but the reality is it is not for some. It irritates some people! These topical compounded formulations (minox-finasteride) can also be nightmares for causing itching in some people. So it could be that once this is removed from the plan that the scalp feels good. But I would want to make sure 100% there is no lichen planopilaris or fibrosing alopecia in a pattern distribution (FAPD) hiding here. If there was any doubt, I’d probably do a biopsy.

How to manage in pregnacy?

I’m not a fan of “negotiating” treatments in pregnancy with patients. When it comes to pregnancy, I am pretty strict and document everything clearly. 3 % of babies have malformations and 8% have complications. Of course, it’s unlikely any of this would be related to these treatments (cetirizine, rosemary) but it is not worth defending this and spending years in the legal system. I am strict with NO. A laser is fine - but that’s it.

All these medications should be stopped at least one month before. She should start a folic acid supplement or prenatal vitamin containing 1 mg folic acid NOW. This will prevent neural tube defects and I tell patients we often use ‘prenatal’ vitamins for hair. Finally, she should see her doctors for advice on PCOS and fertility. I would screen for iron deficiency (as pregnancy is a huge potential to lose iron) as well as screen for vitamin D, fasting A1c, hemoglobin, potassium, cholesterol, TSH.

My personal view is that we have no evidence rosemary or cetirizine helps women all that well and certainly zero evidence it helps in pregnancy. My personal view is it’s just not worth the risk. Why add something that may not do anything. Yes, oral cetirizine is fairly safe (occasionally) in pregnancy. It used to be classified as “category B” in the old system of classifying drugs. We have no evidence for rosemary in pregnancy and the reality is that for it to be effective in AGA it needs to be used twice daily forever (not twice per week or three times per week or even once per day). She has a very irritated-prone scalp and I doubt she can do this twice daily. Essential oils can irritate the scalp! Second, we have zero evidence rosemary helps women. It helps men a very very very small amount. There is one study. It is small (50 patients) and results suggest very minimal change. There are no good studies in women!