Minoxidil, sold under the brand names Loniten and Rogaine among others, is a vasodilator medication used for the treatment of high blood pressure and hair loss. It may also be used off-label to promote beard growth and treat nail problems. The drug promotes hair growth, but its effects are fully reversible and it does not prevent hair loss long term. It is available as a generic medication by prescription in oral tablet form and over-the-counter as a topical liquid or foam. Oral minoxidil is used at high doses to treat high blood pressure and at low doses to treat hair loss, while topical minoxidil is used exclusively for hair loss and related indications. Extended-release oral minoxidil and sublingual minoxidil formulations for hair loss are also being studied and developed.
Side effects of oral minoxidil may include low blood pressure, water retention and edema, salt retention, rapid heartbeat, dizziness, lightheadedness, headaches, excessive hair growth, and temporary hair shedding. Adverse effects of topical minoxidil include skin irritation, itching, dandruff, and temporary hair shedding. Rare but serious adverse effects of oral minoxidil include pericardial effusion, pleural effusion, cardiac tamponade, other cardiovascular complications, and pseudoacromegaly. Minoxidil is a prodrug of minoxidil sulfate, which acts as a KATP potassium channel opener to widen blood vessels and increase hair growth. The effects of minoxidil are dose-dependently similar to the symptoms of Cantú syndrome.
Minoxidil was discovered in 1963 and was introduced for treatment of high blood pressure in 1971. In 1971, researchers unexpectedly discovered that minoxidil causes hair growth, resulting in it being repurposed for treatment of hair loss and approved in topical form for this use in 1988. Topical minoxidil became available over-the-counter in 1996. Low-dose oral minoxidil (LDOM) emerged for treatment of hair loss in 2015 and dramatically increased in popularity starting in 2022. Extended-release oral minoxidil and sublingual minoxidil were developed in the 2020s for hair loss and are in late-stage trials. Aside from its use in humans, minoxidil is extremely toxic to cats and dogs even in small amounts.
Medical uses High blood pressure Minoxidil, when used for hypertension, is generally reserved for use in severe hypertension patients who do not respond to at least two agents and a diuretic. Minoxidil is also generally administered with a loop diuretic to prevent sodium retention and potassium retention. It may also cause a reflex tachycardia and thus is prescribed with a beta blocker.
Hair loss Minoxidil is used for the treatment of hair loss. It is mainly used topically, but in more recent years, it also being used at low doses orally and to a lesser extent sublingually. The drug is effective in helping promote hair growth in both men and women with androgenic alopecia (androgen-dependent pattern hair loss). It works by increasing hair counts as well as by thickening individual hair follicles. Minoxidil is less effective when the area of hair loss is large. In addition, its effectiveness has largely been demonstrated in younger men who have experienced hair loss for less than 5years. Minoxidil use is indicated for central (vertex) hair loss only.
Minoxidil must be used indefinitely for continued support of existing hair follicles and the maintenance of any experienced hair regrowth. Its benefits are tangible but fully reversible, with discontinuation following long-term treatment resulting in rapid hair loss and similar hair density as placebo at 24weeks post-discontinuation. As such, minoxidil does not appear to prevent hair loss long term.
Low-dose oral minoxidil (LDOM) is used off-label against hair loss and to promote hair regrowth. Oral minoxidil is an effective and well-tolerated treatment alternative for patients having difficulty with topical formulations. It is notable in this regard that topical minoxidil for hair loss has very low compliance rates, with almost all users discontinuing it after 1year of use. Consensus statements provide guidance on use of low-dose oral minoxidil for hair loss. Dosing of low-dose oral minoxidil for hair loss has additionally been reviewed. Higher doses are more effective for improving hair loss than lower doses, but also come with greater hypertrichosis incidence.
Another option for hair loss treatment is sublingual minoxidil (SLM), which may have improved tolerability with retained efficacy compared to oral minoxidil.
Minoxidil requires at least 2 to 4months before the first benefits on hair growth can be observed. Maximal effectiveness occurs after 12months.
Beard growth Minoxidil has been studied for enhancement of facial hair or beard growth, including for transgender men.
Nail problems Minoxidil has been studied in the treatment of onychodystrophy (nail problems). It has been assessed in at least 6clinical studies for this purpose, with the employed formulations including 2 to 5% topical minoxidil and 1.25 to 2.5mg/day oral minoxidil. The drug has been found to increase the rate of nail growth, improve nail appearance, increase nail strength, and resolve yellow nail discoloration.
Available forms Minoxidil is available in the form of oral tablets, topical solution, topical foam, and topical spray. The tablets include 2.5, 5 and 10mg forms; the solutions include 2% and 5% forms, and the foam and spray are both 5% concentration. The topical solutions are formulated with polyethylene glycol (PEG) to enhance absorption of minoxidil. The topical solution is often referred to as minoxidil topical solution (MTS) and the topical foam is known as minoxidil topical foam (MTF).
Contraindications In the case of oral minoxidil, absolute contraindications include pheochromocytoma, history of pericardial effusion or cardiac tamponade, history of pericarditis, history of pulmonary hypertension associated with mitral stenosis, hypersensitivity, and pregnancy and breastfeeding, whereas relative contraindications or precautions include hypotension (<90/60 mmhg), kidney impairment or failure, dialysis, history of heart attack, and history of tachycardia or other arrhythmia. Congestive heart failure is an absolute or relative contraindication according to different sources.
Side effects Side effects of oral minoxidil may include salt retention, water retention and edema, rapid heartbeat, dizziness, lightheadedness, headaches, and hypertrichosis (excessive hair growth).
Topically applied minoxidil is generally well-tolerated, but common side effects include itching of the eyes, general itching, irritation at the treated area, and unwanted hair growth elsewhere on the body. Alcohol and propylene glycol present in some topical preparations may dry the scalp, resulting in dandruff and contact dermatitis.
Sublingual minoxidil may have reduced side effects with retained effectiveness compared to oral minoxidil. This is due to less minoxidil sulfate being formed during first-pass metabolism and due to local activation of minoxidil into minoxidil sulfate within hair follicles. In a preliminary clinical trial, no adverse effects or changes in blood pressure occurred with low-dose sublingual minoxidil.
Oral minoxidil has been implicated in causing pericarditis, pericardial effusion, and pleural effusion. Cardiac tamponade secondary to pericardial effusion, which can be life-threatening, is also known to occur. Pericardial effusion has been found to occur in about 3% of people at hypertension doses. This is usually associated with impaired renal function, connective tissue disease, uremic syndrome, congestive heart failure, or marked fluid retention, though cases without these potential risk factors have also been reported. There have been case reports dating back to the 1980s describing these phenomena, including with oral minoxidil and rarely even topical minoxidil. However, these cardiovascular complications are much less common and rare with oral minoxidil at the low doses used to treat hair loss. Potential symptoms indicating these minoxidil-induced cardiovascular complications include dyspnea (shortness of breath) and edema (fluid build-up).
Minoxidil has also been associated with a number of other types of cardiovascular complications, like ischemic heart disease, pulmonary hypertension, left ventricular hypertrophy, and specific electrocardiogram (ECG) abnormalities. Cardiac lesions, such as focal necrosis of the papillary muscle and subendocardial areas of the left ventricle, have been observed in laboratory animals treated with minoxidil as well.
KATP channel openers like levcromakalim and minoxidil have been strongly implicated in inducing headache and migraine.
Pseudoacromegaly is an extremely rare side effect reported with large doses of oral minoxidil. Oral minoxidil has been reported to cause coarsening of facial features in case reports.
Overdose Overdose of minoxidil has been reviewed. In 2013 or 2014, a seven-year-old girl was admitted to a children's hospital in Toulouse in France after accidentally ingesting a teaspoon of Alopexy (a brand name for minoxidil in France). The child vomited constantly after ingestion and showed hypotension and tachycardia for 40 hours. The authors of the report on the incident stressed that the product should be kept out of reach of children, and urged manufacturers to consider more secure child-resistant packaging.
Interactions Combination of oral minoxidil with guanethidine can result in profound orthostatic hypotension.
Low-dose daily aspirin can reduce the effectiveness of topical minoxidil for hair loss. This is thought to be because aspirin inhibits sulfotransferase activity and hence prevents conversion of minoxidil into its active form minoxidil sulfate. Salicylic acid is also a sulfotransferase inhibitor and could likewise affect the effectiveness of topical minoxidil. In addition, paracetamol (acetaminophen) is a sulfate scavenger and may inhibit minoxidil activation into minoxidil sulfate and effectiveness.
Pharmacology Mechanism of action
The mechanism by which minoxidil promotes hair growth is not fully understood. Minoxidil is an adenosine 5'-triphosphate (ATP)-sensitive potassium channel opener, causing hyperpolarization of cell membranes. Theoretically, by widening blood vessels and opening potassium channels, it allows more oxygen, blood, and nutrients to the follicles. Moreover, minoxidil contains a nitric oxide moiety and may act as a nitric oxide agonist. This may cause follicles in the telogen phase to shed, which are then replaced by thicker hairs in a new anagen phase. Minoxidil is a prodrug that is converted by sulfation via the sulfotransferase enzyme SULT1A1 to its active form, minoxidil sulfate. The effect of minoxidil is mediated by adenosine, which triggers intracellular signal transduction via both adenosine A1 receptors and two sub-types of adenosine A2 receptors (A2A and A2B receptors). Minoxidil acts as an activator of the Kir6/SUR2 channel upon selective binding to SUR2. The expression of SUR2B in dermal papilla cells might play a role in the production of adenosine. Minoxidil induces cell growth factors such as VEGF, HGF, IGF-1 and potentiates HGF and IGF-1 actions by the activation of uncoupled sulfonylurea receptor on the plasma membrane of dermal papilla cells.
A number of in vitro effects of minoxidil have been described in monocultures of various skin and hair follicle cell types including stimulation of cell proliferation, inhibition of collagen synthesis, and stimulation of vascular endothelial growth factor, prostaglandin synthesis and leukotriene B4 expression.