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Medical Treatments for Hair Loss in Women

Posted Aug 24 2008 1:49pm
LISA CLARK: We've all seen the commercials for the Hair Club for Men, ads for prescription medications for male hair loss, and even men's spray-on hair. But rarely do we see advertisements addressing women's hair loss issues. Surprisingly, hair loss in women is a common occurrence. It affects more than 30 million women in the United States alone.

Although hair loss can seem a permanent condition, and devastating to many women, there is hope, and there are treatments out there for women, even if you never do see the ads. Here to discuss some of those solutions for women's hair loss are two experts in the field.

Joining us today are Dr. Marty Sawaya, Adjunct Professor at the University of Miami School of Medicine, and Dr. Michael Reed, Assistant Professor of Clinical Dermatology at the New York University School of Medicine, and also in private practice here in Manhattan. Welcome to you both.

The first treatment we want to talk about is minoxidil, known by the brand name of Rogaine. Refresh my memory. How long has this product been available for me?

MARTY SAWAYA, MD: Since 1988.

LISA CLARK: 1988. Here we are, 12 years later, and now it is finally being discussed as a treatment option for women. What took so long?

MARTY SAWAYA, MD: It takes a lot of years of research and development and clinical trial testing, and it was approved as a prescription product in 1988 for men, and then later released a few years later for women, as a prescription product. Now it's over-the-counter. You can buy it at your local drug store, food chain store, freely on your own, and the cost has really come down also. There's 2% Rogaine for men and women, and there's also an extra-strength 5% formulation for men only.

LISA CLARK: When your patients come in, how do you advise them to use Rogaine, and what sorts of results can they expect to see?

MICHAEL L. REED, MD: The usual procedure is to use the strength that they need for their particular degree of hair loss. If it's a person who's never been treated and they have relatively mild hair loss that's just starting, then can start with the lower strength, the 2%. They apply 1 ml. There's a calibrated pipette that they can put a dropper for their head. They have to spread it evenly across the affected area. They don't have to really rub it in, but they massage it and spread it with their fingertips, and it gets absorbed into the scalp.

They do that twice a day. Sometimes people have trouble doing things twice a day, even things they like, much less treating hair loss, but if that's the case, we'll have them sometimes use the higher strength. Women can use the 5%, even though it's not yet been FDA approved; it's perfectly legal and advisable, and it's actually necessary in a lot of them with bad hair loss to use that. Five percent, again, is supposed to be used twice a day, but some people can get away using the entire amount at bedtime.

LISA CLARK: What's formulation like? Is it watery, is it creamy?

MICHAEL L. REED, MD: It's clear, it's colorless, but it has an oily feel to it, due to the presence of something called propylene glycol, which is there in a 50% concentration in the higher strength, and that can be oily, and it can be irritating. In the 2%, it's rather like water or like alcohol; it just disappears into the skin.

LISA CLARK: We'll talk about the medical side effects, but for a cosmetic side effect, does the formulation make it difficult for women to want to use because the cosmetic appearance may not be --?

MICHAEL L. REED, MD: Not usually in the lower strength. In the higher strength, though, some people will complain that it feels a little oily on their hair. And people with thin hair want it to be fluffed up. They don't want it to be matted down on their head.

LISA CLARK: Dr. Sawaya, let's discuss some of the medical side effects to using Rogaine. There are some physical effects that patients might experience.

MARTY SAWAYA, MD: With regards to the vehicle itself, sometimes they may experience some dryness to the scalp, mild burning and tingling. And that's usually, again, due to the vehicle, not the drug itself. So a lot of times I'll have patients put on a moisturizer afterwards, and then wash it out in the morning. Again, some people can get by with using it once a day. I usually will tell patients to put about twice the amount on in the evening if you can't put it on in the morning, but do apply it on a daily basis, preferably twice a day. And if you are having any burning or itching, put a mild moisturizer on that can alleviate some of the dryness and itching.

You may also have some flaking, and that's really the residue of the medicine on the scalp. So it's really not that you have dandruff; it's just the residue of the medication. So shampooing daily, again, is what we will also recommend for most patients, so that they can have a very good cosmetic effect of having a full scalp without having the dryness of it and the actual drug on the scalp if it's bothering them.

LISA CLARK: Ironically, they may lose some hair in initial phase of the treatment, right?

MARTY SAWAYA, MD: It's possible. Not all patients will complain of that. But, again, it's because we're starting a new hair cycle. You're stimulating those little miniaturized follicles to start up and wake up again, so that they can start a new cycle. So they may see some initial shedding in the beginning. But, again, you have to really tell each patient: Stick with it for three to six months, and start noticing the subtle, positive signs, such as decreased shedding.

Part the hair down the center of the scalp. Notice if that part width is getting better and better through the months of use. That is, it's getting to be a tighter part. That's a very, very positive sign, decreased shedding and noticing the part width on your scalp. Those are very, very helpful signs.

LISA CLARK: Are there any special issues, especially for women, especially those that might be related to childbearing issues, in using minoxidil, Rogaine?

MICHAEL L. REED, MD: I think, since we never test drugs on women who are pregnant or may become pregnant, that we have to be a little circumspect. Generally speaking, when a woman becomes pregnant, her hair grows better than any minoxidil preparation will do for her, so I suggest -- I don't tell people to stop if they're trying to become pregnant. I tell them that if they believe they've become pregnant or they become pregnant, they should stop it then. They can start it after the pregnancy again.

LISA CLARK: Let's talk about a couple of other drugs which can be used to combat hair loss for women. These are not topical solutions, they're oral medications. Finasteride?

MARTY SAWAYA, MD: Finasteride, Propecia is really for men only. There are doctors using it off-label for women and, again, at different doses, about 2.5 mg. Propecia is sold as 1 mg of finasteride for men only. It's not approved for women by the FDA, but there are physicians using it off-label for women, at say 2.5 mg or even 5 mg, and they are finding it helpful for some women, depending on their particular phase of androgenetic alopecia. So, again, it's not an indicated use; it's an off-label use.

LISA CLARK: Again, this is a treatment that has primarily been used for men. Are there special concerns about women using it, which means it an off-label?

MARTY SAWAYA, MD: The reason is because young women who may potentially become pregnant, carrying a male fetus, may have a risk of forming small genitalia in the male fetus. It's called hypospadias, and it's a common anomaly in, say, two births out of 100. So they don't want the drug being blamed for this common anomaly that can happen to women even when it's normal pregnancy.

So it's a risk to the male fetus, for a young woman who happens to become pregnant, so therefore it's not indicated for women who may potentially become pregnant, and this is the risk for young women. Some doctors are using it for middle-aged women where there is no risk of pregnancy. But, again, it's that doctor's indication, depending on that particular patient and whether they feel it would be worthwhile for that patient.

Most of the time, I'll probably recommend Rogaine or minoxidil first, and consider any systemic aspects to androgenetic alopecia, whether it would be warranted to look at finasteride in women. So it's not my first-line indication or treatment in women. It's something later on the list that you can consider if you've ruled out other medical problems.

LISA CLARK: Do you agree, Dr. Reed?

MICHAEL L. REED, MD: I think, certainly, if someone is going to use an off-label indication, they should be an expert in the field. They should be an authority who, like we do, treat people like this every day, and not someone who's a general practitioner who heard it works. Because women are so upset about their hair that they might not be thinking rationally and they might become pregnant on it, which could be a potential disaster.

However, understand that it takes about seven years between when we know out there in the trenches of hair loss that something really works, is safe and effective -- it takes seven years between that time and then when it's really FDA approved. This is called drug lag. And during that seven years, a lot of people need help, and so, if someone does know about the drug, really understands it and has a cooperative patient who's not going to become pregnant, especially if she can't become pregnant, then there's no reason why she can't give the drug a try.

LISA CLARK: Let me mangle another medical name here, spironolactone. Describe how that works.

MARTY SAWAYA, MD: This is another old drug that we take from the PDR and use for another indication. This is what we say is an anti-androgen. It's working against dihydro-testosterone by blocking the receptors. It has a lot of effects on the body, but they're hoping to use it in this instance where it can help hair loss.

They've found in some studies in the literature that it's not as helpful in hair loss on the scalp as it is for helping women who have excessive hair growth on the body. You have to use high doses of this medication, and it does have side effects. And it's not a drug, either, that you'd want to take if you have any potential risk of becoming pregnant.

It's not a drug that I would use, and it's not one that I actually do use in considering patients with this kind of problem. But it has been used by many doctors for a long time because our treatments were so limited in women. So, again, you have to understand that this is not a drug that's easy to prescribe. You have to watch and monitor patients. You have to use it at high doses, and women can have side effects.

LISA CLARK: Let's move on and ask about women who are having these treatments, whether they're the oral medications or the topical preparation. Do they need to be concerned about their general cosmetic interactions with, say, mousses or gels or anything? Do they have to be especially concerned about how they treat their hair when they're undergoing these treatments?

MICHAEL L. REED, MD: I tell them that they can do all their normal cosmetic activities. I tell them, which I would tell almost anybody treated for hair loss, not to do things to their hair that's going to pull on it. No corn-rowing or braiding, no tight rollers. Excessive brushing and pulling on the hair is to be avoided. But they can color their hair, they can perm their hair, they can wash their hair, they can blow-dry their hair. Just gentle hair care. Washing their hair on a daily basis may be beneficial to get rid of extra oil in the scalp that might have extra hormone in it. But I don't put any real restrictions on them.

MARTY SAWAYA, MD: Actually, when patients are using minoxidil, because it is an alcohol vehicle drying to the hair fiber, sometimes I will recommend if they are going to color their hair, to stop using minoxidil a day or so before and a day or so after, just because there has been, some patients who state a little bit of hair breakage. So because it is a bit drying on the hair fiber, we will recommend maybe stop using it for a day or so before and a day after.

MICHAEL L. REED, MD: One other thing that we didn't get to is that in higher strengths of minoxidil, women can get some fuzzy stuff on their forehead and temples that they really don't like.

LISA CLARK: Oh, really?

MICHAEL L. REED, MD: That's temporary; it goes away. They can remove it with depilatories or have it waxed, but it's something to be aware of, especially in the higher strengths, because nobody wants hair in the wrong places, just in the right places.

LISA CLARK: Final thoughts on the advances that have finally come for women with hair loss. It must be a good time to have a patient come in to you now, when you have these things that you can offer her.

MARTY SAWAYA, MD: That's true. It's better than it was 10 years ago. We have treatments at hand that we can start using today in women. I think from what studies have recently shown is, the earlier you start treatment, the better off you're going to be, versus if you wait around for a long, long time, you're never going to catch up to what you could have had if you started at an earlier stage. It's a very hopeful time period to recommend treatments and have women follow through, and have a very good, positive outcome.

LISA CLARK: Good to know. I'd like to thank both of you for being here to answer our questions again, Dr. Marty Sawaya and Dr. Michael Reed. Thank you very much.

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