Speaker- Kiran Vasant Godse

Over the next five years, molecules like —minoxidil, tranexamic acid, Janus kinase (JAK) inhibitors, and biologics—will significantly transform the treatment landscape for dermatology. Oral minoxidil emerged as a crucial agent capable of altering treatment effectiveness, prompting the development of an evidence-based consensus statement a year ago to assess its potential. It is commonly prescribed to most patients experiencing hair loss, the high prevalence of hair loss, highlights the need for a safe and effective therapeutic solution. The effectiveness of topical minoxidil was influenced by the activity of the sulfotransferase enzyme in hair follicles. Although a booster formulation of minoxidil became available, it was not suitable for daily use due to, multiple applications and associated itching and irritation. Itching was a prevalent issue, and formulations based on water or coconut oil did not demonstrate optimal efficacy. In India, the demand for a safe and effective solution for minoxidil remained evident.

The clinical unmet need for oral minoxidil arises from the variability in sulfotransferase enzyme activity in hair follicles, which affects the efficacy of topical minoxidil. Additionally, adverse drug reactions (ADRs) related to topical minoxidil, such as itching, irritation, eczema, allergic contact dermatitis, and redness or burning at the application site are very common, and they affect the long term use of minoxidil. As topical minoxidil requires twice-daily application it contributes to compliance issues. Oral minoxidil addresses these challenges by eliminating variability in enzyme activity, as it is converted to minoxidil sulfate by hepatic sulfotransferase (SULT) enzymes, ensuring complete conversion and avoiding topical side effects. Oral minoxidil also improves compliance with once-daily dosing. Originally developed nearly 50 years ago as a topical antihypertensive agent, minoxidil was associated with side effects like hypertrichosis, which later proved beneficial in promoting hair growth in areas such as eyebrows and nails. For hair loss management, clinical evidence supports oral doses ranging from 1.25 mg to 5 mg daily. The maximum dose for blood pressure reduction is 50 mg daily, with pediatric dosing starting at 0.2 mg/kg. However, patients with hemodynamic instability were cautioned against its use. Overall, most patients were able to utilize oral minoxidil safely. 

Minoxidil is a medication used to treat alopecia areata, telogen effluvium, and female-pattern hair loss (FPHL). Its effectiveness is well established, with studies indicating a positive response in most patients, including those with scarring alopecia. However, females are advised against higher doses due to the risk of hypertrichosis and the development of thick eyelashes and eyebrows. Compared to topical treatments, oral minoxidil demonstrated superior efficacy, achieving a success rate of 70% versus 46% for topical formulations. Some of the side effects of Minoxidil, include hypotension, leg swelling, dizziness, fluid retention, and weight gain. Notably, the weight gain observed was attributed to edema rather than an increase in fat. Other common side effects include lightheadedness, headaches, insomnia, and pronounced hair shedding. To mitigate these adverse effects, topical Mometasone lotion and oral minoxidil were recommended during the initial one to two months of treatment to tackle the shedding. If patients experienced leg swelling, evaluating any potential issues related to minoxidil was important. The low-dose formulation was deemed very safe, alleviating concerns regarding mineral imbalances among patients. 

In summary, compared to topical minoxidil, which has certain limitations such as variability in effectiveness due to sulfotransferase enzyme activity and the need for twice-daily application, oral minoxidil is currently the preferred option. It offers better compliance with once-daily dosing and avoids the adverse reactions often seen with topical application, like irritation and dermatitis. Oral minoxidil may be taken long-term to sustain optimal hair growth. It is critical to avoid abrupt discontinuation, as this can trigger shedding; gradual tapering is recommended to maintain results. oral minoxidil has demonstrated robust efficacy in clinical practice, particularly for younger patients, positioning it as a favorable option for long-term management of hair growth.

Minoxidil is a medication that can be used indefinitely, similar to antihypertensive drugs, and may be initiated in adolescents with androgenic alopecia as it does not interfere with hormonal levels. It has been proven to be effective in treating alopecia areata at a dosage of 2.5 mg, often in conjunction with topical steroid lotions. For telogen effluvium, dosages ranging from 1.25 to 2.5 mg can facilitate the quicker transition of lost hairs back to the anagen phase. Although the exact mechanism of action remains incompletely understood, the treatment promotes a rapid shift of shedding hairs into the anagen phase. Dosing recommendations typically involve starting with a low dose and gradually increasing it to minimize the risk of adverse effects and preferably in the nighttime. 

33, European Academy of Dermatology and Venereology Congress, 25-28 September 2024, Amsterdam