Combination oral minoxidil and spironolactone for the treatment of androgenetic alopecia in adolescent girls

Abstract

To the Editor: Androgenetic alopecia (AGA) is an under-recognized form of hair loss in the pediatric population, with very little discussion in the literature, particularly regarding treatment. Topical minoxidil is approved for the treatment of AGA in adults and is used off-label in children and adolescents, although efficacy is variable. Spironolactone has been reported to improve AGA in adult women1Burns L.J. De Souza B. Flynn E. Hagigeorges D. Senna M.M. Spironolactone for treatment of female pattern hair loss.J Am Acad Dermatol. 2020; 83: 276-278Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar as well as in a 9-year-old girl.2Yazdabadi A. Green J. Sinclair R. Successful treatment of female-pattern hair loss with spironolactone in a 9-year-old girl.Australas J Dermatol. 2009; 50: 113-114Crossref PubMed Scopus (18) Google Scholar Oral minoxidil (OM) is approved for the treatment of hypertension, and at standard doses (10-40 mg), potential adverse effects include hypertrichosis (most common), fluid retention, and tachycardia as well as more serious cardiac adverse effects.This risk profile has historically deterred dermatologists from using OM in clinical practice; however, it is being increasingly used at lower doses as a treatment for hair disorders, with the available data suggesting that it is generally safe and well tolerated. Very low-dose OM (0.25 mg-1.25 mg) has been reported to be effective for the treatment of female AGA in adults, both as monotherapy3Beach R.A. Case series of oral minoxidil for androgenetic and traction alopecia: tolerability & the five C's of oral therapy.Dermatol Ther. 2018; 31: e12707Crossref PubMed Scopus (26) Google Scholar as well as in combination with spironolactone.4Sinclair R.D. Female pattern hair loss: a pilot study investigating combination therapy with low-dose oral minoxidil and spironolactone.Int J Dermatol. 2018; 57: 104-109Crossref PubMed Scopus (61) Google Scholar To our knowledge, there are no reports describing the use of OM plus spironolactone for the treatment of AGA in adolescents or the use of a 2.5-mg dose of OM in female patients of any age.Here we present 6 female patients, ages 13 to 18, with AGA treated with OM 2.5 mg daily plus spironolactone 50 mg once (n = 4) or twice daily (n = 2). AGA was diagnosed based on clinical examination combined with trichoscopy, scalp biopsy, or both. Severity of AGA was graded using the Sinclair scale.5Sinclair R. Jolley D. Mallari R. Magee J. The reliability of horizontally sectioned scalp biopsies in the diagnosis of chronic diffuse telogen hair loss in women.J Am Acad Dermatol. 2004; 51: 189-199Abstract Full Text Full Text PDF PubMed Google Scholar Median duration of disease before initiating treatment was 2 years (mean, 2.5; range, 1-5 years).Patient clinical characteristics and response to therapy are detailed in Supplemental Table I (available via Mendeley at https://data.mendeley.com/datasets/vpzhfwf8kr/1). Four patients had suboptimal response to prior treatments, including topical minoxidil monotherapy (n = 2), spironolactone monotherapy (n = 1), and combination topical minoxidil and spironolactone (n = 1). Patients had a Sinclair stage of 2 or 3 at the onset of treatment with OM plus spironolactone, and after 5 to 13 months, 5 patients demonstrated a 1-grade improvement (Fig 1; Supplemental Fig 1, a and b), and 1 patient maintained the same grade but clinically was slightly improved (Supplemental Fig 1, c and d). All patients tolerated treatment well without adverse effects.AGA can cause emotional distress at any age, but given the psychosocial pressures of adolescence, it can be especially devastating for teenagers. Because of its progressive nature, early intervention is of particular importance. In this series, the combination of OM and spironolactone led to objective improvement in 5 of 6 patients. No patients experienced hypertrichosis, which we suspect may be at least in part attributable to the antiandrogen properties of spironolactone; however, controlled studies will be necessary to further explore this as well as optimal dosing regimens.Limitations of this study include the small sample size and retrospective nature; however, the results are promising and indicate that additional investigation is warranted. We suggest that after proper counseling regarding the risks, the use of spironolactone plus OM may be considered for adolescent girls with AGA. To the Editor: Androgenetic alopecia (AGA) is an under-recognized form of hair loss in the pediatric population, with very little discussion in the literature, particularly regarding treatment. Topical minoxidil is approved for the treatment of AGA in adults and is used off-label in children and adolescents, although efficacy is variable. Spironolactone has been reported to improve AGA in adult women1Burns L.J. De Souza B. Flynn E. Hagigeorges D. Senna M.M. Spironolactone for treatment of female pattern hair loss.J Am Acad Dermatol. 2020; 83: 276-278Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar as well as in a 9-year-old girl.2Yazdabadi A. Green J. Sinclair R. Successful treatment of female-pattern hair loss with spironolactone in a 9-year-old girl.Australas J Dermatol. 2009; 50: 113-114Crossref PubMed Scopus (18) Google Scholar Oral minoxidil (OM) is approved for the treatment of hypertension, and at standard doses (10-40 mg), potential adverse effects include hypertrichosis (most common), fluid retention, and tachycardia as well as more serious cardiac adverse effects. This risk profile has historically deterred dermatologists from using OM in clinical practice; however, it is being increasingly used at lower doses as a treatment for hair disorders, with the available data suggesting that it is generally safe and well tolerated. Very low-dose OM (0.25 mg-1.25 mg) has been reported to be effective for the treatment of female AGA in adults, both as monotherapy3Beach R.A. Case series of oral minoxidil for androgenetic and traction alopecia: tolerability & the five C's of oral therapy.Dermatol Ther. 2018; 31: e12707Crossref PubMed Scopus (26) Google Scholar as well as in combination with spironolactone.4Sinclair R.D. Female pattern hair loss: a pilot study investigating combination therapy with low-dose oral minoxidil and spironolactone.Int J Dermatol. 2018; 57: 104-109Crossref PubMed Scopus (61) Google Scholar To our knowledge, there are no reports describing the use of OM plus spironolactone for the treatment of AGA in adolescents or the use of a 2.5-mg dose of OM in female patients of any age. Here we present 6 female patients, ages 13 to 18, with AGA treated with OM 2.5 mg daily plus spironolactone 50 mg once (n = 4) or twice daily (n = 2). AGA was diagnosed based on clinical examination combined with trichoscopy, scalp biopsy, or both. Severity of AGA was graded using the Sinclair scale.5Sinclair R. Jolley D. Mallari R. Magee J. The reliability of horizontally sectioned scalp biopsies in the diagnosis of chronic diffuse telogen hair loss in women.J Am Acad Dermatol. 2004; 51: 189-199Abstract Full Text Full Text PDF PubMed Google Scholar Median duration of disease before initiating treatment was 2 years (mean, 2.5; range, 1-5 years). Patient clinical characteristics and response to therapy are detailed in Supplemental Table I (available via Mendeley at https://data.mendeley.com/datasets/vpzhfwf8kr/1). Four patients had suboptimal response to prior treatments, including topical minoxidil monotherapy (n = 2), spironolactone monotherapy (n = 1), and combination topical minoxidil and spironolactone (n = 1). Patients had a Sinclair stage of 2 or 3 at the onset of treatment with OM plus spironolactone, and after 5 to 13 months, 5 patients demonstrated a 1-grade improvement (Fig 1; Supplemental Fig 1, a and b), and 1 patient maintained the same grade but clinically was slightly improved (Supplemental Fig 1, c and d). All patients tolerated treatment well without adverse effects. AGA can cause emotional distress at any age, but given the psychosocial pressures of adolescence, it can be especially devastating for teenagers. Because of its progressive nature, early intervention is of particular importance. In this series, the combination of OM and spironolactone led to objective improvement in 5 of 6 patients. No patients experienced hypertrichosis, which we suspect may be at least in part attributable to the antiandrogen properties of spironolactone; however, controlled studies will be necessary to further explore this as well as optimal dosing regimens. Limitations of this study include the small sample size and retrospective nature; however, the results are promising and indicate that additional investigation is warranted. We suggest that after proper counseling regarding the risks, the use of spironolactone plus OM may be considered for adolescent girls with AGA. Dr Craiglow has received honoraria and/or fees from Aclaris , Arena Pharmaceuticals , Regeneron , Sanofi Genzyme , and Pfizer . Author Olamiju has no conflicts of interest to declare.