Pill Pushing©

The Best of Pill Pushing - Rogaine - Breaking Bald - (5/17/2018)

By Dr. Ron Gasbarro 

The drug in question – Rogaine (minoxidil). The culture at that time – Fat and bald – words not many men like to hear. Men – and more than a few women – can be vain about their hair. Obesity was something you could correct. But beyond wearing a toupee, fashioning a 12-inch comb-over or joining the Hair Club for Men, there was little you could do about being called the pejorative term “chrome-dome.”  Whether it was a mullet (business in the front, party in the back!), the Mr. T. Mohawk, or Duran Duran-ish feathered hair, having hair was essential in completing one’s public façade. Pattern baldness was definitely not the way to go. 
For men who are losing their hair, how much are they willing to give up to reverse the experience. According to the Statistic Brain Research Institute,  47% of those with hair loss would spend their life savings to get back a full head of hair; 60% of those with hair loss said they would rather have more hair than money or friends; and 30% of those with hair loss they would give up sex if it meant that they would regain their hair – 30%. 
Hope springs eternal. And so did hair when, in 1988, the Upjohn Corporation introduced a topical solution containing 2% minoxidil indicated to treat baldness and hair loss. Rogaine was born and the dreams of flowing manes seemed reachable. 
In the decade prior to its hair ribbon-cutting ceremony, minoxidil was a drug looking for a home. Earliest indications included severe hypertension coupled with renal failure [Pettinger & Mitchell, 1973]. The drug was found to cause regrowth of hair in some patients with hair loss and the company saw dollar sign. Now, minoxidil is indicated for pattern or common hair loss that starts at the crown of the head. How does it regrow hair? Because minoxidil is a vasodilator, it widens the blood vessels and allows more oxygen, blood, and nutrients to travel to the hair follicles. This allows the starved hairs to shed and be replaced by thicker, more nourished hairs [Burton 1975]. Sort of like pruning the deadwood from a lilac bush to make way for the healthier shoots that pop up from the bottom. Does it work for everybody? Tragically, no. The balder you are, the longer you have been bald and the older you are, makes minoxidil less effective [Buhl, 1991]. In other words, Louis CK and Ed Harris need not apply. And Walter White (Breaking Bad) would never even consider it.
The good, the bad, and the ugly – In the early 1990’s, minoxidil was evaluated as a topical treatment for erectile dysfunction [Cavallini, 1991; Radomski, 1994]. Imagine a drug that could grow hair and a penis! However, study results were limp. Shortly thereafter, sildenafil (aka Viagra) emerged and that multi-billion dollar blue pill went viral. 
Nevertheless, Rogaine’s position as the only FDA-approved baldness treatment left in the dust every other baldness remedy, from raw eggs to black pepper paste. According to Upjohn, Rogaine has enjoyed cumulative sales of $700 million in the US and exceeded $1 billion worldwide since its inception. 
Although the following systemic effects are not common where minoxidil is used on the skin, there is some absorption of minoxidil into the bloodstream and the potential exists for cardiovascular problems such as tachycardia (abnormal racing of the heart), angina (chest pains), edema (water retention) or orthostatic hypotension (dizziness when getting out of a bed or chair) [Minoxidil, 2012]. Stop using the product if you experience any of these debilitating side effects. Fluid retention and edema (fluid retention) can be managed with a diuretic, a drug that increases the excretion of fluid. Tachycardia and angina can be controlled by administration of beta-blockers or nitroglycerin. You may end up in the emergency room, but you will have thick lustrous hair should you need to be wheeled to the morgue. 
Impact of the drug on our culture – Along with Botox®, Retin-A®, Viagra®, Cialis® and Levitra®, the successful Rogaine brought out the Narcissus in many of us. Although you can’t be too thin or too rich, apparently you also can’t be too hairy, tumescent, or wrinkle-free. One’s coolness and hip factors are secure with these products, even if we are not too secure inside our heads. As the world continues to watch Prince William’s bald spot grow because photographers continue to shoot him from behind – think of him kneeling in front of the altar at his wedding – the buzz has been that he would be the perfect spokesman for Rogaine. According to a 2011 report by Life & Style Weekly, a Rogaine rep commented on Prince William's hair loss: "We've been watching Prince William's growing bald spot closely for years, and we believe Rogaine can help. William would be the perfect spokesman for Rogaine because whether you're a prince or an average Joe, hereditary hair loss affects one in four men." Methinks the Rogaine rep was more concerned about selling product than giving the world a more hirsute prince.  
Where the drug is today – Now off-patent, the topical forms of the drug are completely over the counter, in 2% and 5% strengths – no prescription needed. Rogaine comes in both foam and solution formulations and is packaged separately for men and women. Rogaine also has its own app via ¡Tunes whereby one is reminded when the product needs to be applied and when you need to buy a new supply (sells more Rogaine for the company too!) 
Oral minoxidil continues to be used, albeit rarely, as an antihypertensive agent because it is a powerful peripheral vasodilator and can decrease the effects of heart disease. However, the package insert contains many serious warnings. For example, oral minoxidil can cause pericardial effusion, an abnormal amount of fluid in the sac that encases the heart. This fluid accumulation can progress to tamponade, a life-threatening situation in which there is so much fluid (usually blood) inside the sac surrounding the heart that it interferes with the performance of the heart. Also, angina pectoris (chest pains) may be worsened. This oral drug should be reserved for hypertensive patients with compromised renal function who do not respond adequately to maximum therapeutic doses of a diuretic and two other antihypertensive agents. Minoxidil tablets must be administered under close supervision, usually concomitantly with a beta-adrenergic blocking agent (beta-blocker) to prevent tachycardia (abnormally fast heart rate) increases the workload of the heart muscle. A diuretic is also necessary to prevent serious fluid accumulation. In experimental animals, the oral form of the drug has been shown to cause that heart muscle to literally die. Good for hair, scary for everything else. 
While Rogaine the product has made a bundle for its manufacturer, it may have some competition nipping at its heels. A Korean study compared the use of low dose minoxidil to peppermint oil and found that the oil grew hair just as well as Rogaine, but without the toxic side effects [Oh, 2014]. You may smell like a stick of Wrigley’s gum but people will only notice your cascading locks. 
Ron Gasbarro, PharmD is a registered pharmacist, medical writer, and principal at Rx-Press.com. Write him at ron@rx-press.com.  
Buhl AE, Conrad SJ, Waldon DJ et al. Potassium channel conductance as a control mechanism in hair follicles. J Invest Dermatol 1993; 101: 148S-52S.

Burton JL, Schutt WH, Caldwell IW. Hypertrichosis due to diazoxide. Br J Dermatol 1975; 93: 707-11.

Cavallini G. Minoxidil versus nitroglycerin: a prospective double-blind controlled trial in transcutaneous erection facilitation for organic impotence. J Urol. 1991;146:50-53.

Koblenzer PJ, Baker L. Hypertrichosis lanuginosa associated with diazoxide therapy in prepubertal children: a clinicopathologic study. Ann N Y Acad Sci 1968; 150: 373-82.

Minoxidil [prescribing information]. Spring Valley, NY: Par Pharmaceuticals, Inc.; 2012.

Oh JY, Park MA, Kim YC. Peppermint oil promotes hair growth without toxic signs. Toxicol Res. 2014;30:297-304.

Pettinger WA, Mitchell HC. Minoxidil – an alternative to nephrectomy for refractory hypertension. N Engl J Med. 1973;289:167-71. 

Radomski SB, Herschorn S, Rangaswamy S. Topical minoxidil in the treatment of male erectile dysfunction. J Urol. 1994;151:1225-6.

“Rogaine: We want Price William!” Life and Style Weekly. Englewood Cliffs, NJ, December 30, 2010. Available at: http://www.lifeandstylemag.com/entertainment/news/rogaine-we-want-prince-william  

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