hi everybody I'm Dr Russell nudson and I'm Dr vicam J aash welcome to this episode of the hair loss show where today we're going to discuss the side effects of minoxidil and we're going to specifically compare tropical minoxidil with oral minoxidil welcome to the hair loss show Dr Russell nudson and Dr vicam J aash discuss issues relating to hair loss and the medical and surgical treatment of hair loss in both men and women right so welcome back to the show thanks again for watching so uh one of the uh one of the medications that we use a lot when we're managing patients with hair loss both men and women is minox and minox comes in in a variety of different uh formats commonly uh you can certainly here in Australia you can get topical monoxil either as a liquid or a foam and that's freely available over the count so you don't need a prescription here in Australia to get that um but there's also you can get monoxil in the oral format and the tablet format and that here in Australia you do need a prescription there are other forms as well there are subl uh forms of minoxidil but in essence you know there what we describe as a topical form of monoxil and an oral form of uh monoxil which we're seeing excellent results really good results in terms of you know helping and managing people that are suffering from from hair loss so just a little history of monoxil was originally orally used to treat high blood pressure and one of the side effects of oral monoxil was General stimulation of hair which tweaked the idea that perhaps you could use Minoxidil to assist as a hair stimulant and so the idea was we only wanted to stimulate hair on the head so we put it into a liquid form and so that came into the marketplace in Australia in 1989 after we did the research in 1984 85 I was one of the five doctors in Australia the research um and so the the idea behind it was that you apply it just to the area that you needed and we've learned a lot obviously in the last you know 40 years or 35 years about monoxil so in the liquid form it's formulated with alcohol propylene glycol as the carrier and water and propylene glycol unfortunately has the potential in a small percentage of patients to call the contact irritant dermatitis and this is one of the complaints we get about the uh the use of the liquid form that you can get a contact dermatitis get an itchy scalp and some people say tness all of that sort of stuff so if you get that then really you don't it's the probably the propine glycol although I also seen it in people when you when you get a special formulation made with no propline glycol in it they still can get that reaction seen that as well so I think there is a reaction potentially to the monoxil itself so that's why later on they the company that was making um the original form of monoxil developed as a foam because the foam would not have uh the propline glycoline would be less oily less greasy and for particularly for women this was a big complaint that they got um oiliness they got greasiness of the hair associated with it so there are a few things that are important to remember about it firstly that you don't measure the amount you use because if you got a small area you use a small amount of if You' got a large area you use a large amount the second thing I would emphasize is that we want it on the skin not on the hair and so what I often say to my patients is use a cotton Bud dip and paint yeah and then you get less of this side effect of greasiness or oiliness of the hair the other thing that people um you know uh can complain about um is more to do with the oral form um you can get hair growth in the face in women from the topical form that's why they formed in a 2% version that's distinct from the 5% version for the men so there was less risk of getting the facial growth which women weren't very happy about um so you can get that you still can get it with the topical form but when you get into the oral form you need to use it in a dose that's not going to affect the blood pressure which is quite a low dose but it can have other effects now in my experience I've had a couple of patients complain about getting palpitations from it so that's a function of the way it affects blood pressure so even in do if you're sensitive you could get a palpitation from it I've had someone tell me that aggravated the migraine so if you understand how migraines work it's it's the pulsatile Dil dilation and constriction of the blood vessels in the scalp that cause the throbbing headache and the nausea and because the drug opens up blood vessels again if you're very sensitive even in low doses it could aggravate a person prone to migraine so I've had that and the other other one that that the people have complained about is weight gain which would be water retention as part of the the side effects so these are kind of the different side effects you can get but apart from the one big one they complain about and they all think they're going to get which is I've heard if I use monoxil all my hair is going to fall out very very quickly sheding and the dreaded monoidal shed the monox shed and they and and people obviously think that's a bad thing whereas I try and you know reverse the idea and tell them it's a good thing because for the 50% of people that respond well to monoxil what's happening is the monoxil is stimulating the hair F will produce the next hair which pushes out the previous hair faster and starts the next cycle so it means that the new hair the stronger hair is coming through well it tells me that if you are shedding on the noxel you're a responder and only about 50% of people are very good at responders because minox has to be converted in the skin into monoxy sulfate to work and that doesn't happen with everyone does no not everybody has enough enzyme to do it yes so if you're shedding it means you're a responder so that's really good and so I mean there's a lot to unpack there so I I guess the first thing let's talk about uh the topical version so uh I'm sure you you you this is in your experience probably the liquid is probably more prevalently available uh readily available in in pharmacies than the foam uh so most people if they're buying uh topical monox that will probably be their Pap than the phone uh so that's probably their first go-to so I think if you're using that that's fine you know as as Russell was saying remember it's got to be applied to the scalp but if you are getting uh and once a day and once a day it says twice a day in the box but I would ignore that because it lasts 21 hours in the skin so again you can make it go a lot further if you're using it once a day and get exactly the same effect well there two yeah so that's that's very true there's also the other aspect of things is that they they're quite prescriptive on the bottle of of the volume that you need and well if someone is thinning over a large area versus someone's thinning in a smaller area well that will inherently dictate the volume of of the actual medication that you need so you want to apply it to to the scalp and remember you know parting the hair and applying it to the scalp in that in that fashion now let's say someone uses the topical Mo oxal liquid starts getting uh it starts getting bit red itchy the next thing to suggest and what we do normally in clinic saying right swap to the foam what about transitioning between the liquid to the to the foam is there should there be a gap in time or you just go right okay I think you need to let the scalp recover yeah before you do it um so I would want the dermatitis if that's what the the problem is to settle down before I um apply the fir um and that's probably not going to take very long it it be weak maybe it would settle down and they're not going to lose hair during that time no not in that week and the other thing that's important to understand um for people who are worried about we to apply it um and grooming is that the foam absorbs in 10 minutes the liquid absorbs in about 60 to 90 minutes right so when people say well you know like how do I have to sort of shower like I had an email last week from Guy saying he doesn't shower for two weeks or he doesn't work two days after he applies the Theo because he's because he's he's worried he's he's washing it off before it's absorbed and I was trying to reassure him that even if he's using the liquid it's an hour not two days and uh and that if it's the foam it's even quicker so there are slight differences in the absorption between them yes um but I think that the the the incidence of side effects from the foam is lower than it is with the liquid but it's not eliminated we still get people that react to the foam because the foam doesn't contain the propylene glycol which is probably caused the main irritant and of course in most of the cases but like you said there are certain people who are probably sensitive to the to the active uh drug I find it if we swap them from the topical to the oral yes usually solves all of those problems yes um it's it's there's side effects on arod oxid dool less than than anything else that we that we use as long as you're using a low enough dose and you can start with a low dose like a half milligram or a milligram and make sure that there's no dramas there particularly lower dose in the women because they don't want the facial hair than the men and then you can gradually increase it as you go along uh and we do that through compounding right so the tablet comes in one size and people can cut it in halves or quarters but with compounding you can specify the dose you want and Vary that and then slowly dial it up with people to see that they're they're not getting any problems with it and the other very important thing about this is that the what we want is something that's easy for people to do yes and if they are not enjoying using the topic or product or they find it difficult to remember to do it or find time to do it that fits in with their sleep schedule or their washing schedule then oral makes it a lot easier for them and it'll work a lot better if they take it then if they don't yes so compliance is a big issue but I think to to the point that you made about the dosing or certainly the side effects with the with oral monoxil if you're a patient and you've been put on oral monoxil and you experience some of those side effects the palpitations or the the migraines uh or the the LI headedness does not mean that you cannot take oral monoxy it just means you need to find what the right doses for you well I mean everybody's unique yes in this world and and and so there is no one- siiz fit sort approach that works for any of these medications and as I said you can start low to make sure that you're okay particularly if someone's had side effects from tropical monoxor you would want to start low on quite low on the orom oxil and then just gradually dial it up if a little bit I mean the the quarter of the 10 is still allegedly at the point where it doesn't affect the blood vessels and there is a in the literature it tells you that even if you use 10 milligrams in a person who's got normal blood pressure doesn't lower blood pressure uh it's it only lowers blood pressure uh for people that um have high blood pressure but I don't think that's entirely correct because if you have borderline borderline low blood pressure I've had patients tell me they get what we call postural hypertension which means they go from sitting to standing and they feel dizzy because they've dropped their blood pressures they've got up so if you're on orom minoxidil and you find that you get dizzy from changing from a line position or a sitting position to a standing position that means that you've got borderline low blood pressure and we have to get the dose down lower yeah so it and and I think that's probably you know for me one of the the the mission critical parts of this whole process which is that not every like you said not everyone is the same everyone has a unique response into How uh how they respond to different medications and so they may need to be taken down that path of right okay well this is how we're going to try and build up and find the optimal dose for you and that's why it's important if you're suffering from hair loss to make sure that someone who knows how to manage this how to navigate through the different you know versions of of the medication and the different doses why that's really important as particularly because that's right the the topical ones are off the shelf uh and so you know you're going to need some good advice if you're going to use it Lally perfect oh good I think that's a really good summary of the of the side effects so uh and I hope I hope you found that uh useful and again thank you very much for watching I would reassure everybody that it's one of our favorite treatments because when we're treating any type of hair loss you know uh when people are concerned about the hair volume even when they're aging right and and as we age we get a little bit thinner and the hairs get a little bit finer anything that is a genuine stimulant that gives people that feeling of a bit more volume uh in their hair is is beneficial so I think that an oxal is a very useful drug it's one of that key it's one of our key treatments that people as you mentioned you know it started in 1984 so it's it's it's held it's still the test of time oh yes we've got plenty of experience with that we know exactly what we're dealing with and and that's that's really important and and you know sort of leads on to a great point because there are you know you get a lot of questions uh about oh what about this Medicaid you know uh you know this medication that's coming on the market that's you know in phase three of of Trials and all this sort of thing what do you think and you know is it better than monoxil and and one of the things I say is that look monoxil has got this great history you're writing on the coiles of you know millions of people before you that have uh you know walked that path and then the other thing is that there are the lookalikes the stem o you so they basically change one or two things in the format of an oxal and go oh this works just just as well well show me the evidence right show me the evidence that changing these this part of the formula to that part of the formula actually gives you an equivalent response don't just say well you know it's it's similar yeah and I think the fact that it's got that much data behind it you know gives me that sort of uh much you know that much more reassurance to be able to authentically you know suggest it to to our patients when we're when we're having that conversation and one last last point is that people who give up on minox give up on it for two reasons either they don't stand it long enough to see a response or number two they're looking for the wrong response so we know that the higher response rate with monoxil is stabilizing you and slowing or stopping further hair Lots at least for a period of time um but they all think that it's failed unless it's regrown here and the other one that I that I want to address because we're talking about mon oxal is all I I hear it stops working after 12 or 18 months no it it's still a stimulant but if you use a stimulant by itself in some people it's not enough to stop progression of the hair it'll just slow it down so it's not that your body becomes used to it it stops working it's just was never going to be 100% effective at stopping further hair loss good well thanks again for watching I hope you that's giving you a really good summary uh and insight in that discussion about the monoidal and its uses and side effects um again please remember to like And subscribe to the channel uh thank you for all your support and uh we look forward to seeing you on the next show thanks everyone byebye 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