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What Guys With Thinning Hair Should Know About Off-Label Hair Growth Prescriptions

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Dermatologists are increasingly prescribing minoxidil—the active ingredient in topical products like Rogaine—as a hair-growth remedy to be taken orally. 

a collage of sean connery with purple and blue color filters hand painted over the top

Photograph: Getty Images; Collage: Gabe Conte

I got a lot of texts this weekend from friends with a link to a New York Times article about oral minoxidil, which is not approved by the FDA but is often administered by doctors for the treatment of hair loss. “Should I be taking this?” was the general tone.  And if I (a grooming professional without a medical degree) was getting a bunch of curious texts, I could only imagine the number of inquiries that dermatologists have been fielding on the topic. So I caught up with one of my most trusted hair doctors, board-certified hair restoration surgeon Alan J. Bauman of Bauman Medical in Boca Raton, FL, to answer some of the most common questions.   

How to treat hair loss

Before we talk about off-label minoxidil, let’s quickly review the most common ways to retain your hair. Short of a transplant, these are the primary medical options for balding guys. (Any supplemental efforts, like shampoos and literal supplements, are exactly that: merely supplemental.)  

Oral finasteride: This is the generic of Propecia. It is usually prescribed in 1mg pills, and it works, but it comes with one big warning: Some 2-3% of users experience lowered libido or compromised erections. (Less commonly, you’ll see topical finasteride, which seems to avoid some of the worst sexual side effects.)  

Topical minoxidil: This is the generic of Rogaine. It is now available over the counter, and is most commonly administered (as a topical serum or foam) to the site of hair loss to extremely favorable success rates. Minoxidil works by increasing blood flow (and thus nutrient delivery) to the hair follicles, which strengthens them and produces stronger, more anchored hairs. It also increases the amount of time these hairs spend atop the head, and minimizes the time they spend dormant between shedding and regrowth phases. So, that’s stronger hair, in longer intervals. Minoxidil is especially useful in treating uniform thinning and patchiness around the crown of the head. And the chief complaints with this topical drug are that it leaves a residue on the scalp or hair. 

In both cases these are treatments for thinning hair, not guys who have gone all the way bald, which is too far gone to recover. 

So what’s the deal with oral minoxidil?

As the Times article explains, many doctors have been prescribing an off-label oral minoxidil tablet for years, and see overwhelming success with the ingestion method—without the mess or irritation of a topical. Since these pills are so cheap and available generically, it doesn’t make a lot of sense for anyone to pursue an FDA approval to the tune of tens of millions of dollars, and thus they will likely remain off label. The term for this type of customized treatment—wherein it doesn’t come from an FDA-approved, commercial provider—is compounding.

“In the U.S., compounding pharmacies are not supposed to tout off-label medication benefits; that’s the whole reason for the FDA-approval: to allow for the marketing,” explains Bauman. “Sometimes drug companies will try to suppress the info if they have an alternative or competing drug that’s coming on the market. The effective ‘lifespan’ of a drug’s profit is the short window while the medication is patent-protected.”

And oral minoxidil isn’t the only option out there. For example, Bauman himself swears by a recipe called Formula 82M, which is a topical combination of tretinoin (a retinol), fluocinolone (a corticosteroid), minoxidil, and finasteride. He’s been prescribing it in his clinic to what he says are astounding results for nearly two decades without FDA approval. 

So, should you be using oral minoxidil? 

The top advice I have for anyone who wants to start a hair retention program is to visit a  dermatologist (or a hair restoration surgeon like Bauman). That’s also going to be the only way to get oral minoxidil.

Bauman suggests starting with the “tried and true” methods first and foremost. These would be oral finasteride and topical minoxidil. “Then as we get further down the road, we can make adjustments and take a more nuanced approach if necessary,” he says.

You’ll want to get a clear indication from your doctor about any risks of these and any compounded medicines. Chances are, they have prescribed it plenty of times and know what to watch for. “If you overdose on oral minoxidil, you can land in the hospital,” Bauman says. “The good news, though, is that that would only happen if you were not paying attention to the recommended low-dose strategy. Risks are low with minoxidil microdosing and if you do get a systemic side effect, it comes out of your system within a day or so.”

One more thing to know: An oral ingestion of minoxidil can cause thicker, darker hair growth all around the entire body; it’s not like the drug knows just to target the top of your head. On one hand, maybe you can finally grow a real beard (which Bauman says he has witnessed in some patients), but on the other, maybe you need to dust off your body grooming skills.

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