welcome to the hair loss show where two of Australia's leading hair restoration surgeons dr. Russell Knudsen and dr. Vikram Jaya Prakash discuss issues relating to hair loss and the medical and surgical treatment of hair loss in both men and women [Music] hi everyone my name is dr. Vikram Jaya Prakash I'm dr. Russell Nelson and welcome to the hell off show and this is episode number 7 so if you've been with us up till now we've gone through the causes of hair loss and what happens and difference between hair loss and shedding and we've sort of outlined what the the methodologies are of treatments so we talked about blockers and now we're going to move on to the other side of the

equation which is stimulation therapy now as we talked about in the last episode stimulation therapy is designed to do exactly what it says it stimulates the hair it doesn't address the underlying issue certainly and things like male pattern hair loss at androgenic alopecia why the hair is miniaturizing in the first place these stimulators don't really address that issue but what they're doing is they're stimulating the hair so the first thing we want to talk about is what is a product that's been in the market for for many years and until for a long time was this you know was the only therapy really we had for hair loss and that is minoxidil so minoxidil I mean you know a lot about minoxidil though

 you because you were certainly one of the initial the doctors that would be involved in the trials and with minoxidil one chair that's correct Vikram so in 1984 I had the privilege of being one of the five doctors in Australia that did the original research in Australia using minoxidil as a lotion to apply to balding scalps so the background to the story is that minoxidil was originally designed as a tablet to treat high blood pressure and one of the unusual side effects that it produced in the method of action

that it utilizes was that people became hairier so 80% of people using oral minoxidil in the dose that they were using for high blood pressure notice increase in here generally so basically on the arms the legs the chest the face you name it they got hairy it was kind of like a werewolf dream of your life but curiously they also noticed that some of the male patients who were balding got some reversal of their balding using oral minoxidil so this stimulated the idea for the pharmacology company to

Minoxidil side effects review Minoxidil for hair loss

investigate whether you could just stimulate the hairs you want to stimulate so in that scenario you put it into a topical lotion and you only apply it where you want the hair to work now so this research just started in 1984 and we kind of have an idea how it partly works but still 35 years later we don't really exactly know how it works it has something to do with potassium channels but it's really

beyond you know are they my level of knowledge or your wealth of knowledge to go any deeper than that but it certainly does have an effect so we did the research on both men and women Australia had the first woman's trial in the world for using topical minoxidil for the female pattern hair loss it came on the market in Australia in 1989 as a prescription medicine and it's safe that's the important thing to notice this is a safe therapy it lasted as a topical therapy only for about ten years before on

prescription before it became an over-the-counter medication so the first thing I want to tell you about the medicine is that it's an over-the-counter medicine you can buy it from the chemist I think that highlights its safety profiles are rare so if anything's available over-the-counter it's gone through the very rigorous testing and it is and I had was a prescription for awhile when they realized nobody was getting harmed they knew they could downgrade it from a prescription medicine to an over-the-counter medication so this is an important thing for people to know so minoxidil had we don't know exactly how it works but it does two things that we really want to focus on number one it has an


effect upon the hair cycle remember we talked about the hair cycle where we have the growth phase we call the antigen cycle so what Minako does is that um gates lengthens the anagen cycle so the way that becomes noticeable to patients is that they decrease their shedding rate now the advantage of that is that if you fear that you have a hair loss problem or an excessive shedding problem then being able to slow down the shedding rate is good because first that you're less worried number two it means more hairs are growing on your head at any one time than otherwise would be the case that said I've

got to tell you that one thing that does make people nervous is that there is a percentage of patients when they start using minoxidil then in the first month or two months they noticed an increase in shedding rate and I think my golly this is supposed to save my hair and yet it's making head for that even faster well the reassuring thing about this is number one it's a temporary phase number two it tells you that when he is finished growing and they stop being attached to the skin they sit there till

something turns them out when you put minoxidil in the system and you start the next growth cycle it pushes the ohhere out so the reason that people go through this temporary increase in shedding is because the new hair is its course you know oh yeah so that's a good thing it is not a bad I know but what was what I see and what I'm sure you see is that people go oh you know what I tried minoxidil topical minoxidil and it made my hair loss worse and I was like you know this is just this is horrible this is not for me and then they gave up and walked away and the problem with that is that they've

invested in the minoxidil they've tried it for a few weeks they've had all the down sides of it which is that initial shedding without without the benefit and so you you know we also what we say to all our patients if you're starting on minoxidil listen be prepared for that shedding and power through it

because the good stuff is coming you know if you've exhausted that leads into the whole concept of stimulators in that if you remember from our discussion on the podcast about the hair cycle when hair sheds out and replacement here doesn't come through for three months so realistically when you're

using stimulation therapy you can't expect the response to happen in weeks it's going to happen over a period of months so for minoxidil specifically we would say to you it is four to six months before you're really going to notice whether you're getting a benefit or not the first thing you might notice here's a reduction in shedding even if you have that little bit of increase in shedding but for you to

noticed improvement in the quality of your hair and therefore the volume of your hair forget it it's not going to happen in under four months and you'd be very lucky if you're one of the people together at four months it's more in the second six months so you've got a power through as you said and be

patient so people who come and say to us that they've tried and opsal and didn't work there are two questions we asked them number one is how long did you use it for because they may not have used it for long enough and number two I asked them to define failure because what they mean is they didn't grow any extra hair but if I say to them all but did you get worse while you were using

 Minoxidil side effects review Minoxidil for hair loss

minoxidil and said well no and I said then the next question is well what happened when you stopped using minoxidil my so all got thinner so I say the first goal of stimulation therapy is to make sure that you're not deteriorating that's an acceptable result it may not be your favorite result but it's an acceptable result and this is something we talk about all the time is that with medical therapy and I know you say this I said is that the goal of medical therapy at the baseline is stability if we can

maintain stability you and I'm gonna be high-fiving our patients all day long isn't this right because even if the patient isn't ecstatic yes you're not going backwards right this is like leaking buckets all right you know we've got to stop this leak coming out of the bucket so obviously the second phase which takes longer for people to know this is whether they're going to get improvement so if you ask

 what are the percentage success rate of these things there is again it's a complicated thing so let's walk you through it in bite-sized chunks first if you look at the trials about 40% of people that used the Knoxville topically were able to get a noticeable improvement in the quality of their hairs now if we break that 40% into what that actually means it is mostly about increasing the diameter of the shaft of the hair so a weaker hair is becoming a stronger hair and that's what's producing the notable

improvement there is a little bit of an increase in the number of hairs that will grow at any one time but the major benefit of using my nostril is to increase the thickness of the hair shaft so that's the first thing that people need to understand that's what we're trying to achieve so if we look at it from therapy we're saying you need to be on it because we're going to stimulate the hairs and we're going to try and kick them now what I said before is that minoxidil can be used for any type of hair loss not just baldness and man or female pattern thinning for people that have had Maltz which is like

synchronized shedding that maybe after the birth of the child maybe after a fever maybe after transient medication maybe after an acute stressful event even conditions like la pêche alopecia areata where the immune system switch was off the hair follicle we can stimulate the hair follicle to sleep

 Minoxidil side effects review Minoxidil for hair loss

we can get to come back faster so that's the benefit of using the therapy so yes 40 percent of people over time will notice an improvement there's another 40 percent of people who just noticed that they're not getting worse at least in the short term you know one to two years so that's the second

benefit of it so maybe eighty percent of our patients are going to use minoxidil as some kind of success some degree of success and then people say to me well you know how to find I don't know if it's working I said well probably the only way to be sure is to stop it and see what happens so if you stopped the therapy and you stopped stimulating the hair with minoxidil if you notice an increase in shedding some four to eight weeks later then you know that was having an impact upon the hair cycle
so sometimes you have to withdraw to the third green to be sure that it's working about the therapy now the next thing we need to talk about is what's written on the box it says one mil to be used twice a day now there's a reason why it says that it's because that's what we did in the trial and ninety-eight for that's what we submitted the government in 1985 and so the Therapeutic Goods Administration

said yes you can mother you can market it for a mill twice a day that doesn't really address two critical factors number one is how long does the effect last in the skin the answer is 21 hours so realistically it only has to be used once a day if you want to use it twice a day thats fine you're not gonna do any harm but realistically you're needs to be used once a day the second thing is addressing the one mill the reason that one mill was the number was that they were trying to standardize how

everybody in the trial was being treated but but again in real-life situations some people have a small area of hair loss some people have a large area of hair loss so if you have a small area of hair loss like you would put a cream on a rash you just cover the area and the amount is the amount if you've got a larger area you use a larger amount so it really doesn't matter about measuring it to the one mill you

 Minoxidil side effects review Minoxidil for hair loss

don't have to stick to the one mill you just need to cover the area you try to treat so those are two things I want to emphasize number one is once a day is a very reasonable frequency of use number two treat the entire area you want don't just worry about the one mill answer cool so there's a couple

of other things you know so you know sometimes we get a lot of feedback from patients who are on minoxidil or trialing minoxidil and so here's a few things that we commonly go here I'm on 5% minoxidil I hear there's a 7% minoxidil so it must be better than 5% or eyelids now that sounds like a logical thing until you understand what we call a dose response curve which means if you increase the dose do you increase the response the positive response so with minoxidil it works like this yes it works up to about 5% here all right at the 5% mark you're getting this response you go to 7% you

might get that response if you go to 8% you might get that response if you go to 10% you might get that response it's almost a flatline right so basically the reason behind this is marketing because people believe that strongest solutions better so don't be fooled by that if really 7% or 6% or 8% or 9% was better than 5% why isn't it available at the chemist seriously why isn't it so it is so as you can see you know 5% is applicable across the board yes theoretically there's an advantage to 7% but it's

absolutely miniscule and you're not you know it's not gonna be noticeable by most people and the same is true with the inverse because there is a version so if you look at minoxidil which is Rogaine or regain that you might see if the at the chemist there is a men's version of it and there is a female version of it so for men mostly that will use 5% for women you can use 5% or 2% now the reason that we have these two different ones is because some women are very fearful of getting increased

facial hair from absorption through the skin using the 5% and the interesting fact is that if you start on 5% you get a quicker response than if then you start on the 2% it's not necessarily a better response so what you can do in this situation is if we have women who are using 5% and they're noticing a little bit of increased facial here we can downgrade them to 2 to 3% to help that because that's reversible

by the way that increased the stimulation is reversible which also tells you if you stop the third that you lose the effect so it is a reversible effect in all cases so you can often maintain someone on 2%

after you've started them on them for 5% so that's okay so there are difference between the pink box and the blue box is that marketing pink to the women seems to work better than than just marking the blue men's version so that again is a marketing principle not necessarily a science principle the other

thing that we commonly see is people come and say oh look I've started minoxidil I really don't like it it makes my hair greasy or I'm getting really squishy it's or itchy flaky scalp and that comes down to

the preparation and in fact minoxidil comes in two preparations there's a liquid and there's a foam and the liquid is the the base preparation is propylene glycol and that can cause itching us and flaky scalp in about 30% people that use that so I generally sort of say to people look there are two options the foam is sometimes a lot better tolerated in a lot of people and it's like comes in a mousse can you shake it and squirt a bit into the into the cap and then you can just use your finger or a cotton but just

 Minoxidil side effects review Minoxidil for hair loss

to paint it on and the other key there is that it is there is absolutely no point in applying the Minako to the hair right the minoxidil has to be on the scalp it doesn't do anything if you soak your hair in the Knoxville because the hair is not going to their hair is effectively dead rope and therefore is not going

 to absorb and you're not going to get any benefits so painting it onto the scalp is important so foam I find is better tolerated in the vesicle it's less crazy because it doesn't have the page a yeah all right this page a free which is the reason I developed it was because you know not just a dermatological

reaction was the flaking that Vikram was talking about we also remember finding that were having styling issues with it so this is why they developed a Petrie free version of it to do that but in Turkish tree is interesting too because the farm absorbs quicker through the skin than the lotion so the lotion takes 60 to 90 minutes to absorb through the skin foam takes ten minutes to absorb through the skin so when people are saying well when can I wash my hair afterwards or when they can't get sweaty

afterwards as long as you applied the lotion maybe ninety minutes before washing or sport you're going to be okay as long as you put it on 15 minutes before with the foam for 15 minutes before sport or washing you're going to be okay you don't really have to keep it on for 4 6 8 hours and wash it out

the next morning it really will absorb through a lot quicker than that cool so in summary Minox all really really has been around for a long time very safe really good stimulator of hair growth that

comes in a liquid and a foam and the 5 percent is applicable for most people and most people don't react don't react and the other thing to note it note that you don't need to take it twice a day once a day is perfectly fine if you take it you know start taking it be aware that there is going to be an initial shedding phase after after use of some people which you may experience some shedding absolute and but power through that and then the growth will come after that and it can you can take it as an oral form as well okay that that's back to prescription medicine so oral minoxidil is something that's increasingly being used because people don't like necessarily use a topical solution in amongst their

 hair for styling reasons so you can use a much lower dose rather than the tablet that was used for high blood pressure in fact we use such a low dose that doesn't affect the blood pressure but again you'd have to have that prescribed by a doctor as somebody who knows what he's talking about like

 Minoxidil side effects review Minoxidil for hair loss

in that specialist who works with hair loss would understand this rather than their general practitioner they would be very reluctant to do this so it's a very useful medication for any type of hair loss and it has a role in the treatment of baldness and most people might start with this first but it's a short term

therapy for balding in my opinion because for most people it's not targeting the problem which is the DHT buildup in the follicle it doesn't have that effect so it's slowing things down without necessarily stop what are your thoughts and compliance I mean how you've used it for a long time have you seen

people going ah yeah I've been on minoxidil once a day well use it every night and I've been on it for 20 odd years yes there are people like that but the truth of the matter is most people Rover and whatever out they stop for different reasons they forget they get discouraged because they're expecting it to be better when in fact it's stable and often they come to me and say you I realized

 when I stopped that I've got worse so maybe I should start back kind of again but is there something better the answer is there's no 100% answer for anything in hair loss but it is a very useful medicine and I rank it just behind using in baldness I rank it behind using blockers first and other types of hair loss I record number one and I know this is going down another rabbit hole but you can combined therapies country the blockers and stimulator we'll talk about that at the end because there are there

are certain conditions where it makes sense to combine a blocker and a stimulator but certainly I want you to know it's safe I want you to know it works pretty well and that it's a very useful part of a treatment program for virtually any type of hair loss there are some times you might only use it short-term but mostly you're gonna have to use it long-term perfect okay I hope that's been abused to you I think that's great I mean I think we've covered a lot with minoxidil so yeah I think that's fantastic I mean we'll on the next episode we'll go through some of the other stimulators for hair loss okay but we'll see you next episode thank you see you then