Dr. Damkerng Pathomvanich

Thanks for allowing me to share my experience for the use of Oral Minoxidil in the treatment of Androgenic Alopecia. Minoxidil is a peripheral vasodilator used officially as an antihypertensive. It occurs as a white crystalline powder and is soluble in alcohol, propylene glycol and slightly soluble in water. The chemical name is 2, 4, - pyrimidine-diamine, 6-(1- piperidinyl), 3-oxide with molecular wt. 209.25. More than 90% of drug is absorbed from gastrointestinal tract, reaching the maximum plasma level within first hour and declining rapidly thereafter. The average half-life in humans is 4.2 hours. Approximately 90% is metabolized predominantly in Liver by conjugation with glucuronic acid, with some by conversion to more polar products. All metabolites are excreted in urine. Minoxidil is a direct acting peripheral vasodilator capable of reducing both elevated systolic and diastolic blood pressure. It does not interfere with the vasomotor reflux and is therefore unlikely to produce orthostatic hypotension. The primary use is for the treatment of hypertension. Dosage is usually 2.5 to 100 mg per day as a single dose for adults. The side effect is salt and water retention, with swelling of hands and feet, face, lower legs; rapid weight gain can occur. Cardiovascular effects including chest pain, hypotension, and fast and irregular heart beat are possible effects. Hypertrichiosis without virilism as elongation, thickening and increased pigmentation of fine body hair are seen in about 80% of users, developing within 3-6 weeks after starting the therapy. Hypertrichosis is usually first noticed on the temples, glabella, forehead or along the sideburns. Later it may extend to a back, arms, legs, and scalp. Upon discontinuation of minoxidil the growth of new hair is arrested, but 1- 6 months may be required to resume pretreatment appearance. No endocrine abnormalities have been found to explain to this abnormal hair growth. Other effects like thrombocytopenia, nausea, vomiting are uncommon. Breast tenderness occurs in less than 1%. Allergic rashes, blurred vision; flushing of the skin; headache; decreased sexual desire or impotence; numbness or tingling in the hands, feet or face have all been reported. Contraindication Minoxidil should not be used in Pheochromocytoma or those who are sensitive to the components of the preparations. It may produce pericardial effusion and occasional tamponade. Angina pectoris may be exacerbated. Full details of the drug usage and side effects may be found in the PDR. Minoxidil may pass from mother to the child through breast milk. Therefore, women who are pregnant and breast feeding should not use minoxidil. When I started my private practice 20 years ago, I have seen a large number of patients who were taking oral minoxidil other than minoxidil lotion from other physicians and some patients even took on their own. I was entirely against taking oral minoxidil since it is not approved by the FDA and encouraged those patients to change to minoxidil lotion only, in fear of the side effects from oral minoxidil. After many years of practice, I have realized the remarkable effect on hair growth from oral minoxidil compared with the lotion. In many patients the result has changed from minimal hair over the scalp i.e. miniaturized hair to the cosmetic fullness of hair i.e. more terminal hair growth over both the front and the crown areas. Some have responded only at the crown but not at the front; also, there were patients who did not respond other than hypertrichosis. I have a few patients, whom I turned them down for hair transplantation surgery since they were poor candidates’ i.e. poor donor and severe degree of hair loss. One of them took oral minoxidil on his own and I was amazed when he returned to see me in four months, his temples hair was full with moderate hair growth at the crown but not at the front and made him a candidate for hair transplantation. Please see the attached photograph below. I did two sessions of hair transplant surgery on him and he was happy with the final results. I prescribed oral minoxidil for hair loss treatment in less than 1% of patients in my practice over past 20 years. These are those hopeless patients who have the hair loss problem with no response from finasteride, dutasteride and minoxidil lotion but the patient wants to have some treatment option to treat the hair loss. I use it with caution, since there is no study regarding the dosage and safety in treating androgenic alopecia. I do not prescribe this medicine to patients who are known to have cardiovascular disease, history of deranged blood pressure, liver and kidney dysfunction. What is the optimal dose of oral minoxidil for the hair growth with minimal side effects? I have learned from other physicians, who have prescribed minoxidil extensively to treat androgenic alopecia and was informed that 5 mg daily was enough to stimulate the hair growth without any effect on blood pressure and heart rate. One of my patients, who took oral minoxidil tablet and lives close by the clinic, came to the clinic twice a day for blood pressure monitoring for one month and all the reading were within the normal limits of his baseline; therefore, I am no longer monitoring the blood pressure as often as I did in the past. I have been using 5 mg daily for years and in some patient taken a low dose such as 2.5 mg tab per day or 5mg every other day still reported significant hair growth and stopped the hair loss to his satisfaction. The most common side effect in my practice was puffy eyelids, leg swelling. Similar to any other forms of hair growth product, the gain hair will shed in 3-4 months on stopping the pill. This oral form should not be used in women due to hypertrichosis, it may persist in cases even on discontinuing the drug. All of my patients were informed that the US FDA did not approve the use of oral minoxidil for hair growth and they have to take at their own risk, after understanding the risk and complications of the drug. I believe all the drug have side effects whether they are finasteride, dutasteride, spironolactone or dianee (for female hair loss). The long term treatment with oral minoxidil has more benefit than the chances of over said side effects at the low dose 2.5 - 5 mg once daily needs to be further studied. I advise the patient once the hair loss has stopped and experienced hair gained to stop oral minoxidil and switch back to minoxidil lotion for the long term maintenance usage. However, most of the patients did not want to switch to minoxidil lotion since there was no side effect noted. In some patient who switched to minoxidil lotion reported progressive hair loss. I did not prescribe the diuretic as a routine since most of patients who experience water retention, refused to continue with this drug. Publications from Upjohn explicitly stated that a diuretic "must be" taken in conjunction with Loniten in most cases. The rationale is that while Loniten lowers blood pressure, your body's defense mechanism will automatically return your blood pressure to the original elevated level. Your body accomplishes that by retaining water and salt so that there will be more fluid to pump throughout the body. So in order for Loniten to be safe to consume, it is necessary to use a diuretic medication to remove excess water and salt from your body. Spironolactone is a natural choice for most hair loss sufferers since not only is Spironolactone a diuretic, it is also a potent anti-androgen. In conclusion, only few percentage of the bald population in the world approaches the hair restoration clinics for the solution for hair loss. Of these there are many people who have marked social and emotional impact of hair loss in their lives thus, affecting their psychology. Most of these patients are very well benefited by the treatments like topical minoxidil, oral finasteride and the currently available artistic hair transplant surgeries offered by the clinics. However there are number of patients, who are poor candidates for the hair transplant as they have poor donor area i.e. small donor area, thinning over donor area or have poor quality (more miniaturization at donor site) with large area of baldness NW-Class VII and searching for any possible hope that might improve their hair loss. These patients need to be emphasize regarding the side effects of oral minoxidil and with no FDA approval for hair loss indication. If patient consent's for this treatment, we propose to these terminal hair loss but high hoping patient that they might get benefit from opting to the oral minoxidil as the last sort of therapy till further new drug is available. Best regards, D. Pathomvanich MD FACS

The crown was responsive to the medical treatment [ 5% Minoxidil lotion and 1 mg oral Finasteride] The scar healed nicely but with one spot of hypertrophic nodule.We gave him one time Kenakorte injection and the nodule was softer.

The side views show the new hairline and temples.

The Thai male age 25 had the hair transplantation to restore the frontal receding. He had receded hairline altogether with thin hair look from the front to the crown [Class IV NW] The hairloss was slow down at the time of the surgery. We recommended him to have the medical treatment along with the hair transplantation at the front.The size of the procedure was 3,288 grafts or 6,129 hairs. He wanted to restore the temples. The result was 8 months after the surgery. The hairs grew well and he was responsive to the medicine for we saw the thicker look at the crown area inwhich we did not put the transplanted hair on.

The cut wound immediate after the surgery -we had retention stitches in addition to the contimuous skin sutures. The scar healed nicely after 6 months.

Oblique view -before and after

Front view before and after

The patient had dark brown hair and he colored his hair blonde. He had one session of strip technique hair transplantation with Dr.Pathomvanich at DHT Clinic Bangkok,Thailand. He wanted to have the lower hairline.The estimated area to reconstruct was 53 cm2 and he had 2,562 FUGs or 4,647 hairs. The outcome had bee assessed at 6 months after surgery.The hair grew well and the patient was satisfied. The strip that we took was 35.6 cm2 and 19 cm long. The scar healed nicely as photo shown.

The Chinese man age 48 under went the hair transplantation with Dr.Pathomvanich at DHT clinic, Bangkok. He had black hair, coarse and straight. He needed to have to dense packing in the front and reconstruction of the temples. Dr.Pathomvanich used the strip technique with Trichophytic closure.The total number of graft was 2,543 FUGs or 4,221 hairs. The 200 FUGs were spent to both temples. Consider the photos taken 1 year after surgery, with wet hair , we can see the full growth of the transplanted hairs.

The patient has african type skin and hair, The hair is coarse and kinky. he has no previous history of hypertrophic scar. The scalp was quite loose and we could harvest as wide as 2 cm in the center of the strip. The follicles were curve as C-shape so it took a little longer for the cutting process. The grafts were inserted manually with both one-hand and two-hand technique. 30% of the grafts were using the curve needle for stick and place [mostly in the forelock area] He had little pain after surgery but could be abating with Tylenol. The swelling was not much as the pictuires showing his grafted area at day 5. One year after surgery, he was very happy with the result.The scar was invisible.

We have done ,again the megasession for the baldness class VI. He had good donor hair and average skin laxity. The hairline design was reasonably fit to his age.[try not to get it so low] The hair was salt and pepper in color. The parted side was on the left and we concentrated more number of grafts on that. 1 hair graft =615 2 hair graft =2,655 3 hair graft= 201

There is no trick.He did not wear any concealer.

The 48 year old man had one session of 2,995 FUGs or 5,436 hairs transplantation on his front and crown area. The hair is medium size, salt & pepper color and straight. 1-hair unit=654 FUGs 2-hair unit=2,241 FUGs 3-hair unit=100 FUGs The donor area was closed with trichophytic closure and retention sutures were applied. The pictures show his result after 10 months follow up. The scar was minimal.

The 62 years old male patient with NW class VII after 1 session of hair transplantation .The number of graft was 2,725 FUGs or 4,947 hairs.The patient had salt and pepper color hair, medium size and little wavy. The postop. pictures were taken 7 months after. The donor site experienced some effluvium but eventually the hair fully grew back.

The 54 years old Caucasian man had one session of 4,505 FUGs or 9,212 hair transplantation.He had androgenetic alopecia class V-VI [Norwood-Hamilton] and prefer to finish the frontal to mid scalp. His hair was salt and pepper color and little wavy. The frontal hairline was newly created with single hair units and detail of the transplantation are as follow: 1 hair 597 FUGs, 2 hair 2,861 FUGs,3 hair 433 FUGs. The left sideburn was filled with other 34 ,2 hair unit grafts.The photos were taken 7 months post-op.

A 33 years old transgender with male pattern baldness class III had one session of hair transplantation 2,572 grafts ,4,662 hairs to create the new hairline.The photos were taken 2 years after surgery.

Dr. Pathomvanich - 70 years old male with fine and gray hair after three sessions 7,855 grafts ,15,382 hairs .The pictures were taken at 7 months after the last surgery.

The patient was seen on December 22, 2008. He has 1 session at the clinic in Bangkok but unhappy with the result and wanted to add more density. I looked at the record,his bald area that need to be transplanted measured 48 cm2. Since he has 1st session at Yosakarn clinic (cosmetic clinic,not a full time hair).He also was informed about incorrect direction and angle that were transplanted previously.He said he had 1000 grafts from the first session and based on 48 cm2 of the balding area, to achieve adequate cosmetic improvement he will need (50%) 2400 grafts.So 2400-1000=1400 grafts.The strip is roughly 13x1 cm2 but not include the tail on both side that will be closed to 15 cm2. His grafts was break down as follows 601 single hair grafts,830 two hairs grafts,63 three hairs grafts with a total of 1494 grafts. We cannot use the old scar since the old scar is big. This is only close to 50% density to achieve cosmetic improvement ,for higher density he might need to add more depend on his expectations at the time of consultation. From my experience, celebrity always required higher density as in his case as a model. Another point is the grafts survival is 90 % on average that need to be put into consideration. Over crowded grafts on subsequent session will result in poor growth from vascular impairment.Too dense the hair line will look like hair piece and future hair loss need to be cosidered. I need him to send me the pictures of the donor scar from my surgery on the right side to compare with the first session. The 1000 grafts in addition base on the calculation is to give him 72% density.It is just the rough estimation.If he wants to add on 500 grafts he will get 61% density.If he add only 200 grafts will give him 55 % density and his eye can not detect the small change and will result in unhappiness. nawoak,hair transplant is the art and science,we work on the living cell it's not the merchandize that you can count exactly.There are many factors involved he need to wait another 3- 4 months to complete one year to see the final result before he makes a decision since 9 months is still premature for complete evaluation of the final result. I like to post his comment on 9/08/09 to me From: (email removed) Sent: Tue 9/08/09 5:01 AM To: path_d@hotmail.com Hello, this is (name removed) the French from Tokyo. I had an operation with you on last Dec. I m happy with the result, but I still need a 3rd operation to adjust and fill up the front line and hide the back previous scare. My guess would be around 500 FU. I m thinking about going around mid Oct. if I have time and money then. Are you busy on that time? Also I have been promoting you on Internet in a French forum. It seems that a French guy from Singapore was supposed to visite you end of August. Did he come? Regards, (name removed)

A 54 years old man with male pattern baldness classified as NW VI had done a session of 3,339 FUGs, 6,465 hairs. We transplanted 776 single hair grafts with 0.8 mm slit incisions.The 2-3 hair with the number of 2,563 grafts were totally inserted using 1 mm slit incisions.The photos were taken 2 years later.

37 year old male patient after one session of hair transplantation.He had 2,698 FUGs ,5,545 hairs on the frontal hairline and the midscalp.

32 yrs transgender after three sessions of hair transplantation surgery with the number of 5,473 grafts or 10,214 hairs. The photos were taken 1 year after last surgery.