Spironolactone For Hair Loss

Despite the fact that nearly 80% of men and 50% of women (suggested article: Reasons For hair Loss In Women) will experience hair loss at some point in their lives, treating and preventing loss remains an elusive and difficult problem for hair researchers (Nestor et. al., 2021). Because of this, the US Food and Drug Administration (US FDA) has only ever approved two mediations for use in genetic hair loss: finasteride (“Propecia”) for use in male patients and minoxidil (“Rogaine”) approved for both male and female patients. While these medications can be helpful, the lack of additional options or treatments to combine with finasteride and/or minoxidil leave hair loss sufferers seeking alternatives “outside of the box.” This has led to a surge in treatments like natural supplements, medical devices, and “off label” use of medications. 

“Off label” use  of a medication refers to a scenario where a doctor prescribes a medication to a patient to treat a problem that is different or unrelated to the original problem the drug was approved to treat. For example: if a doctor prescribed a drug originally FDA approved to treat high blood pressure or fluid retention to treat hair loss instead, this would be an instance of “off label” use. And that is exactly what we see with the drug spironolactone.

While it was never intended as a treatment for hair loss, through careful observative by astute physicians we discovered that it may be one of the “off label” drugs actually capable of doing just that! But what was it originally intended for? How does spironolactone work for hair loss? Is it safe and are there any potential negative side effects? Can spironolactone be used in both male and female hair loss suffers? What type of results can patients expect? Finally, what does spironolactone cost? To discover the answer to these and other important questions, read on! 

 Spironolactone was originally developed as a “diuretic” medication. Diuretic medications, better known as “water pills” are medications that act on the kidneys to help alter the excretion of fluid and electrolytes from the body. As such, it is an effective treatment for conditions like hypertension (high blood pressure), heart failure, liver disease, and certain electrolyte imbalances.

Spironolactone was first discovered in 1957 and introduced in 1959, so it has a very long history of usage (Sittig, 1988). A timeline like this allows physicians not only the opportunity to study the safety and efficacy of the drug, but also to note any known or previously unknown side effects. And one of the unknown side effects noticed with spironolactone was its effect on hair!

Physicians noticed changes in both scalp and body hair in patients taking spironolactone (Ioannides, 2015). After further research, it was discovered that this was mainly the result of spironolactone blocking androgen – testosterone, dihydrotestosterone (DHT), etc — receptors in target tissues and reducing the body’s production of testosterone (Ioannides et. al., 2015). Since DHT, the well known off-shoot of testosterone, is responsible for binding to androgen receptors in hair follicles and causing hair loss in both male and certain female patients, blocking these receptors and reducing the amount of testosterone made in the body should logically help with hair loss.

But does it? Is spironolactone actually an effective treatment for slowing hair loss, maintaining native hair, and even regrowing some lost hair? 

A review of the research shows that there have been two large systematic reviews of the studies investigating spironolactone as a hair loss treatment: one by Chaofan et. al. published in Clinical, Cosmetic, and Investigative Dermatology in 2023 and one by Majed, A. published in Cureus also in 2023. Both, understandably, found very similar outcomes and came to very similar conclusions.

The past studies have investigated both oral and topical spironolactone treatments for hair loss. The oral spironolactone treatments looked at only female patients. Chaofan et. al.’s review found that at doses ranging from 25mg to 200mg of spironolactone taken orally daily, 81% of patients demonstrated improved hair growth (by photographic assessment) (Chaofan et. al., 2023). Majed’s review showed oral spironolactone resulted in an overall rate of “improved hair loss” in 56% of female patients (Majed, 2023).

Chaofan et. al. also highlighted studies comparing spironolactone to cyproterone acetate (another off-label mediation used for female hair loss), and found that 200mg of daily oral spironolactone was equally effective at both restoring hair count and preventing future loss when compared to 50mg of oral cyproterone acetate daily (Chaofan et. al., 2023). This finding is particularly interesting because not only was it comparing two different off-label drugs, but it also looked at both hair regrowth and the prevention of future hair loss.

While the data are quite promising, Majed did find that over 37% of female patients showed minimal to no improvement with oral spironolactone usage (Majed, 2023). However, both groups came to the same conclusion with respect to oral spironolactone as a treatment for female hair loss: spironolactone is an effective treatment (though Majed did note that the variable response in some patients should be investigated further). 

Chaofan et. al.’s review also involved an analysis of topical spironolactone treatment. The review showed that using a 1% spironolactone gel daily resulted in a clinical improvement assed by photography in 80% of patients (Chaofan et. al., 2023). This included an increase in healthy hair (“anagen”) a decrease in shrinking, weak, unhealthy hair (“telogen” or “vellus” ) and an improvement in the ratio of healthy to unhealthy hair after 12 months of treatment (Chaofan et. al., 2023). What was particularly interesting in these studies as well was that they included both male and female patients – whereas the oral studies only included female patients. While topical spironolactone studies are more limited, the results are encouraging. 

Both systemic reviews also found something interesting: a significant portion of the research conducted on spironolactone involved combination therapy or the use of spironolactone combined with other hair loss therapies. But what did this show? Is spironolactone more effective when used with other hair loss treatments? If so, which ones? 

Majed found studies investigating oral spironolactone in combination with other well known hair loss treatments, including: minoxidil (oral and topical), iron supplementation, microneedling, and low level laser therapy (LLLT) (Majed, 2023). The overall “rate of improved hair loss” was over 65% with combined therapies compared to 56% with spironolactone monotherapy (Majed, 2023). Also noted, was that the number of patients seeing minimal to no improvement was less with the combined therapies compared to monotherapy; over 37% of female patients on oral monotherapy showed little to no improvement whereas only 31% saw little to no improvement on combined therapy (Majed, 2023). This led Majed to conclude that combination therapy may provide even more efficacy compared to using spironolactone alone (Majed, 2023). 

In their review, Chaofan et. al. came to similar conclusions about combination therapy. In the studies analyzing topical spironolactone (1%) in male and female patients, improvement was noted in 80% of patients (Chaofan et. al., 2023). When adding 5% minoxidil gel to the 1% spironolactone gel, however, improvement was noted in 100% of patients (Chofan et. al., 2023). Another short study (12 weeks) comparing 5% topical spironolactone monotherapy to 5% minoxidil (topical) monotherapy and a combination of 5% spironolactone and 5% minoxidil noted a positive response only in the combination group. At 12 short weeks, patients on the combination showed increased number of upright, growing hairs and fewer weaker hairs (“follicular units” growing with one hair instead of normal multiple hair groupings) (Chaofan et. al., 2023). 

 Chaofan’s group also evaluated a number of other combination studies where different medications and/or medical devices were utilized. These included: oral and topical minoxidil, iron supplementation, LLLT, and “other unspecified” treatments. The entirety of the combination treatments showed an improvement and were deemed effective in over 94% of patients. This was much higher when compared to spironolactone monotherapy or even minoxidil monotherapy (Chaofan et. al., 2023).

In general, both reviews found that spironolactone was not only effective but may also be even more effective when combined with other therapies. Spironolactone can help slow down or stop hair loss, particularly in cases where hair thinning is caused by androgenetic alopecia or genetic male/female hair loss (a condition influenced by hormonal imbalances). However, its ability to actually regrow hair can vary from person to person. While some people may experience regrowth, especially in areas where hair follicles are still active, others may see only a reduction in further hair loss rather than significant new hair growth. And, as previously stated, it’s often most effective when used as part of a broader treatment plan, particularly in combination with other therapies like minoxidil.

So we know that spironolactone (with and without other therapies) is effective for hair loss, but is it safe? Are there adverse side effects? And are any potential side effects related to how the medication works? 

Most hair loss medications must be taken permanently in order to work. This is because androgenic alopecia (male and female pattern hair loss) is a progressive genetic condition. This means hair loss patients are “hard-wired” to gradually experience hair loss over a prolonged period of time. Utilizing a medication to slow or stop the loss does not mean you have altered its potential or “cured” it. It only means you have found something to temporarily stop it. If this measure is removed, the loss simply continues. So, those seeking to benefit from a medication like spironolactone will likely need to take it long-term. However, there are some general considerations when it comes to starting, continuing, and evaluating the usage of spironolactone for hair loss: 

Initial Trial Period: Many healthcare providers recommend staying on spironolactone for hair loss for at least 6 to 12 months to assess its effectiveness. Hair growth cycles are slow, so it can take several months before noticeable changes in hair loss or regrowth occur.

Long-Term Use: If spironolactone is effective and well-tolerated, it can be used long-term. Some people may stay on the medication for years to maintain the benefits. Since androgenetic alopecia is a chronic condition, discontinuing spironolactone might lead to the return of hair loss.

Regular Monitoring: While on spironolactone, regular check-ups with a healthcare provider are essential. This ensures the treatment is working as intended and allows for adjustments to dosage or the introduction of complementary treatments if necessary.

Discontinuation: If a person decides to stop taking spironolactone, it should be done under medical supervision, and alternative treatments may be considered to manage hair loss. Stopping abruptly might result in a return to previous levels of hair loss.

Thank you to  Deeply Rooted Scalp + Hair Clinic for providing this spironolactone for hair loss before and after photo of one of their patient’s undergoing spironolactone treatment for hair loss.

This client is a 30 year old female who had been experiencing increased hair shedding for approximately 3 years. The hair loss was most prominent in her center part, temples, and crown. She experienced a period of significant stress and weight loss leading up to the start of her hair loss, but with stress reduction and a stable weight, she was not seeing an improvement. Topical minoxidil was also not very helpful at improving her hair density. On examination, signs of androgenetic alopecia could be seen. Since topical minoxidil did not seem to be helping, a switch to a low dose of oral minoxidil was made. A low dose of spironolactone was also started. Results are after 11 months of treatment.

The dosage of spironolactone for hair loss varies based on individual needs, the severity of hair loss, and the guidance of a healthcare provider. Both the systematic reviews from Chaofan et. al. (2023) and Majed (2023) found the dosages used in nearly all studies ranged from 25mg daily to 200mg daily, with 80mg to 110mg daily being the average and/or most common dosages.

Many doctors seem to start female patients at a dose of 50mg daily and, based on tolerance, increase to 100mg even up to 200mg daily depending on results. The maximum dose reported seems to be around 300mg, and this is uncommon. Additionally, doses as low as 25mg showed benefit in a number of studies. Furthermore, there was an increased reporting of side effects in those using higher doses (80-110mg) compared to lower doses (25mg) (Chaofan et. al, 2023). So, there may be utility in taking the lowest dose possible – while still seeing clinical benefit. However, this must all be discussed with a healthcare provider familiar with both the patient’s medical history and prescribing spironolactone for hair loss. Doses of topical spironolactone typically range from 1% to 5% (as monotherapy) (Chaofan et. al., 2023).

While spironolactone is typically used to prevent hair loss, there are rare cases where individuals may experience a temporary increase in shedding when they first start the medication. This phenomenon, known as telogen effluvium, occurs when hair follicles prematurely enter the resting phase before eventually regrowing. However, this side effect is usually short-lived, and hair growth resumes once the body adjusts to the medication. For most people, spironolactone proves beneficial in reducing hair loss and enhancing hair health over time. So technically, spironolactone can cause hair loss in some individuals, in the form of temporary shedding. 

Traditionally, off-label use of spironolactone for hair loss is something only recommended for female patients, not men. This is because taking spironolactone orally distributes the medication throughout the entire body. Blocking androgen receptors throughout the entire body and lowering the production of testosterone can result in significant negative side effects for men, including increased fatty tissue in the breasts, feminization of features, and sexual dysfunction.

However, Chaofan et. al.’s (2023) review of topical spironolactone studies showed a significant number of male patients participating in studies using anywhere from 1% to 5% (some in combination with 5% minoxidil as well) topical spironolactone. While upwards of 20% of all patients in these studies reported experiencing scalp irritation, no male patient reported any systemic side effects and no participant discontinued treatment due to adverse effects (Chaofan et. al., 2023). This seems to suggest that topical spironolactone is a targeted treatment and stays locally to where it is placed. However, spironolactone remains a treatment typically recommended to female hair loss sufferers only and more research is needed before it is widely recommended for men.

So, now that we know spironolactone can be a safe and effective hair loss treatment – especially for female patients, one important question remains: how much does it cost?

The cost of spironolactone for hair loss can vary based on several factors, including the dosage, location, insurance coverage, and whether you’re purchasing a brand-name version or a generic one. Spironolactone is available in both generic and brand-name versions, with the generic version typically being much less expensive. If you have health insurance, the cost may be partially or fully covered, depending on your plan and whether the medication is considered medically necessary.

Co-pays for generic versions can be as low as $10 to $30 for a 30-day supply. For those without insurance, the cost of generic spironolactone can range from $15 to $50 per month, depending on the pharmacy and dosage. Brand name versions can be more expensive, potentially costing over $100 per month.

Some pharmacies offer discount programs or savings cards that can reduce the out-of-pocket cost. Additionally, online prescription services may offer lower prices for generic versions. The higher the dosage, the higher the cost. For example, a 100 mg dose taken daily may cost more than a 25 mg dose. Overall, while spironolactone is generally affordable, costs can vary, so it’s a good idea to check with local pharmacies, look for discount options, and consult with your healthcare provider about ways to manage the cost effectively.

Author:

Dr. Blake Bloxham, New York Hair Transplant Surgeon 

Mandy Robertson, Vancouver Trichologist

References:

Chaofan, W., Yimei, D, Lingbo, B., Xuewen, L., Min, Z., and Weixin, F. (2023). The Efficacy and Safety of Oral and Topical Spironolactone in Androgenetic Alopecia Treatment: A Systematic Review. Clin Cosmet Investig Dermatol. 16: 603–612 Ioannides D, Lazaridou E. (2015). Female pattern hair loss. Curr Probl Dermatol. 47:45–54 Majed, A. (2023). The Efficacy and Safety of Oral Spironolactone in the Treatment of Female Pattern Hair Loss: A Systematic Review and Meta-Analysis. Cureus. Aug; 15(8): e43559 Nestor MS, Ablon G, Gade A, Han H, Fischer DL. (2021). Treatment options for androgenetic alopecia: efficacy, side effects, compliance, financial considerations, and ethics. J Cosmet Dermatol. 20(12):3759–3781. Sittig M (1988). Pharmaceutical Manufacturing Encyclopedia. William Andrew. p. 1385