Low-Dose Minoxidil for Alopecia May Not Be Safe for Patients with SLE

New findings suggest dermatologists avoid 5 mg-per-day doses of oral minoxidil for alopecia in those with systemic lupus erythematosus (SLE) and other risk factors for pericardial side effects, or prescribe in collaboration with a cardiologist and/or rheumatologist.1

Although evidence indicates those with SLE maintain a greater risk of developing pericardial side effects due to antihypertensive oral minoxidil doses, the risk of side effects from low-dose minxoidil were acknowledged as largely unknown.2

Given this lack of data, investigators, led by Devyn Zaminski, an MD candidate from the New York University (NYU) Grossman School of Medicine, noted dermatologists may have been hesitant to prescribe it to those with SLE.

“This hesitancy may result in the underutilization of [low-dose oral minoxidil] in patients with SLE who could otherwise benefit from this therapy for the treatment of alopecia,” Zaminski and colleagues wrote. “To address this knowledge gap, our study sought to examine the tolerability of [low dose oral minoxidil] in patients with SLE.”1

Effects of Low-Dose Oral Minoxidil in Patients with SLE

The investigators set out to identify individuals with SLE who were prescribed low-dose oral minoxidil at NYU Langone Health after their study received its approval. They accomplished this identification using the International Classification of Diseases, Tenth Revision codes related to SLE, looking at the timeframe between July 2011 - July 2023.

The team defined side effects linked to low-dose oral minoxidil based on symptoms explicitly attributed to the drug’s implementation within study subjects’ medical records. They also conducted a thorough review of patient charts, with their aim being an overall evaluation of comorbid conditions, demographic information, and medication regimens.

After accounting for their inclusion criteria, the investigative team involved 22 individuals with SLE with diverse racial and ethnic backgrounds. These subjects were then followed for a cumulative duration of 21.3 patient-years, receiving 35 distinct low-dose oral minoxidil regimens for alopecia (0.625–5 mg per day) and/or hypertension (2.5–5 mg per day).

Overall, the team did not identify any cases of pericardial side effects reported among those taking doses up to 2.5 mg daily.1 However, they did find that 2 individuals who had been prescribed the low-dose 5 mg per day regimen for alopecia and/or hypertension had been shown to have pericardial effusions.

In both of the participants impacted, experiences with fluid retention linked to their pericardial effusions were reported.1 These effects presented as either lower extremity edema or anasarca, and the team highlighted that both subjects had multiple predisposing risk factors for pericardial complications due to low-dose oral minoxidil.

Such risk factors included congestive heart failure (CHF), a prior history of pericardial effusion, and chronic kidney disease (CKD). There was 1 individual who was undergoing hemodialysis.

In both of these trial participants, a discontinuation of low-dose oral minoxidil, along with appropriate treatment—including pericardial window placement in 1 subject and oral or intravenous diuretics among both subjects—led to pericardial effusion resolution. Additionally, it was noted that neither individual resumed their minoxidil treatment.

Previous research aligned with these findings, according to investigators, supporting the overall safety of low-dose minoxidil given this cohort's lack of pericardial side effects at doses of ≤2.5 mg per day. Investigators noted this study was the first known cohort analysis assessing low-dose oral minoxidil tolerability in SLE, encompassing over 2 decades of cumulative exposure.

However, the pericardial effusions highlighted in this analysis among those on the 5 mg per day treatment regimen, specifically in patients who had additional risk factors, were notable. Both of these subjects had also been receiving at least 3 other antihypertensive medications, a factor which the investigators highlighted had previously been identified as a contributor to systemic side effects from low-dose oral minoxidil in prior data.3

“Limitations of this study include its retrospective nature and small sample size, which limited the ability to perform statistical analyses,” they concluded. “Nevertheless, to our knowledge, this is the only study to date assessing the tolerability of [low dose oral minoxidil] in patients with SLE.”1

References

1. Zaminski, D., Alhanshali, L., Shapiro, J., Caplan, A.S., Femia, A.N., Lo Sicco, K. and Mazori, D.R. (2025), Tolerability of Low-Dose Oral Minoxidil in Patients With Systemic Lupus Erythematosus: A Retrospective Cohort Study. Int J Dermatol. https://doi.org/10.1111/ijd.17734.

2. S. Vañó-Galván, R. Pirmez, A. Hermosa-Gelbard, et al., “Safety of Low-Dose Oral Minoxidil for Hair Loss: A Multicenter Study of 1404 Patients,” Journal of the American Academy of Dermatology 84, no. 6 (2021): 1644–1651.

3. J. Jimenez-Cauhe, R. Pirmez, P. Müller-Ramos, et al., “Safety of Low-Dose Oral Minoxidil in Patients With Hypertension and Arrhythmia: A Multicenter Study of 264 Patients,” Actas Dermo-Sifiliográficas 115, no. 1 (2024): 28–35, https://doi.org/10.1016/j.ad.2023.07.019.