Minoxidil with Microneedling Superior to Minoxidil and Oral Spironolactone — Donovan Hair Clinic

A new study set out to determine whether adding microneedling to a topical minoxidil based plan or adding oral spironolactone to a topical minoxidil based plan would work better than topical minoxidil alone.

The authors designed a prospective, single-center, parallel-group, evaluator blinded, randomized trial that included 120 pre-menopause women with proven FPHL.

Patients were randomly assigned to three groups, namely a MINOX group (5% topical MX alone, once daily), the MINOX + SPIRO group (MINOX plus SPIRO 80–100 mg daily), and the MINOX+MN group (MINOX plus MN every 2 weeks, 12 sessions).


Several parameters were evaluated at baseline and week 24 to determine treatment outcomes including:

a) in hair density and diameter by dermoscopy

b) scalp tissue structure (epidermal thickness, dermis thickness, and average hair follicle diameter under ultrasound biomicroscopy),

c) physician’s global assessment (using a 7-point global-assessment scale and Sinclair’s stage change),

d) patient evaluation (Women’s Androgenetic Alopecia Quality of Life Questionnaire and 6 point Sinclair’s hair-shedding score)

e) side effects.


Patients were accepted to the trial if they met the following criteria: (1) aged 18–45 years; (2) female; (3) with normal hormone levels in the blood and regular menstrual cycle (estradiol, progesterone, prolactin, follicle-stimulating hormone, luteinizing hormone, and testosterone were tested during day 2–5 of the menstrual period. Patients with the hormonal level in the reference range of follicular phase could be enrolled); (4) FPHL diagnosis is proved by Sinclair class for II and III.




(1) Patients washed their hair before treatment

(2) alcohol cotton balls were used to clean the treatment sites three times

(3) 1ml of 5% MX was topically applied;

(4) an electrodynamic microneedling was inserted at a depth of 0.7– 1.0 mm;

(5) the treatment endpoints were punctate hemorrhage and redness at the treatment site;

(6) patients were told to not wash their hair within 8h and not to use MX within 24h.


During the entire study period, no other treatment expected to be effective for FPHL was allowed.




In total, 115 participants completed the trial including 38 in the MINOX ONLY group, 37 in the MINOX + SPIRO group and 40 in the MINOX + MN GROUP. 5 patients dropped out of the study.

Mean age of patients was around 31 years and did not differ among groups. Patients had hair loss between 4.5 and 6 years. These did parameters not differ between groups.  In fact, there were no difference between the groups in baseline characteristics (age, BMI, family history, duration of hair loss)

At week 24, the hair density increased most in MINOX + MN group and increased least in MINOX group. MINOX + SPIRO was second place.

The change was 9.95 hairs in the MINOX group, 16.76 hairs in the MINOX + SPIRO group and 30.33 in the MINOX + MN group. These were all statistically significant differences.


The hair shaft diameter significantly increased in all treatment groups (p < 0.001, respectively), but there were no significant differences among the three groups (p = 0.905).  Diameter increased by about 15 um.


Both physician’s and patient assessments showed improvement in all three groups.


When  investigators examined global photographs, 55.27% of patients in the MINOX group, 86.49% of patients in the MINOX + SPIRO group, and 95.00% of patients in the MINOX + MN group were rated as having improvement at week 24. No patient in the MINOX + SPIRO group or the MINOX + MN group was rated as worsening but 5 % of the MINOX only group was rated as having worsening hair loss


The Sinclair score improved the most in the MINOX + MN group and second in the MINOX + SPIRO group and least in the MINOX only group.


Hair shedding scores and quality of life improved in all three groups by week 24.

Scalp pruritus was the most common side effect. The MINOX + SPIRO group had the most reported adverse effects and these included menstrual disorder in 15 patients, hyperkalemia in 1  patient and edema of the limbs in 1 patient. Menstrual disorder was the most common. There was one infection in the MN + MN group


This was a very nice study showing potential superiority of minoxidil and microneedling in the treatment of AGA. Side effects are less for MINOX + MN than for minoxidil + spironolactone. Of course, one wonders whether a combination of all three treatments might be even more superior.


Xuelei Liang et al. Efficacy and Safety of 5% Minoxidil Alone, Minoxidil Plus Oral Spironolactone, and Minoxidil Plus Microneedling on Female Pattern Hair Loss: A Prospective, Single-Center, Parallel-Group, Evaluator Blinded, Randomized Trial. Front Med (Lausanne). 2022 Jul 11;9:905140.

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