Safety of Oral Bicalutamide in Female Pattern Hair Loss

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• This retrospective review evaluated the safety profile of bicalutamide, an anti-androgen, in treating 316 patients with female pattern hair loss at a dose of 10 mg daily. Unlike flutamide, bicalutamide is a selective anti-androgen and does not affect luteinizing hormone and testosterone levels. The most common adverse event was a mild elevation of liver transaminases in 9 patients (2.85%), which was less than two times the upper limit of normal and asymptomatic in all cases. This was reversible without dose adjustment in 4 of 9 patients and with dose adjustment in 2 of 9 patients. Peripheral edema (2.53%) and gastrointestinal complaints (1.9%) were also noted.

• While flutamide is associated with severe liver toxicity, bicalutamide caused only mild, reversible transaminase elevation in this study. Bicalutamide can be considered as an anti-androgen in the treatment of female pattern hair loss.

– Margaret Hammond, MD

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Paradi Mirmirani MD

Treatment of female pattern hair loss is often one of the more challenging issues facing dermatologists. This article suggests that we may have one more drug, bicalutamide, to add to our therapeutic armamentarium. Similar to flutamide, bicalutamide is an androgen receptor blocker, but it has the advantage of fewer side effects due to its peripheral tissue selectivity.

In this retrospective study, the primary endpoint of safety and the secondary endpoint of efficacy were somewhat difficult to evaluate because the majority of patients were on a combined regimen with minoxidil and spironolactone. Nevertheless, only a small percentage of patients (<3%) experienced side effects of transaminitis, peripheral edema, or gastrointestinal symptoms, indicating that the treatment regimen was well-tolerated. Given its mechanism of action, bicalutamide may be a good candidate for women with hair loss due to androgen excess, or in women with hirsutism secondary to use of topical or oral minoxidil. Because bicalutamide is pregnancy category X, its use is restricted to women who are not desirous of pregnancy or who are postmenopausal. In the United States, bicalutamide is available in an unscored 50-mg tablet, so it would be somewhat difficult to replicate the 10-mg low dose that was studied. Further studies will be needed to assess the efficacy of bicalutamide in the treatment of female pattern hair loss, but these data suggest that this potent anti-androgen, given in low doses, is well-tolerated with few side effects.

Abstract

The pathogenesis of female pattern hair loss (FPHL) involves androgen-mediated hair follicle miniaturization and perturbation of the hair cycle in genetically susceptible follicles. Spironolactone, cyproterone acetate and flutamide have been shown to be efficacious in the treatment of FPHL. Use of flutamide requires caution due to the risk of significant liver toxicity, particularly at high doses.

Journal of the American Academy of Dermatology

Safety of Oral Bicalutamide in Female Pattern Hair Loss: A Retrospective Review of 316 Patients

J Am Acad Dermatol 2020 Mar 22;[EPub Ahead of Print], FF Ismail, N Meah, L Trindade de Carvalho, B Bhoyrul, D Wall, R Sinclair 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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