Effect of Treatment With Spironolactone on Blood Pressure in Patients With Alopecia

Spironolactone is an aldosterone antagonist that is FDA-approved for the management of heart failure, hypertension, and edema. It is also a steroidal anti-androgen used off-label at doses of 25 to 200 mg per day for the treatment of androgen-related disorders, such as female pattern hair loss (including women with ER+ breast cancer), hirsutism, and acne. The most common side effects of spironolactone are hyperkalemia (and its potential effect on cardiac rhythm), a decrease in libido, increased frequency of urination, and — in women — irregular menses and the potential for feminization of a male fetus if taken during pregnancy. Hyperkalemia is a particular risk in patients eating excess potassium-containing foods, using salt substitutes, or taking angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Spironolactone increases the risk of lithium toxicity.

The authors of this article have added valuable information on the potential effect of spironolactone on blood pressure (BP). In 23 normotensive women with alopecia, there was no significant change in diastolic or systolic BP at spironolactone doses of 50, 100, 150, or 200 mg per day, with only 1 patient reporting dizziness and 1 patient reporting tachycardia. This is particularly relevant, given that patients with female pattern hair loss are commonly treated with both spironolactone and low-dose oral minoxidil (LDOM), with the latter being associated with a known risk of hypotension. In patients with female pattern hair loss, LDOM is typically combined with doses of spironolactone at 100 to 200 mg per day (specific for female pattern hair loss) or 25 to 50 mg per day (used to offset the peripheral edema seen with LDOM). Although the data presented here are reassuring, further data are needed on BP and related symptomatology in a larger cohort of patients with FPHL on spironolactone 100 to 200 mg per day, including those on concomitant antihypertensive agents, with known serum potassium levels and in the face of its addition to LDOM.