Yagiz Matthew (Matt) Akiska, MD, MPH, answers questions from NAAF about the consensus statement on the use of minoxidil in children and adolescents with hair loss. What prompted you and your colleagues to develop a consensus statement on the use of minoxidil in children and adolescents with hair loss? Low-dose oral minoxidil is increasingly being used to treat hair loss, including in children, but its use for hair loss is off-label and there has been very little standardized guidance for younger patients. In particular, clinicians have had limited guidance on practical questions such as which children may be appropriate candidates, how to dose the medication, what baseline evaluation is needed, and how patients should be monitored. This project was also a natural follow-up to our group’s previous international Delphi consensus statement on low-dose oral minoxidil use for hair loss in adults and adolescents published in JAMA Dermatology. In that consensus, clinicians with substantial experience treating younger pediatric patients were not well represented. We therefore saw an important opportunity to build on that work with a study specifically designed around the unique considerations of children younger than 12 years. We ultimately brought together experts with significant pediatric experience from nine countries and used a three-round modified Delphi process to identify areas of agreement; and, equally importantly, areas where uncertainty remains. Our goal was to provide clinicians and families with a practical, pediatric-specific framework while recognizing that these recommendations are based on expert consensus and are not a substitute for prospective clinical trials. What are the most important recommendations from the consensus statement—particularly regarding when and how minoxidil may be used in pediatric patients? One of the key recommendations was that low-dose oral minoxidil can be considered in children aged 4 years to younger than 12, with treatment individualized based on the diagnosis and benefit-risk assessment. Importantly, we did not reach consensus for children younger than 4 years, reflecting limited clinical experience in this age group and concerns about developmental differences in drug metabolism that may affect minoxidil exposure. Experts supported its use across several types of hair disorders. This included conditions involving hair-follicle miniaturization (e.g. androgenetic alopecia, traction alopecia, and alopecia areata), hair-cycle disorders (e.g. loose anagen hair syndrome, short anagen syndrome, and telogen effluvium), and certain hair-shaft disorders. The panel also supported adjunctive use in select scarring alopecias when there are remaining follicles that could potentially benefit recognizing that minoxidil cannot restore follicles that have already scarred. We also established practical guidance for dosing, safety, and monitoring. Both fixed tablet-based and weight-based dosing approaches reached consensus, allowing clinicians flexibility based on patient needs and regional differences in formulation availability and access. Dose increases can then be considered based on clinical response, tolerability, and physician judgment. Importantly, the recommendations also identify situations where additional evaluation or specialist input may be appropriate rather than suggesting a one-size-fits-all approach. Experts identified situations where it may be particularly useful; such as diffuse hair loss, difficulty or sensory issues with topical application, inadequate response to topical treatment, or caregiver preference after shared decision-making. Because minoxidil use in children is generally off-label, what does the available evidence tell us about its safety, and what should parents and healthcare providers know about potential side effects? This is an area where it is especially important to balance reassurance with the limitations of the evidence. A strength of our consensus was the inclusion of a pediatric cardiologist and pharmacologist to specifically help us interpret and address some of the pediatric-specific safety concerns. Available clinical experience and published pediatric reports have been encouraging regarding tolerability at low doses, but we still do not have randomized clinical trials evaluating efficacy or long-term safety in children younger than 12 years. The most recognizable side effect is hypertrichosis, or increased hair growth outside the scalp. Families should also be counseled to watch for symptoms such as lightheadedness or dizziness, a fast or abnormal heartbeat, swelling of the feet or legs, headache, facial swelling, abnormal weight gain, or signs of an allergic reaction. The panel also recommended urgent ophthalmologic evaluation for unexplained vision loss. At the same time, our panel did not feel that every otherwise low-risk child requires extensive routine testing or repeated blood-pressure monitoring simply because they are taking low-dose oral minoxidil. The approach should instead be risk-based. A child’s medical history, blood pressure, other medications, and cardiovascular, renal, or hepatic history should be considered, and additional testing or specialist consultation may be appropriate when a precaution or contraindication is identified. Perhaps most importantly, families should understand where uncertainty remains. Questions about very long-term safety, use in very young children, and several uncommon potential adverse effects still require prospective study. That is one reason we were careful to report not only what experts agreed on, but also what they could not reach consensus on. For children with alopecia areata specifically, what role can minoxidil play? Is it primarily used to encourage hair growth rather than treat the underlying autoimmune disease? Yes, that distinction is very important. Alopecia areata is an autoimmune disease, and minoxidil has traditionally been used primarily to support hair growth rather than as a treatment for the underlying autoimmune process. It can therefore be particularly useful as an adjunct to disease-directed therapies such as corticosteroids or JAK inhibitors. Emerging clinical and mechanistic evidence suggests that combining minoxidil with immunomodulatory therapy may provide complementary—and potentially synergistic—benefits, with one therapy targeting the underlying disease process while minoxidil supports and may accelerate hair regrowth. Our panel specifically reached consensus that low-dose oral minoxidil can be co-administered with these therapies. However, particularly in children, further prospective studies are needed to define the magnitude of this benefit. That distinction is especially important for families: minoxidil can help create an environment that supports hair growth, but it should not be viewed as a treatment that turns off the autoimmune process responsible for alopecia areata. What do you hope these recommendations will change for healthcare providers treating children with hair loss—and for families trying to understand their treatment options? Our main hope is that these recommendations provide a shared decision-making framework to inform conversations and clinical treatment plans. Before this study, clinicians considering oral minoxidil in a younger child had very little pediatric-specific guidance on fundamental questions such as age, dosing, contraindications, monitoring, and counseling. We now have a structured clinical algorithm that walks clinicians through those decisions, from determining whether the hair disorder is one that may benefit, to screening for contraindications and precautions, choosing between oral and topical treatment, selecting a dosing strategy, and counseling families about monitoring and expectations. The algorithm in the paper also emphasizes that visible improvement generally takes at least three months and commonly occurs over 3 to 12 months, which can help set realistic expectations for families. For families, I hope the recommendations make these discussions less uncertain. Off-label does not mean that a treatment is inherently inappropriate, but it does mean that patients and caregivers should understand what we know, what we do not know, and why their clinician is recommending a particular approach. Ideally, this work gives clinicians and families a more consistent foundation for that shared decision-making. NAAF helped fund this research. How did NAAF’s support contribute to the project, and what questions still need to be answered about treating hair loss in children? NAAF’s support was incredibly meaningful to me personally and instrumental in allowing this work to be done. I was fortunate to receive the NAAF Student Internship Award in both 2025 and 2026, which supported my ability to dedicate time to this research and help coordinate a large international collaboration. I am also tremendously grateful to Dr. Cathryn Sibbald, the senior author of this study, whose mentorship and support were instrumental throughout the entire project, from developing the study and navigating the Delphi process to bringing together an extraordinary international group of experts and ultimately seeing the work through to publication. Importantly, NAAF supported the research while maintaining its scientific independence and had no role in the study design, data collection or analysis, interpretation of the findings, or decision to publish. There is still much more to learn. These recommendations are based on expert consensus rather than randomized clinical trials, and prospective pediatric studies are needed to better define efficacy, optimal dosing, and long-term safety. We also need more pediatric-friendly formulations, particularly liquid preparations that allow precise dosing in younger and smaller children. One of the most valuable aspects of this project is that it not only identifies where experts agree, but also highlights where uncertainty remains, and, hopefully, helps provide a roadmap for the next generation of pediatric hair-loss research. Read more about the Consensus Statement in NAAF news. About Matt Akiska, MD, MPH Yagiz Matthew (Matt) Akiska, MD, MPH, is a first-year resident at MedStar Washington Hospital Center in Washington, D.C., an incoming Dermatology Resident at the University of Maryland School of Medicine, and prolific researcher. A graduate of the George Washington University School of Medicine and Health Sciences, Matt was a recipient of NAAF’s Student Internship Award in 2025 and 2026.
