2025-10-29 08:56:43
Presenters: Nestor MS,1,2,3 Lam W,1 DeVries A,1,4 Chaudry A,1 Hawkins S,5 Leavitt M6
Affiliations: 1Center for Clinical and Cosmetic Research, Aventura, FL; 2Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL; 3Department of Surgery, Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, FL; 4Rocky Vista University College of Osteopathic Medicine, Parker, CO; 5Hair Medicine Institute, Alpharetta, GA; 6Advanced Dermatology and Cosmetic Surgery, Maitland, FL
Background: Treatment-induced hair shedding–commonly referred to as “dread shed”–is a distressing and unfortunately an expected response following initiation of certain hair treatments for androgenetic alopecia which may lead to early discontinuation. This review aims to characterize the pathophysiology of this phenomenon.
Methods: A targeted PubMed search up to July 2025 was performed using key words such as “minoxidil”, “hair shedding”, “finasteride”, “spironolactone”, “dutasteride”, “platelet rich plasma", “microneedling”, and “nutraceuticals”. Results were screened for relevance and articles written in only English. Additional articles were included via citation tracking. The authors' expert clinical opinions were also included.
Results: The search result yielded 67 articles and 21 met screening criteria. Hair shedding was most commonly mentioned in articles on topical and oral minoxidil. Antiandrogens such as spironolactone, finasteride, and dutasteride did not directly discuss shedding in data. One study reported 3 cases of transient effluvium among 210 patients that underwent platelet rich plasma (PRP) with microneedling occurring 4 to 6 weeks post-treatment and resolving by Week 8. Clinical trials on nutraceuticals did not describe a distinct shedding phase. Across all treatment methods, few studies clearly defined onset of shedding and its duration and its impact on patient adherence.
Discussion: The “dread shed” pathophysiology remains undercharacterized but is a significant consideration in alopecia therapies. Oral and topical minoxidil were most commonly implicated. This was either attributed to a positive outcome of the synchronization of the hair follicle cycle and early anagen induction or to the negative effect of the stress of initiating minoxidil which resulted in telogen effluvium. The transient effluvium after PRP was attributed to the induction of the anagen phase secondary to growth factors. A randomized controlled trial on dutasteride and finasteride showed a significantly increased hair count at Week 12 and Week 24. This was consistent with multiple other studies. As such, there is insufficient data to support that antiandrogens may cause a temporary hair shedding phase despite frequent discussion in the clinical setting and online forums. Although, the transient shedding phase would be expected in theory with the progressive shift in hormone levels. Trials on nutraceuticals showed an increase in terminal hair count and a reduction in hair shed count, along with an increase in vellus hair count in the initial 3-month and 6-month treatment period. These findings may suggest that nutraceuticals may be less likely to induce transient effluvium secondary to a gentle modulation of hormones and a subtle change in environment that is not enough to resynchronize the hair follicle cycle. In most of these studies, however, efficacy measurements did not occur until at least 90 days after start of treatment. As such, the occurrence of dread shed in these cases cannot be accurately determined or even ruled out. This may reflect a delay in monitoring for hair shedding during the initial treatment period, leading to an underestimation of the incidence of hair shedding with the use of nutraceuticals. Despite its prevalence and discussion in the clinical setting, online forums, and in patient facing materials, this phenomenon is poorly represented in peer-reviewed literature. Further research to understand “dread shed” is warranted to guide clinical expectations and improve patient satisfaction.
Disclosures: The authors have no financial disclosures to report.
Funding: This study received no funding from any sources.
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