Low-Dose Oral Minoxidil Use for Pediatric Hair Disorders

Importance: Low-dose oral minoxidil (LDOM) is increasingly used off-label to treat pediatric hair disorders; however, standardized guidance for patient selection, dosing, safety, and monitoring in patients younger than 12 years is lacking. Objective: To establish expert consensus recommendations for LDOM use in pediatric patients (age <12 years) with hair disorders. Evidence Review: Survey development was informed by a review of the literature on LDOM pharmacology, safety, and clinical use, with emphasis on pediatric populations. A modified Delphi process was conducted from June 30, 2025, to March 7, 2026. Of 98 clinicians completing a prescreening survey, 51 met eligibility criteria (>10 pediatric patients treated with LDOM) and were invited to participate. Three iterative survey rounds were conducted using REDCap with multidisciplinary input. Consensus was defined as 70% or greater agreement on a 5-point Likert scale. Findings: Of 51 experts, 50 from 9 countries completed rounds 1 and 2, and 49 (98.0% retention rate) completed round 3, reflecting broad international representation. Of 127 initial items considered, 84 achieved consensus. LDOM is supported for pediatric patients (aged ≥4 to <12 years) for hair follicle miniaturization (100%), hair cycle abnormalities (100%), and hair shaft disorders (84%), with adjunctive use in select scarring alopecia (98%). Preference for LDOM over topical minoxidil included concerns for logistical difficulty, poor tolerability, inadequate efficacy, caregiver preference, diffuse hair loss, sensory sensitivities, or risk of toxic effects in domestic animals (pets) (74%-96%). Both fixed weight-based and mg/kg dosing strategies met consensus. Fixed dosing aligned with available tablet formulations (weight <20 kg, 0.250-0.625 mg; 20-40 kg, 1.250 mg; >40 kg, 1.875 mg [ 80%]), while a starting dosage of 0.01 to 0.02 mg/kg/d (73.5%) provided a flexible alternative. Dosage escalation of 50% to 100% and reassessment every 3 to 6 months reached consensus. Contraindications included pericardial effusion or tamponade and pheochromocytoma. For experts, routine baseline testing and blood pressure monitoring were not universally necessary in patients at low risk. LDOM was supported as long-term therapy with tapering strategies, and as combination therapy with additional agents (eg, spironolactone, corticosteroids, Janus kinase inhibitors, and other immunosuppressants) as appropriate for subtype of hair loss. Conclusions and Relevance: This international consensus statement provides a structured, pediatric-specific framework for LDOM use, supporting it as a flexible, nonimmunosuppressive therapeutic strategy and addressing key gaps in dosing, safety, and monitoring.