Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2025;15(3):5337 1 Low Risk of Hypotension in Women Treated with Spironolactone for Hair Loss Rachel C. Hill1, Yu Wang2, Bilal Shaikh3, Michael M. Ong1, Paul J. Christos3, Shari R. Lipner4 1 Weill Cornell Medical College, New York 2 Wake Forest School of Medicine, Department of Dermatology, Wake Forest, NC 3 Weill Cornell Medicine, Division of Biostatistics, Department of Population Health Sciences, New York 4 Weill Cornell Medicine, Department of Dermatology, New York Key words: Spironolactone, Hypotension, Blood pressure monitoring, Androgenetic alopecia, Hair loss treatment, Dermatology research Citation: Hill RC, Wang Y, Shaikh B, et al. Low Risk of Hypotension in Women Treated with Spironolactone for Hair Loss. Dermatol Pract Concept. 2025;15(3):5337. DOI: https://doi.org/10.5826/dpc.1503a5337 Accepted: April 30, 2025; Published: July 2025 Copyright: ©2025 Hill et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: This investigation was supported by the National Center for Advancing Translational Sciences (NCATS) grant # UL1-TR-002384 of the Clinical and Translational Science Center at Weill Cornell Medical College. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Shari R. Lipner, MD PhD, Department of Dermatology, Weill Cornell Medicine, 1305 York Avenue, 10021 New York, NY, USA. ORCID – 0000-0001-5913-9304. E-mail: shl9032@med.cornell.edu Introduction Spironolactone, an antihypertensive medication, is used off-label for androgenetic alopecia (AGA) treatment. A ret- rospective study of 23 female AGA patients demonstrated no statistically significant impact of oral spironolactone on systolic or diastolic blood pressure (BP) [1]. Similarly, our retrospective study of 1173 women taking spironolactone for acne, alopecia, or hirsutism found that only 0.26% had hypotension requiring a therapy change [2]. We analyzed a patient subgroup prescribed spironolactone specifically for hair loss for potential BP changes, hypothesizing that spi- ronolactone does not cause significant hypotension. Findings In our previous study, we collected demographics and BP measurements from females taking spironolactone for acne, alopecia, or hirsutism in the period 2006-2021 and excluded patients with prior hypertension diagnoses and/or taking renin-angiotensin-aldosterone system modulators [2]. Here, we included only patients taking spironolactone for alo- pecia. We compared baseline BP to follow-up BP recorded ≥1-day after spironolactone course start date, with absolute hypotension defined as systolic BP<90. We identified 185 female patients prescribed spironolac- tone for alopecia, with mean age of 41-years (range 19–76), 64% <45-years, and 34.2% non-white patients (Table 1). Median maximum daily dose was 100 mg (Q1,Q3=50,100), with range 25—200 mg (Table 1). Of 185 patients, five de- veloped hypotension. Age and maximum daily dose were not hypotension predictors (both P>0.05). The average duration from initial BP measurement to first follow-up measurement was 123.5-days (range=1–1065 days). Mean baseline systolic BP was 113.6 mmHg, with mean first follow-up systolic BP 112.72, representing a 2 Research Letter | Dermatol Pract Concept. 2025;15(3):5337 Table 1. Patient Characteristics. Patient Characteristics Overall, N=185 Hypotension Status p-value1No, N=180 Yes, N=5 Age on course start date, years 0.5 Median (IQR) 39 (30,51) 39 (30,51) 41 (33,62) Mean (SD) 41 (13) 41 (13) 46 (16) Range 19–76 19–76 29–63 Age Group, years n(%) >0.9 <25 13 (7%) 13 (7%) 0 (0%) 25-34 62 (34%) 60 (33%) 2 (40%) 35-44 43 (23%) 42 (23%) 1 (20%) 45 or older 67 (36%) 65 (36%) 2 (40%) Race Groups, n(%) >0.9 Asian 16 (10%) 16 (10%) 0 (0%) Black/African American 7 (4%) 7 (4%) 0 (0%) Other 33 (20%) 33 (21%) 0 (0%) White 106 (65%) 103 (65%) 3 (100%) Ethnic Groups, n(%) >0.9 Hispanic/Latin/SpanishOrigin 21 (15%) 21 (15%) 0 (0%) Not Hispanic/Latin/SpanishOrigin 118 (85%) 115 (85%) 3 (100%) Max Daily Dose, mg 0.2 Median (Q1,Q3) 100 (50,100) 100 (50,100) 100 (100,200) Mean (SD) 99 (51) 98 (50) 135 (60) Range 25,200 25,200 75,200 Max Daily Dose Group, mg n(%) 0.2 ≤50 60 (32%) 60 (33%) 0(0%) 75-100 35 (19%) 33 (18%) 2 (40%) 125-200 90 (49%) 87 (48%) 3 (60%) 1Wilcoxon rank sum test; Fisher’s exact test; Pearson’s chi-squared test. non-significant mean change of -0.88 mmHg (P=0.34). Mean baseline diastolic BP was 72.68 mmHg, with mean first follow-up diastolic BP 72.62, representing a non- significant mean change of -0.0 mmHg (P=0.94). Maximum daily dose of spironolactone did not significantly affect mean change in systolic or diastolic BP (Table 2), even at higher doses (100-200 mg) that are typically initiated for AGA (P>0.05) [3]. We showed that spironolactone-treated alopecia patients did not have significant BP changes, even at doses ≥100 mg, consistent with Desai et. al., demonstrating small effect size of spironolactone on systolic BP (0.12). [1] Desai et. al reported a mean age of 39.74-years but did not describe range. We included women ages 19–76, supporting spironolactone’s safety profile across broad age ranges. Conclusion In a retrospective study of 79 women treated with spironolac- tone (50-200 mg) for AGA, hypotension symptoms, includ- ing dizziness/lightheadedness, were infrequent (n=13, 17%) and uncommonly led to drug discontinuation (3.8%). [4] In a systematic review including 286 spironolactone-treated AGA patients, serious side effects, including hypotension, af- fected <2% of patients. [5] Our findings corroborate other studies showing that hypotension is infrequent with spirono- lactone treatment of alopecia. Limitations include our retrospective design, lack of in- formation about clinical symptoms, and having potentially included non-AGA patients. In sum, our findings corroborate a smaller study of women taking oral spironolactone for AGA, highlighting that Research Letter | Dermatol Pract Concept. 2025;15(3):5337 3 T ab le 2 . C om pa ri so n of C ha ng es in S ys to lic a nd D ia st ol ic B P fr om B as el in e B P to F ir st F ol lo w -U p B P M ea su re m en t. M ax im um D ai ly D os e G ro up ( m g) A ge G ro up N um be r of Pa ti en ts , n M ea n B as el in e Sy st ol ic B P M ea n Fo llo w -U p Sy st ol ic B P M ea n C ha ng e Sy st ol ic B P M ea n B as el in e D ia st ol ic B P M ea n Fo llo w -U p D ia st ol ic B P M ea n C ha ng e D ia st ol ic B P P V al ue Sy st ol ic P V al ue D ia st ol ic Su m m ar y st at is ti cs 18 5 11 3. 6 11 2. 72 -0 .8 8 72 .6 8 72 .6 2 -0 .0 5 0. 34 0. 94 Su m m ar y st at is ti cs ( by d os e an d ag e gr ou p) ≤5 0 <2 5 7 10 8. 29 10 6. 71 -1 .5 7 71 .0 0 71 .2 9 0 .2 9 0. 70 0. 95 ≤5 0 25 -3 4 12 11 4. 58 11 2. 50 -2 .0 8 75 .9 2 73 .3 3 -2 .5 8 0. 52 0. 54 ≤5 0 35 -4 4 14 11 1. 93 10 9. 36 -2 .5 7 72 .0 0 70 .0 0 -2 .0 0 0. 39 0. 46 ≤5 0 ≥4 5 27 11 4. 52 11 1. 41 -3 .1 1 72 .4 8 70 .6 3 -1 .8 5 0. 24 0. 29 75 -1 00 <2 5 3 10 4. 33 11 0. 33 6 .0 0 68 .3 3 69 .6 7 1 .3 3 0. 62 0. 86 75 -1 00 25 -3 4 33 11 2. 97 11 2. 88 -0 .0 9 73 .2 4 72 .9 4 -0 .3 0 0. 96 0. 87 75 -1 00 35 -4 4 22 11 5. 91 11 5. 41 -0 .5 0 74 .4 5 75 .6 8 1 .2 3 0. 85 0. 52 75 -1 00 ≥4 5 32 11 2. 94 11 6. 31 3 .3 8 72 .2 8 73 .7 2 1 .4 4 0. 12 0. 33 12 5- 20 0 <2 5 3 11 1. 33 10 2. 00 -9 .3 3 63 .6 7 65 .6 7 2 .0 0 0. 14 0. 58 12 5- 20 0 25 -3 4 17 11 4. 59 10 9. 88 -4 .7 1 71 .1 2 72 .6 5 1 .5 3 0. 26 0. 53 12 5- 20 0 35 -4 4 7 11 1. 00 11 1. 14 0 .1 4 72 .4 3 72 .1 4 -0 .2 9 0. 97 0. 95 12 5- 20 0 ≥4 5 s 8 12 0. 00 11 8. 50 -1 .5 0 74 .0 0 74 .0 0 0 .0 0 0. 81 1. 00 A ve ra ge t im e el ap se d be tw ee n sp ir on ol ac to ne in it ia ti on a nd f ir st f ol lo w -u p B P m ea su re m en t: 1 23 .4 9 da ys ( ra ng e 1 da y to 1 06 5 da ys ). A ve ra ge t im e el ap se d be tw ee n ba se lin e B P to f ir st f ol lo w -u p B P m ea su re m en t: 1 38 .5 5 da ys ( ra ng e 1 da y to 1 07 4 da ys ). B P = bl oo d pr es su re . 4 Research Letter | Dermatol Pract Concept. 2025;15(3):5337 with hypotension in a single-center retrospective study. J Am Acad Dermatol. 2024;90(6):1245-1247. DOI:10.1016/j.jaad.2024 .01.057 3. Sinclair R, Wewerinke M, Jolley D. Treatment of female pattern hair loss with oral antiandrogens.  Br J Dermatol. 2005;152(3):466-473. DOI:10.1111/j.1365-2133.2005.06218.x 4. Burns LJ, De Souza B, Flynn E, Hagigeorges D, Senna MM. Spironolactone for treatment of female pattern hair loss. J Am Acad Dermatol. 2020;83(1):276-278. DOI:10.1016/j.jaad.2020 .03.087 5. James JF, Jamerson TA, Aguh C. Efficacy and safety profile of oral spironolactone use for androgenic alopecia: A systematic re- view. J Am Acad Dermatol. 2022;86(2):425-429. DOI:10.1016 /j.jaad.2021.07.048 hypotension is uncommon. Patients with alopecia can be as- sured that even high doses of spironolactone are unlikely to cause clinically significant BP changes. Future studies are needed to evaluate the safety of spironolactone treatment in alopecia patients who are already taking antihypertensive medications. References 1. Desai D, Nohria A, Sikora M, et al. Examining blood pressure changes with spironolactone for alopecia: A retrospective anal- ysis.  J Am Acad Dermatol. Published online August 27, 2024. DOI:10.1016/j.jaad.2024.07.1523 2. Hill RC, Wang Y, Shaikh B, Ong M, Christos PJ, Lipner SR. Spirono- lactone treatment for dermatologic indications is not associated