Increased Interest in Oral Minoxidil for Hair Loss Treatment Following Publication of August 2022 New York Times Article: A Google Trends Analysis

Abstract Introduction: Androgenetic alopecia (AGA) is the most common form of hair loss, with negative impact on patient quality of life. Oral minoxidil is used off-label for AGA treatment. We hypothesized increased public interest in oral minoxidil for hair loss treatment following the New York Times (NYT) Article on oral minoxidil: “An Old Medicine Grows New Hair for Pennies a Day, Doctors Say.” The objective of this study was to quantify interest in oral minoxidil for hair loss treatment before and after the NYT article and help inform dermatologists about treatments of interest to their patients. Method: We performed a cross-sectional analysis of Google Trends evaluating relative prevalence of “oral minoxidil,” “minoxidil,” “hair loss,” and “Rogaine®” 2/2022–5/2023. t tests compared mean search volume and linear regression analysis quantified changes in public interest over time. Results: Oral minoxidil and minoxidil search volumes increased from 0.86 to 3.00 and 22.43 to 32.60, respectively, before and after the NYT article (both p < 0.05). Minoxidil searches continually increased by 500,000 searches per month (p < 0.001). Conclusions: There was a significant and sustained increase in Google searches for oral minoxidil after publication of the NYT article, indicating increased patient interest. Larger clinical trials are needed to provide evidence-based care to AGA patients.


Introduction
Androgenetic alopecia (AGA) is the most common form of hair loss, affecting up to 80% of males and 50% of females over their lifetimes.Men characteristically present with a receding frontal hairline and nonscarring hair loss at the scalp vertex, while women present with overall thinning [1].Both men and women with AGA often experience low self-esteem [2], and there are limited treatment options.Topical minoxidil, oral finasteride, and low-level light therapy are the only Food and Drug Administration (FDA) approved therapies for AGA treatment for male patients, and only topical minoxidil and light therapy are approved for female patients [1].
Topical minoxidil was FDA approved in 1988 for male patients and in 1992 for female patients and is a first-line therapy for patients with AGA for men and women [1].In a 48-week, double-blind, placebo-controlled, randomized, multicenter trial of 393 men ages 18-49 years comparing efficacy of 5-2% topical minoxidil, patients experienced 45% greater hair regrowth in the group using 5% minoxidil at week 48.In addition, men using 5% topical minoxidil had increased nonvellus hair count at the first evaluation time point (8 weeks) indicating an earlier response to treatment than the control group (p = 0.021) [3].Similarly, in a 48-week, double-blind, placebo-controlled, randomized, multicenter trial of 381 women ages 18-49 years, comparing 5-2% topical minoxidil, the 5% solution was superior in primary efficacy end points: promoting hair growth as measured by change in nonvellus hair count and patient/investigator assessments of hair growth and scalp coverage (p < 0.05) [4].Both studies found that both 2% and 5% topical minoxidil improved psychosocial perceptions of hair loss [3,4].
Most patients who use topical minoxidil are not compliant with the frequency of application demonstrating clinical efficacy in clinical trials.For example, in a retrospective study of 400 consecutive patients with AGA who were prescribed either 2% or 5% topical minoxidil in the previous 5 years, the discontinuation rate was 86% and even higher (93.6%) in the 47% of patients who experienced at least one side effect.The discontinuation rate was not associated with sex, age, or previous treatment [5].While topical minoxidil was effective in promoting hair growth in clinical trials, poor compliance rates may be attributed to dosing (once to twice daily), duration of treatment (typically 6 months before hair growth is seen), and adverse events including scalp pruritus, increased scale, and erythema.In addition, it may be aesthetically unacceptable to patients who have naturally curly hair and try to maintain their hair straight.It may also cause hypertrichosis, which is unacceptable to many women.Given the significant negative effects that AGA on patient quality of life, it is unsurprising that billions of dollars are spent yearly on hair loss remedies globally [6] and that patients turn to the media for updates on advancements in hair loss treatments [7].There is an established need for alternative therapies for AGA that demonstrates clinical efficacy, ease of use, and minimal side effects to improve patient compliance.We hypothesized that patient interest in oral minoxidil would increase following the publication of the August 18, 2022, New York Times article, "An Old Medicine Grows New Hair for Pennies a Day, Doctors Say" [7].Increased layperson awareness about oral minoxidil's efficacy for AGA might lead to more patients requesting this therapy for their hair loss.Our study aimed to quantify layperson interest in oral minoxidil to provide dermatologists with a better understanding of the therapies that patients with AGA are most interested in.Armed with this knowledge, dermatologist might be better prepared to explain risks and benefits of use of oral minoxidil for treatment of AGA and dispel misconceptions surrounding this treatment.

Materials and Methods
Google Trends (http://www.google.com/trends) was used to quantify search volumes as a proxy to assessing the broad interest in dermatologic issues in the USA [8].Google Trends uses a relative Search Volume Index where the reported data is normalized on a scale from 0 to 100, with 0 indicating no searches and 100 indicating peak search volume relative to all searches on the topic within the given time interval and region selected.We conducted a cross-sectional analysis of Google Trends to evaluate the relative prevalence of certain key terms, including "oral minoxidil," "minoxidil," "hair loss," and "Rogaine ® " in the USA between February 2022 and May 2023 (shown in Fig. 1).We compared relative search volume for these key terms before and after publication of the August 18th NYT article to assess for changes in public interest following the article.We used t tests to compare mean search volume 6 months prior and 9 months following article publication.We also performed a linear regression analysis to quantify perceived changes in public interest over time.Analyses were performed using Microsoft Excel (Microsoft, Seattle, WA, USA) and SAS Software (SAS Studio Release 3.8, Cary, NC, USA).An α value of 0.05 was used to identify statistically significant changes in search volume pre-and post-NYT article.

Results
The baseline search volume for oral minoxidil, measured as the number of searches in the 6 months prior to the August 2022 NYT article, was near 0, whereas searches for hair loss had a relatively high baseline relative search volume at 50 (shown in Fig. 1).The search volumes for oral minoxidil increased from 0.86 units before the NYT article to 3.00 units following the article (p < 0.05).With linear regression analysis, there was a 1.3 million increase in searches each month following article release; however, this month-to-month search volume increase was not statistically significant (p = 0.092).The search volumes for minoxidil increased from 22.43 units before to 32.60 units after the NYT article (p < 0.05), and minoxidil searches continually increased by 500,000 searches per month (p < 0.001).The search volume for Rogaine ® and hair loss remained relatively constant pre-and post-NYT article (p = 0.89 and p = 0.55, respectively).

Discussion
There was a significant and sustained increase in Google searches for oral minoxidil after publication of the August 2022 NYT article, indicating increased patient interest.While not FDA approved for treatment of AGA, oral minoxidil has been studied for AGA management.In a 2020, systematic review of 17 studies including 634 patients, oral minoxidil promoted hair regrowth, and AGA was the most often studied condition with 35% of studies including AGA patients.Other hair conditions studied included telogen effluvium, lichen planopilaris, loose anagen hair syndrome, monilethrix, alopecia areata, and permanent chemotherapy-induced alopecia [9].Therefore, oral minoxidil may have wider applications beyond AGA, meriting further study.
The high compliance rates associated with oral minoxidil therapy might suggest that patients prefer oral minoxidil to topical formulations for hair loss treatment.In a 2021, retrospective multicenter study of 1,404 male (32.8%) and female (67.2%) patients treated with lowdose oral minoxidil (mean dose 1.63 mg/day) for alopecia of various causes, mainly AGA (82.4%), less than 2% of patients discontinued the therapy for any reason.There are several factors that were hypothesized to contribute to higher compliance rates with oral minoxidil than established poor compliance with topical minoxidil.Oral administration is more convenient than topical application, with topical application some areas may be missed, and oral administration circumvents local side effects associated with topical minoxidil such as irritation and allergic contact dermatitis [10].
A 2023 review of commenters on the August 2022 NYT article identified that discussion of the negative psychological consequences of hair loss was a common theme and that women compared to men more often expressed psychosocial stress due to hair loss [11].In addition, there was increased interest among all article commenters to try oral minoxidil for hair loss treatment, with women showing greater interest than men.We found that Google Trends demonstrated an increase in queries for oral minoxidil around the same time, providing further evidence of the increased interest in this medication among patients for hair loss treatment.The NYT article may have improved layperson awareness of the use of oral minoxidil for hair loss, leading to an increased number of patients requesting this therapy from their dermatologists.
Google is unique amongst the public search engines in that data on search trends is publicly available; but the sole use of Google Trends in this study limits its generalizability to Google users.In addition, search volumes are only representative of online queries; information on actual patient interest/seeking a prescription for oral minoxidil from a dermatologist cannot be ascertained with these data.This study is also limited by use of alternative key words, for example, "oral minoxidil" versus "minoxidil pill" may produce dissimilar search volume results.Despite these limitations, Google Trends has been demonstrated to be a useful tool to better understand public interest in dermatologic conditions and therapies [8].
In conclusion, there was a significant and sustained increase in Google searches for oral minoxidil after publication of the August 18, 2022, NYT article, "An Old Medicine Grows New Hair for Pennies a Day, Doctors Say," indicating increased patient interest.Larger studies in both men and women on the efficacy and safety of oral minoxidil for hair loss are needed to provide evidencebased care to a population of patients with growing interest in this therapy.

Statement of Ethics
An ethics statement was not required for this study type, no human or animal subjects or materials were used.