This case report describes a 35-year-old man who developed erectile dysfunction and loss of libido after using topical minoxidil 5% for 4 months to treat male pattern baldness. Organic and psychological causes were ruled out through evaluation. Symptoms improved after discontinuing minoxidil but returned when use was resumed. The report concludes that topical minoxidil was the likely cause of the patient's sexual dysfunction, as minoxidil can be absorbed systemically and cause sympathetic nervous system activation, which can induce erectile dysfunction. This case suggests topical minoxidil should be considered a potential cause of unexplained erectile dysfunction.

1. Open Access Journal
Indian Journal of Medical Research and Pharmaceutical Sciences
May 2017;4(5) ISSN: ISSN: 2349-5340
DOI: 10.5281/zenodo.580856 Impact Factor: 3.052
© Indian Journal of Medical Research and Pharmaceutical Sciences http://www.ijmprs.com/
[23]
TOPICAL MINOXIDIL 5% INDUCED MALE SEXUAL DYSFUNCTION
Mazen, Al zo'ubi MD*
*
Internal Medicine Department, King Hussein Medical Center, Royal Medical Services, Jordan
Abstract
Keywords:
minoxidil, minoxidil-
induced erectile
dysfunction, side effect.
Minoxidil is an antihypertensive vasodilator medication. It also slows or stops hair
loss and promotes hair regrowth in some people. The exact way that this medicine
works is not known.
If hair growth is going to occur with the use of minoxidil, it usually occurs after the
medicine has been used for several months and lasts only if the medicine continues to
be used. Hair loss will begin again within a few months after minoxidil treatment is
stopped.
Adverse reactions include irritation of the skin, itching, contact dermatitis, and
dryness of the scalp or flaking. An increase in the absorption of minoxidil from the
scalp can occur in patients with damaged skin, leading to increased side effects.
Minoxidil may cause serious side effects, including unwanted facial/body hair,
dizziness, fast/irregular heartbeat, fainting, chest pain, swelling of hands/feet, unusual
weight gain, tiredness, difficulty breathing especially when lying down.
Erectile dysfunction (impotence) is the inability to get and keep an erection firm
enough for sex. Erectile dysfunction can be caused by Physical causes, Hormonal
disorders, Structural/anatomical disorder, drugs induced, and Psychological causes.
We report a case of erectile dysfunction in a young patient not known to have any
medical illness. In the view of unyielding clinical and laboratory evaluation, a drug-
induced erectile dysfunction and decreased libido were suspected.
Because of the use of topical minoxidil 5% over the last 4 months, and the
improvement of the patient's condition, including palpitation, chest tightness,
dizziness, and erectile dysfunction and libido after discontinuation of topical
minoxidil 5%, and the recurrence of symptoms following it's re-administration, and
after ruling out organic and psychogenic causes, we concluded that topical minoxidil
5% was the cause of the patient's clinical picture and should be considered as a cause
of unexplained erectile dysfunction and decrease libido.
Introduction
Minoxidil is a potent direct-acting peripheral vasodilator agent that reduces peripheral resistance and produces a fall
in blood pressure (1).
Topical minoxidil is available without a prescription as 2% solution, 5% solution, and 5% foam. Due to evidence in
support of the greater efficacy of minoxidil 5% solution compared with minoxidil 2% solution in men, use of the 5%
concentration is recommended (2).
Side effects from minoxidil are infrequent. The most common side effects are contact dermatitis and irritant
dermatitis (3). Nevertheless, due to the potential for systemic absorption when the scalp skin barrier is not intact,
caution should be used in patients with cardiovascular disease. Hypertrichosis of the face may occur (4), but
generally is not a problem for men.

2. Open Access Journal
Indian Journal of Medical Research and Pharmaceutical Sciences
May 2017;4(5) ISSN: ISSN: 2349-5340
DOI: 10.5281/zenodo.580856 Impact Factor: 3.052
© Indian Journal of Medical Research and Pharmaceutical Sciences http://www.ijmprs.com/
[24]
Sex is a multifaceted activity. Though essentially it is meant for procreation, it has also been a source of pleasure, a
natural relaxant, it confirms one's gender, bolsters one's self-esteem and sense of attractiveness for mutually
satisfying intimacy and relationship (5).
Sexual dysfunction is any problem that prevents a person from desiring or enjoying sexual activity. Male sexual
dysfunction impaired or inadequate ability of a man to carry on his sex life to his own satisfaction. Symptoms
include difficulties in starting and maintaining an erection, premature ejaculation, inability to ejaculate, and loss of
desire.
Many factors may contribute to sexual dysfunction, or diminished potential for pleasure experienced during any
stage of intimate physical activity, including desire, arousal, and orgasm. These include structural damage, disease
processes, depression and other mental health conditions (6), and medications (7).
Case report
A 35 years old male, married, a father of a single daughter patient, not known to have any medical illness
previously, he quitted smoking 4 years ago, and practicing a regular daily physical fitness exercise.
Presented to internal medicine clinic with a racing heart, chest tightness, and occasional dizziness over the last 3
weeks, two weeks ago he noticed that he has a soft erection, which progressed over days until morning erection and
libido were lost.
For two months, he has had an itchy and burning scalp; which referred by him to the use of topical minoxidil 5%
that started 4 months ago 1cc twice daily to treat his male pattern baldness.
On clinical examination blood pressure was at the lower limits of the normal range; 90/60-100/70, without
orthostatic hypotension, and his pulse was 110 bpm and regular. His scalp was erythematous with multiples
scratches. On external genitalia examination, no abnormality detected.
Laboratory evaluation revealed normal FBS, KFT, LFT, and blood sugar level.
ECG showed sinus tachycardia with no other abnormality.
Two-dimensional echogram also within normal parameters.
D-Dimer was negative.
His hormonal profile was as follow:
T4: 1.57 ng/dl (0.932 - 1.71).
TSH: 1.10 uIU/ml (0.270 – 4.20)
TESTOSTERONE 422.7 ng/dl (249.0 – 836.0)
PROLACTIN 5.30 ng/ml (1.39 – 24.2).
LH 9.04 mIU/ml (2.4 – 12.6)
FSH 4.95 mIU//ml (3.5 – 12.5)
Urological counseling revealed no organic cause for his complaint, and asked to refer the patient to a psychiatric
clinic.
Psychiatric counseling informed that the patient almost has a normal psychological condition apart from anxiety due
to his impotence and loss of libido.
Because topical minoxidil 5% was the only drug used by the patient it was discontinued. Over 3-4 days of
discontinuation the patient started to regain his libido, and morning erection, as well as palpitation and chest
tightness, decreased significantly. Ten days of discontinuation the patient free of any symptom, and regain his sexual

3. Open Access Journal
Indian Journal of Medical Research and Pharmaceutical Sciences
May 2017;4(5) ISSN: ISSN: 2349-5340
DOI: 10.5281/zenodo.580856 Impact Factor: 3.052
© Indian Journal of Medical Research and Pharmaceutical Sciences http://www.ijmprs.com/
[25]
life as normal as before the usage of minoxidil.
Two weeks later; the patient resumed minoxidil application for 2 weeks again symptoms reappeared. Again, the
drug was discontinued and the symptoms disappeared.
Discussion
A literature search did not reveal any case reports on the association between topical minoxidil 5% solution use and
erectile dysfunction. However, we report this case of impotence related to topical minoxidil 5% solution therapy.
Our patient is a young healthy man, and the organic and psychological cause of erectile dysfunction were ruled out.
Small amounts of the applied minoxidil are absorbed and appear in the systemic circulation: 2-5 mg day may be
systemically available as compared with effective antihypertensive oral doses in the range of 10-40 mg day (8).
Although the amount absorbed is relatively small, it is conceivable that the use of topical minoxidil causes systemic
cardiovascular effects.
As with other topically applied drugs, inflammation or disease processes associated with decreased integrity of the
epidermal barrier (e.g. excoriations of the scalp, severe sunburn, scalp psoriasis) may increase percutaneous
absorption of minoxidil and potentially increase the likelihood of systemic adverse effects (9).
Serum and 24-hour urinary minoxidil determinations showed enhanced systemic minoxidil absorption, which was
probably secondary to the irritant dermatitis in some patient (10).
The arteriolar vasodilation induced by minoxidil activates the peripheral sympathetic nervous system (SNS) via
carotid and aortic baroreceptor reflexes. In tandem with activation of the SNS, both the pulse rate and cardiac output
increase (11,12). Minoxidil administration evokes an increase in plasma renin activity, largely due to activation of
the SNS (13-15). The activation of the renin-angiotensin axis elicits an increase in plasma and urinary aldosterone
levels (13-15). As well as, minoxidil possesses alpha-adrenoceptor agonist activity in addition to potassium-channel-
opening activity (16).
As a part of erection biology, the peripheral nervous system helps transmit the central impulses to the end organ.
Sympathetic pathways generally provide inhibitory impulses, whereas parasympathetic and somatic innervation is
pro-erectogenic, the most important component responsible for penile erection is the corpus cavernosum; smooth-
muscle relaxation within this tissue is the endpoint of all stimuli resulting in an erection, Alpha-adrenergic agents
induce smooth muscle contraction and result in DE tumescence (17). Antagonism of alpha-adrenergic signaling
enables other independent relaxatory pathways to predominate within the penile trabecular smooth muscle (18).
Allergic dermatitis which manifested by the patient as itchy and burning scalp, which is seen on examination as an
erythematous and scratched scalp, leads to increase in absorption of topical minoxidil systematically. This increase
in absorption leads to low blood pressure values manifested as dizziness. Because of arteriolar vasodilatation caused
by absorbed minoxidil and the direct adrenergic effect of minoxidil; sympathetic system activated. Sympathetic
system activation flagged by chest tightness and racing heart also led to corpus cavernosum smooth muscle
contraction and result in DE tumescence.
In the patient reported here, the absence of organic and psychological cause of erectile dysfunction, and the indirect
effect on minoxidil on the sympathetic system suggests that erectile dysfunction most likely induced by topical
minoxidil 5%.
Conclusion
Attributing a clinical condition to specific drug intake, after exclusion of other potential causes, may prove a
complicated scenario. Topical minoxidil 5% application should be considered as a cause of unexplained erectile
dysfunction.

4. Open Access Journal
Indian Journal of Medical Research and Pharmaceutical Sciences
May 2017;4(5) ISSN: ISSN: 2349-5340
DOI: 10.5281/zenodo.580856 Impact Factor: 3.052
© Indian Journal of Medical Research and Pharmaceutical Sciences http://www.ijmprs.com/
[26]
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5. Open Access Journal
Indian Journal of Medical Research and Pharmaceutical Sciences
May 2017;4(5) ISSN: ISSN: 2349-5340
DOI: 10.5281/zenodo.580856 Impact Factor: 3.052
© Indian Journal of Medical Research and Pharmaceutical Sciences http://www.ijmprs.com/
[27]
Author Bibliography
Dr. Mazen Al zo'ubi.
Internal medicine specialist, fellow of rheumatology,
Rheumatology division, internal medicine department,
king Hussein medical Centre, the royal medical services
of Jordan, Amman, Jordan.
Cite an Article
Al zo'ubi , Mazen. "TOPICAL MINOXIDIL 5% INDUCED MALE SEXUAL DYSFUNCTION." Indian
Journal of Medical Research and Pharmaceutical Sciences 4.5 (2017): 23-27. Web. 18 May 2017