Androgenetic alopecia (AA) is the most common cause of non-scarring alopecia both in men and women, and is frequent reason for consultation, since its cosmetic relevance is important for a healthy self-esteem and to meet social standards, as it´s strongly related to physical attractiveness and youth [1].  AA is gender specific regarding frequency, form and severity, although impacts equally in the quality of life. Several factors have been identified in the physiopathology, the most outstanding are, in men, the increased activity of type II 5α-reductase as responsible for the increase in dihydrotestosterone (DHT, active metabolite of testosterone). In women, the reduction in aromatase activity which converts 17-β-estradiol is highly liable. In both cases, miniaturization of the hair follicle progressively occurs [1]. Only two oral drugs are treatment approved by the FDA, oral finasteride for males or topical minoxidil for either gender. However, many oral and topical supplements are available as cosmeceuticals, as well as shampoos and lotions with very variable success rates [1]. Asatona AG (Zug, Switzerland) developed a lotion with 0.0033% melatonin, ginko biloba and biotin, which is similar to Lambdapil ™, applied qd before bed. Studies proved this concentration of melatonin did not alter endogenous melatonin secretion. The product was well tolerated, without reported side effects. The hair density number, diameter, anagen/telogen ratio and vellus hair/terminal hair ratio were all improved in almost 60% of the studied cases, with the most benefit observed at 90 days [2].  Melatonin is a neurohormone, and also an antioxidant synthesized in hair follicles. Several studies have shown that decreases hair loss, improves hair texture and reduces seborrheic dermatitis [3]. Biotin (B7) is cofactor for carboxylase enzymes involved in fatty acid synthesis, gluconeogenesis, amino acid catabolism and mitocondrial function in hair root cells. It also possesses an apparently undeserved beneficial effect in hair and nail growth, although widely promoted as beneficial for these purposes, research is limited on this topic, and so far, it is only recommended in those cases where low biotin levels are documented [3,4]. Ginkgo Biloba is a very popular herbal remedy that is thought to help with many problems, among them, improving the circulation of blood to the brain and skin. The majority of herbalists who prescribe this for loss of hair do so believing that the increase of blood to the brain and skin delivers more nutrients to the hair follicles and so promotes hair re-growth. However, we could not find articles regarding its benefits in hair loss [5].

We present a 45 year-old woman with initial stages of AA. She received a commercial lotion containing melatonine, ginko biloba and biotin, to apply in the involved areas of the scalp every night. After three months of treatment, cysts and nodules started to appear on both cheeks, and then extended to nose and chin. Seborrhea was also increased all over the face and she reported slight pruritus (Figure 1).

Figure 1: Clinical picture of acneiform dermatosis and seborrhea.

On her follow-up consultation, she outlined these facial changes that were cosmetically unacceptable, although she did notice improvement on the hair density. So, the lotion was suspended and started treatment for the acneiform dermatitis with minocycline PO qd for three months and a medicated soap for facial cleansing. This cleared up completely the acneiform reaction and the patient suggested trying again the AA treatment for a trial, since we tried to find reports on adverse effects based on the commercial name of the product and couldn´t find any. Thus, she restarted the nightly application and after one week she the acne form eruptions reappeared and halted immediately the treatment, with improvement of the facial skin appearance over the next days, and the lotion suspended indefinitely.

As AA is such a common complaint and has a big impact in the patient’s quality of life, many treatment options area available in the market, some are medical and, the majority as cosmeceuticals. Although there are no articles published under the commercial name of the formulation, we were able to find an article with the same components of the drug, describing several studies in which its benefitis on hair growth were proved. The authors also mention a significant reduction in seborrheic dermatitis of the scalp, and briefly state that the side effects encountered were moderate/severe headache and gastrointestinal problems. However, their incidence was identical to the placebo group, so the preparation was not statistically related to these side effects [2]. In our bibliographic search, we did not find any articles regarding side effects of this product, nor of any information regarding melatonin and acne. We were able to find two articles that mention Ginko biloba as part of several products as an aid treatment to acne patients, with positive results. And, the information available regarding this combination is that it is helpful to treat AA, as our patient noticed [6,7]. According to the literature, melatonin limits oxidative stress as it effectively scavenges free radicals, stops hair loss and improves seborrea [2]. It has an antiandrogenetic effect responsable for the prolongation of the hair cycle and the reduction of miniaturization of the hairs. The scientific explanation of how Ginko biloba works in AA is not available, and apparently biotin, although essential for life, its deficit is quite unfrequented. However, being a hydro soluble molecule, it has no apparent toxic risk, and thus, is widely taken as supplement, but its use and benefits remain obscure. This particular case is an example of a side effect related to biotin, because although it is known that high dose biotin can help with acne, it can also trigger acne itself, as it hinders the absorption of vitamin B5 in the intestine. With biotin supplementation, its amount outweighs the quantity of vitamin B5, causing a relative B5 deficiency, and this could favor acne flares, as a paradox effect. It is important to note that biotin supplementation may interfere with lab results, such as thyroid stimulating hormone, N-terminal pro-brain natriuretic peptide, parathyroid hormone, and free triiodothyronine [8-10]. In conclusion, although biotin is normally harmless, it still may cause some side effects.

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