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Direct melanocyte cytotoxicity damaging the pigment-producing cells themselves is effective at reducing melanin rapidly, but it also creates unpredictable outcomes when those cells respond defensively, and it explains why prolonged use can produce outcomes worse than the original problem

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The follicles at the back and sides of the scalp are largely resistant to DHT, which is why pattern hair loss affects those areas last

The subsequent pathophysiologic mechanisms can be summarized as acute tubular apoptosis, oxidative stress, inflammation, microcirculatory dysfunction, vascular barrier function disorder, local hypoxia, and tissue edema (84)