What are the best lines of treatment for androgenic alopecia, and do they differ between idiopathic androgenic alopecia (normal testosterone levels with hypersensitivity to androgens) and androgenic alopecia associated with hyperandrogenism or elevated total testosterone levels without other signs of hyperandrogenism?

Treatment of Androgenetic Alopecia: Standard Approaches and Special Considerations for Hyperandrogenism

The first-line treatments for androgenetic alopecia (AGA) are topical minoxidil for both sexes and oral finasteride for men, with combination therapy showing superior results compared to monotherapy. 1 For AGA associated with hyperandrogenism or elevated testosterone levels, anti-androgen therapy should be added to the standard treatment regimen.

Standard Treatment for Idiopathic Androgenetic Alopecia

First-line Treatments

• Topical Minoxidil:

  • Men: 5% solution/foam
  • Women: 2% or 5% solution/foam
  • Mechanism: Vasodilator that prolongs anagen phase and increases hair diameter
  • Apply twice daily to affected areas

• Oral Finasteride:

  • Men: 1mg daily
  • Mechanism: Type II 5α-reductase inhibitor that blocks conversion of testosterone to DHT 2
  • Reduces serum DHT by approximately 70% with continued treatment 2
  • Not FDA-approved for women due to teratogenicity risks

Second-line Treatments

• Low-level laser light therapy (LLLT):

  • FDA-cleared for both men and women
  • Typically used 3 times per week

• Platelet-Rich Plasma (PRP):

  • Shows significant increases in hair density when administered as intradermal injections 3
  • Typically administered in 3 sessions, 1 month apart
  • May be more effective when combined with minoxidil than minoxidil alone 3

Treatment for AGA Associated with Hyperandrogenism

When AGA presents with clinical signs of hyperandrogenism (hirsutism, oligomenorrhea, infertility, clitoromegaly, truncal obesity), the treatment approach should be modified 3:

Diagnostic Workup

1. Laboratory testing:

   • Total and free testosterone
   • Dehydroepiandrosterone sulfate (DHEAS)
   • Luteinizing hormone (LH)
   • Follicle-stimulating hormone (FSH)
   • Consider 17-hydroxyprogesterone if suspecting congenital adrenal hyperplasia

2. Imaging:

   • Pelvic ultrasound if PCOS is suspected

Treatment Algorithm

1. Continue standard AGA treatments (minoxidil ± finasteride in men)

2. Add anti-androgen therapy:

   • Spironolactone (for women):

     • Starting at 50mg daily, can increase to 100-200mg daily
     • Potassium monitoring generally not needed in patients without risk factors for hyperkalemia 3

   • Combined oral contraceptives (for women):

     • Preferably containing anti-androgenic progestins (drospirenone, cyproterone acetate)
     • Helps regulate menstrual cycles while reducing androgen levels

3. For isolated elevated testosterone without other hyperandrogenism signs:

   • Begin with standard AGA treatments
   • Add low-dose anti-androgen therapy
   • Monitor testosterone levels every 3-6 months

Monitoring Treatment Response

Treatment response should be assessed using multiple methods 3:

1. Photography: Standardized before-and-after photos
2. Trichoscopy: To evaluate hair density, miniaturization, and presence of vellus hairs
3. Hair counts: In a defined area
4. Hair diameter measurements
5. Pull test: To assess hair fragility
6. Patient self-assessment questionnaires

Important Clinical Considerations

• Treatment expectations: Set realistic expectations - treatments slow progression and may partially reverse hair loss but rarely restore full pre-AGA hair density

• Treatment duration: All treatments require continuous use to maintain results; discontinuation leads to return to baseline within 3-6 months

• Combination therapy: Complex combined therapy protocols show better results than monotherapy 3

• Treatment timing: Early intervention produces better outcomes

• Monitoring for hyperandrogenism: In women with AGA, especially with early onset or rapid progression, evaluate for underlying hyperandrogenism

• Referral: Consider endocrinology referral for patients with abnormal endocrine testing or persistent concerns for underlying endocrine disorders 3

Emerging Treatments

• Platelet-Rich Fibrin (PRF): Shows promising results as a safe and effective treatment for AGA, particularly in mild cases 3

• Combined PRP with microneedling: May enhance delivery and efficacy of treatment