What is the current protocol for the management of Androgenic (male/female pattern baldness) Alopecia?

Current Protocol for Management of Androgenetic Alopecia

Start with topical minoxidil 5% applied twice daily as first-line therapy, which must be continued indefinitely to maintain results. 1, 2, 3

First-Line Treatment Approach

For Male Pattern Baldness

• Topical minoxidil 5% (1 mL) applied twice daily to the scalp is the FDA-approved first-line treatment 2, 3
• Results typically appear at 2 months, though some patients require 4 months of continuous use before seeing improvement 3
• Hair regrowth begins as soft, downy, colorless hairs that gradually become thicker 3
• Expect temporary increased hair shedding for up to 2 weeks when starting treatment—this indicates old hairs are being replaced 3

For Female Pattern Baldness

• Topical minoxidil is the American Academy of Dermatology's recommended first-line treatment 1
• Women should use minoxidil 2% or 5% formulations, not the male-specific 5% products that may cause facial hair growth 3

Advanced Combination Therapy (Superior Efficacy)

The combination of topical minoxidil 5% with topical finasteride 0.25% represents the most effective medical treatment approach, demonstrating significantly superior efficacy compared to either monotherapy. 2

For Males

• Oral finasteride 1 mg daily combined with topical minoxidil 5% twice daily provides better outcomes than either alone 4, 5
• Oral finasteride achieves 80% clinical cure rates (increased hair intensity) versus 52% with minoxidil alone 4
• Topical finasteride 0.25% daily is an alternative that reduces systemic absorption while maintaining efficacy 5

Important Finasteride Considerations

• Sexual side effects (loss of libido) occur in approximately 15% of patients but resolve upon discontinuation 4
• Finasteride decreases serum DHT and prostate-specific antigen levels 4
• Women of childbearing potential should not use finasteride due to teratogenic risks 3

Platelet-Rich Plasma (PRP) Protocol

PRP combined with topical minoxidil is significantly more effective than minoxidil monotherapy and should be considered for patients seeking enhanced results. 1, 2, 6

Treatment Phase Protocol

• Use manual double-spin method for PRP preparation 7
• Perform minimum 3-5 sessions at 1-month intervals 7, 1
• Dose: 5-7 mL PRP, using 0.05 to 0.1 mL/cm² 7
• Injection technique: 90-degree angle, 2-4 mm depth, injections 1 cm apart 7
• Recommended platelet concentration: 1 to 1.5 million platelets per µL 7
• PRP activation is NOT required for androgenetic alopecia 7

Maintenance Phase

• 1 session every 6 months after initial treatment phase 7, 2

Expected Results with PRP

• PRP increases hair density by 27.7-45.9/cm² compared to baseline 2
• Combined PRP with minoxidil increases hair density 1.74 times and hair diameter 14.3 times 2

Critical PRP Administration Details

• Apply pharmaceutical-grade topical anesthetic cream before injection due to significant pain 7, 1
• Patient must shampoo and detangle hair before session, with no hair products applied 7
• Use 30G × 4 mm needles to minimize discomfort 7

Alternative Advanced Options

Platelet-Rich Fibrin (PRF)

• PRF represents a promising alternative to PRP with theoretical advantages including longer growth factor release and potentially lower cost 2
• Same protocol as PRP: 3-5 sessions at 1-month intervals, maintenance every 6 months 1
• Particularly effective in mild androgenetic alopecia cases 2

Low-Level Laser Therapy (LLLT)

• FDA-approved treatment option with demonstrated efficacy 1, 8
• Network meta-analysis shows LLLT as superior treatment in relative effects 8
• Recommended usage: three times per week 1
• Devices use wavelengths between 630-660 nm, applied at home for 15-30 minutes daily 5

Oral Minoxidil (Off-Label)

• Initial dose: 2.5 mg daily for males, with frequent increase to 5 mg daily 5
• Main adverse effect is hypertrichosis, followed by less common dizziness or lower limb edema 5
• Not FDA-approved but multiple clinical studies demonstrate effectiveness 5

Dutasteride (Off-Label)

• Oral dutasteride 0.5 mg daily induces better responses than finasteride, especially in frontal area 5
• Considered second-line option 9

Monitoring Treatment Efficacy

Evaluate treatment response using multiple objective methods at regular intervals. 1, 2

Assessment Tools

• Standardized before-and-after photographs 7, 1, 2
• Trichoscopy to evaluate hair density and diameter 1, 2
• Hair pull tests to evaluate hair fragility 1, 2
• Patient self-assessment questionnaires 1, 2

Key Response Indicators

• Increased hair density and shaft diameter 1, 2
• Decreased proportion of telogen hairs 1, 2
• Improved patient satisfaction scores 1, 2
• Negative hair pull test after treatment 2

Timing of Evaluation

• Evaluate after 4 months of minoxidil therapy; if no results, discontinue 3
• Evaluate PRP/PRF combination therapy after one year 7
• Hair regrowth has not been shown to last longer than 48 weeks in large clinical trials with continuous minoxidil treatment 3

Critical Pitfalls to Avoid

• Discontinuing minoxidil leads to complete reversal of hair growth benefits—patients must understand this is lifelong therapy 1, 3
• Inadequate follow-up to assess treatment response leads to suboptimal outcomes 1
• Treatment efficacy decreases with severity and duration of alopecia—earlier intervention yields better results 1
• Minoxidil 5% is not for frontal baldness or receding hairline, only vertex (top of scalp) hair loss 3
• Women should not use male-formulated minoxidil 5% products due to risk of facial hair growth and lack of superior efficacy over 2% formulations 3