Treatment Options for Androgenetic Alopecia (Baldness)
First-Line Treatment
Start with topical minoxidil 5% applied 1 mL twice daily directly to the scalp, which must be continued indefinitely as discontinuation reverses all hair growth benefits. 1, 2
Minoxidil Monotherapy Details
- For men: Use 5% minoxidil solution twice daily 2, 3
- For women: Use 2% minoxidil (women should NOT use 5% formulation as it works no better than 2% and may cause facial hair growth) 2
- Timeline for results: Initial improvements may appear at 2 months, but allow at least 4 months before determining efficacy 2
- Expected initial response: Temporary increase in hair shedding for up to 2 weeks is normal and indicates the medication is working by replacing old hairs with new growth 2
- Mechanism: Reactivates hair follicles and stimulates the transition from telogen (resting) to anagen (growth) phase 1
Second-Line Treatment: Add Oral Finasteride (Men Only)
For men who need additional benefit beyond minoxidil alone, add oral finasteride 1 mg daily. 4, 3
Finasteride Key Points
- FDA-approved for male pattern baldness 5, 3
- Mechanism: Inhibits 5-alpha-reductase, reducing conversion of testosterone to dihydrotestosterone (DHT), the primary mediator of follicle miniaturization 6, 7
- Contraindications: Absolutely contraindicated in women of childbearing potential due to risk during pregnancy 4
- Critical side effects to counsel patients about:
- Sexual dysfunction (decreased libido, erectile dysfunction, ejaculation disorders) that may persist after discontinuation in rare cases 4
- Increased risk of high-grade prostate cancer (Gleason 8-10) detected in clinical trials (1.8% vs 1.1% placebo) 4
- Rare reports of male breast cancer, testicular pain, and male infertility 4
Advanced Treatment: Combination Therapy with Platelet-Rich Plasma (PRP)
For patients seeking superior results, combine topical minoxidil 5% twice daily with PRP injections, which demonstrates significantly better outcomes than either treatment alone. 1, 8, 9
PRP Treatment Protocol
- Preparation method: Use manual double-spin method with target platelet concentration of 1.0-1.5 million platelets per microliter 9
- Critical detail: Use NON-activated PRP, which shows 31% greater increases in hair count and total hair density compared to activated PRP 9
- Initial treatment phase: 3-5 sessions spaced exactly one month apart 1, 9
- Dosing per session: 5-7 mL PRP total, administered at 0.05-0.1 mL/cm² 1, 9
- Injection technique: 30-gauge × 4 mm needles, 90-degree angle, 2-4 mm depth, injections spaced 1 cm apart across affected areas 9
- Pain management: Apply pharmaceutical-grade topical anesthetic cream before injection (pain is the primary complaint) 1, 9
- Maintenance phase: One session every 6 months after initial treatment to sustain results 1, 9
Expected Outcomes with PRP Combination Therapy
- Timeline: Initial improvements visible at 2-3 months; full assessment at 6 months 9
- Quantified results at 6 months: Hair density increases 1.74-fold, hair diameter increases 14.3-fold, telogen phase hair decreases 9.3-fold 9
- Best responders: Mild to moderate androgenetic alopecia with shorter duration of hair loss 1, 9
Alternative Advanced Option: Low-Level Laser Light Therapy (LLLT)
LLLT is the only FDA-cleared non-pharmaceutical treatment for androgenetic alopecia and can be used as monotherapy or combined with other treatments. 10, 5, 3
- Recommended frequency: Three times per week 1
- Evidence: Meta-analysis confirms superiority over placebo (P < 0.00001) 3
- Advantages: No systemic side effects, can be used by both men and women 10, 5
Emerging Treatment: Platelet-Rich Fibrin (PRF)
PRF is emerging as a potentially superior alternative to PRP with theoretical advantages including lower cost and easier preparation, though evidence is still developing. 1, 9
- Protocol: 3-5 sessions at 1-month intervals, then maintenance every 6 months 1
- Advantages over PRP: Similar efficacy with lower cost and simpler preparation 9
Monitoring Treatment Response
Evaluate treatment efficacy using multiple objective measures, not just patient perception. 1
Assessment Tools
- Standardized before-and-after photographs (same lighting, angle, hair position) 1, 9
- Trichoscopy to measure hair density and diameter objectively 1
- Hair pull tests to evaluate hair fragility 1
- Patient self-assessment questionnaires for quality of life impact 1
- Timeline for assessment: Evaluate response after one year of combination therapy 1
Critical Clinical Pitfalls to Avoid
Common Mistakes
- Discontinuing minoxidil: All benefits reverse completely upon stopping—patients must understand this is lifelong therapy 1, 2
- Using activated PRP: Non-activated PRP produces superior results; activation should be avoided 9
- Inadequate follow-up: Failure to assess treatment response leads to suboptimal outcomes 1
- Treating advanced/long-standing alopecia: Treatment efficacy decreases significantly with severity and duration of hair loss 1
- Expecting rapid results: Hair grows only 0.5-1 inch per month; realistic expectations are essential 2
Patient Selection
- Best candidates for treatment: Men with vertex (crown) hair loss, not frontal baldness or receding hairline 2
- Poor candidates: Extensive long-standing alopecia (consider wigs instead), patchy hair loss (evaluate for other causes), scarring alopecia 2
Treatment Algorithm Summary
- Start all patients on topical minoxidil 5% (men) or 2% (women) twice daily 1, 2
- For men needing additional benefit, add oral finasteride 1 mg daily after counseling about sexual side effects and prostate cancer risk 4, 3
- For patients seeking maximal results, add PRP (non-activated) 3-5 monthly sessions plus maintenance every 6 months while continuing minoxidil 1, 9
- Consider LLLT as alternative or adjunct, particularly for patients who cannot tolerate medications 10, 3
- Monitor objectively with photographs and trichoscopy at regular intervals 1