What are the treatment options for female androgenetic alopecia (female pattern hair loss)?

Treatment of Female Androgenetic Alopecia

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

First-Line Treatment: Topical Minoxidil

• Minoxidil 5% (1 mL) applied twice daily is the American Academy of Dermatology's recommended first-line treatment for female pattern hair loss. 1
• This concentration is superior to 2% formulations and must be continued indefinitely, as discontinuation leads to complete reversal of hair growth benefits. 1
• Meta-analysis confirms minoxidil is effective in women with androgenetic alopecia (P < .00001). 3

Enhanced Treatment: Combination Therapy with PRP

For patients seeking superior results or inadequate response to minoxidil alone, add platelet-rich plasma (PRP) therapy to topical minoxidil 5%. 1, 2

Why Combination Therapy Works Better

• PRP combined with minoxidil is significantly more effective than minoxidil monotherapy, showing the highest increase in hair density in comparative studies. 1, 4
• PRP increases hair density by 27.7-45.9/cm² compared to baseline. 2
• Combined therapy increases hair density 1.74 times and hair diameter 14.3 times compared to baseline. 2
• PRP induces proliferation of dermal papilla cells, increases vascularization of perifollicular tissue, and accelerates telogen-to-anagen transition. 1

Specific PRP Protocol

Initial Treatment Phase:

• Perform 3-5 sessions spaced exactly one month apart. 1, 2
• Use 5-7 mL of PRP per session at a rate of 0.05 to 0.1 mL/cm². 1
• Inject at 90-degree angle, 2-4 mm depth, with injections 1 cm apart. 1
• Use 30G × 4 mm needles to minimize discomfort. 1

Maintenance Phase:

• Continue with 1 session every 6 months after completing initial treatment phase. 1, 2

Throughout Treatment:

• Continue topical minoxidil 5% (1 mL) twice daily during and after PRP sessions. 1

Important Procedural Details

• Apply pharmaceutical-grade topical anesthetic cream before injection due to significant pain. 1
• Patient must shampoo and detangle hair before each session, with no hair products applied. 1
• Use manual double-spin method for PRP preparation with platelet concentration of 1 to 1.5 million platelets per µL. 1
• PRP activation is NOT required for androgenetic alopecia. 1

Alternative Advanced Option: Platelet-Rich Fibrin (PRF)

• PRF represents a promising alternative to PRP with theoretical advantages including longer growth factor release and potentially lower cost. 2
• PRF functions as both scaffold and reservoir for growth factors with prolonged release. 2
• Liquid-PRF is safe, easy, time and cost-effective for managing androgenetic alopecia. 5
• However, high-quality comparative studies are lacking, so PRP remains the better-evidenced choice. 2

Additional Treatment Option: Low-Level Laser Therapy (LLLT)

• LLLT is FDA-cleared and demonstrates efficacy in female androgenetic alopecia. 1, 6
• Recommended usage is three times per week. 1
• Meta-analysis confirms LLLT is superior to placebo (P < .00001) for promoting hair growth. 3
• Can be used as monotherapy or combined with minoxidil. 6

Monitoring Treatment Response

Evaluate treatment efficacy using multiple objective methods at regular intervals:

• Standardized before-and-after photographs taken under identical lighting and positioning. 1, 2
• Trichoscopy to evaluate hair density and diameter. 1, 2
• Hair pull tests to evaluate hair fragility (should become negative after successful treatment). 2
• Patient self-assessment questionnaires for subjective improvement. 1, 2

Key indicators of positive response include:

• Increased hair density and shaft diameter. 2
• Decreased proportion of telogen hairs. 2
• Improved patient satisfaction scores. 2
• Negative hair pull test after treatment (83% of patients in studies). 5

Evaluate treatment response after one year of combination therapy. 1

Critical Pitfalls to Avoid

• Inadequate follow-up to assess treatment response leads to suboptimal outcomes. 1
• Stopping minoxidil causes complete reversal of benefits—patients must understand this is lifelong therapy. 1
• The efficacy of treatments decreases with the severity and duration of alopecia, so earlier intervention is better. 1
• Using PRP without proper anesthesia causes significant pain and poor patient compliance. 1

Treatment Algorithm Summary

1. All patients: Start topical minoxidil 5% twice daily indefinitely
2. Inadequate response or desire for enhanced results: Add PRP therapy (3-5 monthly sessions, then maintenance every 6 months)
3. Alternative/adjunctive option: LLLT three times per week
4. Monitor response: Use photographs, trichoscopy, hair pull tests, and patient questionnaires at regular intervals