What are the treatment options for androgenic (male/female pattern) alopecia?

Treatment Options for Androgenic Alopecia

For male androgenic alopecia, start with oral finasteride 1 mg daily as first-line therapy, which is FDA-approved and demonstrates sustained efficacy over 5 years with durable hair regrowth. 1, 2, 3, 4

FDA-Approved First-Line Treatments

Oral Finasteride (Men Only)

• Finasteride 1 mg daily is the optimal dose established through dose-ranging studies comparing 0.01 mg, 0.2 mg, 1 mg, and 5 mg, with 1 mg demonstrating superior efficacy to lower doses without additional benefit at 5 mg. 3
• Results appear as early as 2-4 months, with continued improvement over 5 years of treatment. 4
• Long-term data shows durable improvements in scalp hair growth over 5 years, while placebo-treated patients experienced progressive hair loss. 4
• Critical caveat: Sexual adverse effects (erectile dysfunction, decreased libido, ejaculation disorders) may persist after discontinuation in rare cases, and patients must be counseled about this risk. 2
• Additional rare adverse effects include male breast cancer, testicular pain, and male infertility. 2
• Women should never use finasteride, particularly during pregnancy or breastfeeding due to potential harm. 1

Topical Minoxidil (Men and Women)

• Minoxidil 5% solution twice daily is FDA-approved for men and works by reactivating hair follicles. 1
• Results may occur at 2 months but typically require at least 4 months of consistent twice-daily use. 1
• Expect temporary increased hair shedding for up to 2 weeks when starting treatment—this is normal and indicates old hairs are being replaced. 1
• Initial regrowth appears as soft, downy, colorless hairs that gradually become thicker and pigmented. 1
• Most effective for vertex hair loss in men; less effective for frontal baldness or receding hairline. 1
• Women should use minoxidil 2% formulations, not the 5% solution approved for men. 1

Emerging and Alternative Treatments

Oral Minoxidil (Off-Label)

• Start at 2.5 mg daily, with frequent dose escalation to 5 mg daily based on response. 5
• Main adverse effect is hypertrichosis (unwanted body hair growth), followed by less common dizziness or lower limb edema. 5
• Not FDA-approved for androgenic alopecia but supported by clinical studies. 5

Topical Finasteride (Off-Label)

• Topical finasteride 0.25% daily demonstrates efficacy with less systemic dihydrotestosterone suppression compared to oral administration. 5
• Useful option for patients concerned about systemic side effects of oral therapy. 5

Oral Dutasteride (Off-Label)

• Dutasteride 0.5 mg daily shows superior responses compared to finasteride, particularly in the frontal scalp area. 5
• Not FDA-approved for androgenic alopecia but demonstrates better efficacy than finasteride in clinical trials. 5

Platelet-Rich Plasma (PRP)

• Recommended protocol: 3-5 sessions at 1-month intervals during treatment phase, then maintenance sessions every 6 months. 6
• Use 5-7 mL PRP per session, applying 0.05 to 0.1 mL/cm² at 1 cm intervals, injected at 90-degree angle to 2-4 mm depth. 6
• Manual double-spin method preparation with 1 to 1.5 million platelets per µL concentration. 6
• Activation of PRP is not required for androgenic alopecia treatment. 6
• Evidence is controversial and highly variable across studies due to inconsistent protocols, preparations, and follow-up periods. 6
• Some trials show significant improvement in hair count and density at 6 months, while others show no statistically significant difference from placebo. 6
• Best results when combined with other therapies (minoxidil, finasteride) and started early in disease course. 6

Platelet-Rich Fibrin (PRF)

• PRF appears promising as a safe, time and cost-effective adjuvant modality with theoretical advantages over PRP. 6
• Particularly valuable for mild cases of androgenic alopecia. 6
• Major limitation: Lacks randomized controlled trials and standardized protocols. 6

Low-Level Laser Therapy

• Devices with wavelengths 630-660 nm used at home daily for 15-30 minutes. 5
• FDA-approved but limited clinical trial evidence, particularly lacking comparative studies with other treatments. 5

Treatment Algorithm

Step 1: For men with androgenic alopecia affecting vertex and mid-frontal scalp:

• Start oral finasteride 1 mg daily as monotherapy. 3, 4
• Counsel extensively about sexual side effects that may persist after discontinuation. 2

Step 2: If inadequate response after 4-6 months or patient declines finasteride:

• Add topical minoxidil 5% twice daily. 1
• Consider topical finasteride 0.25% daily as alternative to oral formulation. 5

Step 3: For patients seeking additional benefit:

• Consider oral dutasteride 0.5 mg daily (superior to finasteride, especially frontally). 5
• Add PRP therapy (3-5 monthly sessions, then maintenance every 6 months) as adjunct. 6

Step 4: For extensive hair loss or inadequate medical response:

• Refer for hair transplantation surgery. 7
• Continue medical therapy post-transplant to maintain non-transplanted hair. 7

Critical Pitfalls to Avoid

• Do not use finasteride in women, especially those of childbearing potential—it causes harm during pregnancy. 1
• Do not promise complete hair regrowth—not everyone responds, and no one regrows all lost hair. 1
• Do not discontinue treatment prematurely—minoxidil requires minimum 4 months for assessment, and stopping either medication results in loss of gained hair within months. 1, 4
• Do not ignore the psychological impact—hair loss significantly affects quality of life and may require psychological support or cosmetic options like wigs. 7, 8
• Do not recommend supplements without documented deficiency—zinc and vitamin D supplementation lacks evidence unless blood tests confirm deficiency. 9
• Do not use PRP as monotherapy in moderate-to-severe cases—evidence supports it best as adjunctive therapy with proven treatments. 6

Special Populations

Women with Androgenic Alopecia

• Use minoxidil 2% solution, not the 5% formulation approved for men. 1
• Finasteride and dutasteride are contraindicated. 1
• Consider hormonal evaluation and treatment if indicated. 8

Patients with Extensive or Long-Standing Hair Loss

• Medical therapy response is poor in longstanding extensive alopecia. 7
• Wigs or hairpieces may be more appropriate than pursuing treatments unlikely to succeed. 7

Monitoring and Follow-Up

• Schedule follow-up at 3-4 months to assess initial response to treatment. 7, 1
• Continue monitoring every 3-6 months during first year. 7
• Provide written instructions for self-monitoring and realistic expectations. 7
• Document with standardized photographs at baseline and follow-up visits. 6