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

Hair Loss Treatment

For androgenetic alopecia (male/female pattern baldness), initiate combination therapy with oral finasteride 1 mg daily (men only) and topical minoxidil 5% twice daily, as these are the only FDA-approved treatments proven to halt progression and stimulate regrowth. 1

First-Line Pharmacological Treatment

For Men with Androgenetic Alopecia

• Start oral finasteride 1 mg daily as it inhibits 5-alpha reductase and has demonstrated effectiveness in stopping hair loss and promoting regrowth 1
• Add topical minoxidil 5% applied twice daily directly to the scalp, as it reactivates hair follicles and provides more regrowth than the 2% formulation 1, 2
• Results appear at 2 months in some patients, but allow at least 4 months before assessing response 2
• Hair regrowth typically manifests as soft, downy, colorless hairs initially (like peach fuzz) that gradually become thicker 2

For Women with Androgenetic Alopecia

• Use topical minoxidil as monotherapy (women should NOT use the 5% formulation or oral finasteride) 1
• The 2% minoxidil formulation is appropriate for women, as the 5% version works no better and may cause unwanted facial hair growth 2

Critical Timing Expectations

• Expect temporary increased hair shedding for up to 2 weeks when starting minoxidil—this indicates old hairs are being replaced by new growth 2
• Hair grows only 1/2 to 1 inch per month, so visible results require patience 2
• Treatment must be continuous; hair regrowth has not been shown to last longer than 48 weeks without ongoing treatment 2

Adjunctive Therapy Options

Platelet-Rich Plasma (PRP)

• Consider PRP injections as add-on therapy with protocols of 3-5 sessions at 1-month intervals, then maintenance every 6 months 1
• Evidence shows improvement in hair count, though the procedure lacks standardization across studies 3

Low-Level Laser Therapy (LLLT)

• LLLT devices (630-660 nm wavelength) are FDA-cleared for androgenetic alopecia treatment 4
• Use at home daily for 15-30 minutes, though evidence comparing efficacy to pharmacological options is limited 3

Confirming the Diagnosis

Key Clinical Features of Androgenetic Alopecia

• Look for temporal, vertex, or mid-frontal scalp involvement in a characteristic pattern 1
• Men typically show hair loss at the crown and temples; women show diffuse thinning over the central scalp 5
• Family history of gradual thinning or hair loss supports the diagnosis 2

When the Diagnosis is NOT Androgenetic Alopecia

• Patchy, round areas of complete hair loss suggest alopecia areata, which requires entirely different treatment 1, 6
• Alopecia areata shows exclamation mark hairs, yellow dots on dermoscopy, and may have nail involvement 7
• Scalp inflammation with scaling suggests tinea capitis requiring oral antifungals 5
• Sudden diffuse shedding after stress or illness indicates telogen effluvium, which is self-limited 5

Treatment Algorithm for Alopecia Areata (If Misdiagnosed)

First Approach: Watchful Waiting

• For limited patchy hair loss under 1 year duration, reassurance alone is legitimate as spontaneous remission occurs in up to 80% of these patients 6, 7
• Advise that regrowth cannot be expected within 3 months of patch development 6

Active Treatment: Intralesional Corticosteroids

• Inject triamcinolone acetonide 5-10 mg/mL monthly just beneath the dermis in the upper subcutis 6
• Each 0.05-0.1 mL injection produces a tuft of hair growth approximately 0.5 cm in diameter 6
• Achieves 62% full regrowth in patients with fewer than five patches less than 3 cm diameter 6
• Response becomes evident after 2-3 months, with effects lasting approximately 9 months 6

Common Pitfalls to Avoid

Minoxidil Application Errors

• Apply directly to the scalp, not the hair—the medication must reach the follicles 2
• Do not stop treatment if temporary shedding occurs in the first 2 weeks; this is expected 2
• Missing doses reduces effectiveness; twice-daily application is essential 2

Finasteride Misconceptions

• Finasteride is contraindicated in women of childbearing potential due to teratogenic risk 2
• Sexual adverse effects are a concern for some men, though clinical trials demonstrate safety 3
• Topical finasteride 0.25% daily is an alternative to avoid systemic exposure, with demonstrated efficacy and less marked decrease in serum dihydrotestosterone 3

Misdiagnosis Risks

• Do not treat alopecia areata with finasteride or minoxidil monotherapy—these are ineffective for autoimmune hair loss 6
• If hair loss is patchy rather than patterned, or if there is no family history, consider alternative diagnoses 2
• Scarring alopecia requires dermatology referral, not primary care management 8

When to Refer to Dermatology

• No response after 4 months of combination finasteride and minoxidil therapy 2
• Atypical hair loss pattern not consistent with androgenetic alopecia 7
• Suspected scarring alopecia (permanent follicle destruction) 8
• Alopecia areata not responding to intralesional corticosteroids after 4-6 months 6

Emerging Treatments with Limited Evidence

• Oral minoxidil 2.5-5 mg daily shows effectiveness in clinical studies but lacks FDA approval for androgenetic alopecia; main adverse effect is hypertrichosis 3
• Dutasteride 0.5 mg demonstrates better responses than finasteride, especially in the frontal area, though not FDA-approved for this indication 3
• Topical androgen receptor antagonists (pyrilutamide, GT20029) are in clinical trials 3

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