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

Treatment Options for Androgenetic Alopecia (Hair Loss)

First-Line Treatment

Topical minoxidil 5% applied twice daily is the primary first-line treatment for androgenetic alopecia, which must be continued indefinitely as discontinuation reverses all hair growth benefits. 1, 2, 3

• Apply 1 mL twice daily directly to the scalp in areas of hair loss using the dropper applicator 4
• Results typically appear at 2 months with twice-daily use, though some patients may require 4 months of treatment before seeing improvement 4
• The medication works by reactivating hair follicles to stimulate regrowth 4
• Initial shedding may occur for up to 2 weeks when starting treatment, which is expected as old hairs are replaced by new growth 4

Enhanced Combination Therapy (Superior to Monotherapy)

For patients seeking optimal results, combining topical minoxidil 5% with platelet-rich plasma (PRP) therapy demonstrates significantly superior efficacy compared to minoxidil alone. 1, 2, 3

PRP Treatment Protocol:

• Initial phase: 3-5 treatment sessions spaced 1 month apart 1, 2
• Maintenance phase: 1 session every 6 months after completing initial treatment 1, 2
• Dosing: 5-7 mL of PRP per session, injected at 0.05-0.1 mL/cm² 1
• Technique: Use 30G × 4mm needles at 90-degree angle, 2-4mm depth, with injections spaced 1 cm apart 1
• Preparation: Manual double-spin method with platelet concentration of 1-1.5 million platelets per µL; activation is NOT required 1
• Pain management: Apply pharmaceutical-grade topical anesthetic cream before injection due to significant discomfort 1

Expected Outcomes with Combination Therapy:

• Hair density increases by 27.7-45.9 hairs/cm² compared to baseline 2
• Combined therapy increases hair density 1.74 times and hair diameter 14.3 times 2
• 83% of patients achieve negative hair pull test (indicating reduced hair fragility) after PRP combined with minoxidil 1

Alternative Advanced Option

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

• This option avoids systemic finasteride exposure while maintaining efficacy 5
• Topical finasteride causes less marked decrease in serum dihydrotestosterone levels than oral intake 5

Monitoring Treatment Response

Evaluate treatment efficacy using multiple objective methods at regular intervals to ensure adequate response. 1, 2, 3

Assessment Tools:

• Standardized before-and-after photographs 1, 2, 3
• Trichoscopy to evaluate hair density and diameter 1, 3
• Hair pull tests to evaluate hair fragility 1
• Patient self-assessment questionnaires 1, 3

Key Response Indicators:

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

Important Application Guidelines for Minoxidil

• Allow minoxidil to remain on scalp for approximately 4 hours before washing 4
• If using hair styling products, apply minoxidil first and allow it to soak into the scalp before applying styling aids 4
• Use mild shampoo if washing scalp before application 4
• Hair coloring, perming, or relaxers are permitted, but ensure all minoxidil is washed off before chemical treatments and wait 24 hours after chemical treatments before resuming minoxidil 4

Critical Warnings and Contraindications

Do not use minoxidil 5% if: 4

• You are a woman (women should use 2% minoxidil formulation instead) 3, 4
• Hair loss is on the front of scalp or receding hairline (minoxidil 5% is intended for vertex/crown hair loss only) 4
• Scalp is red, inflamed, infected, irritated, or painful 4
• Under 18 years of age 4

Stop use immediately and consult a physician if: 4

• Chest pain, rapid heartbeat, faintness, or dizziness occurs 4
• Sudden unexplained weight gain or swelling of hands/feet develops 4
• Scalp irritation or redness persists 4
• Unwanted facial hair growth occurs 4
• No hair regrowth is seen after 4 months 4

Common Side Effects

• Most common: itching and skin irritation of treated scalp area 4
• Alcohol content may cause burning if accidentally applied to eyes (rinse with cool tap water if this occurs) 4
• Rare: unwanted hair growth on face or body (reversible upon discontinuation) 4
• With oral minoxidil: dose-dependent hypertrichosis (unwanted body hair growth) 3

Emerging Alternative: Platelet-Rich Fibrin (PRF)

PRF represents a promising alternative to PRP with theoretical advantages including longer growth factor release, though high-quality comparative studies are currently lacking. 2

• PRF functions as both scaffold and reservoir for growth factors with prolonged release 2
• May be more cost-effective than PRP 2
• Shows particular efficacy in mild androgenetic alopecia cases 2
• No randomized controlled trials comparing PRF to PRP are currently available 6

Additional Treatment Options (Lower Evidence Quality)

Low-level laser light therapy (LLLT) is FDA-cleared for androgenetic alopecia and demonstrates efficacy in clinical trials. 7, 8

• Recommended usage: three times per week 1
• Devices use wavelengths between 630-660 nm 5
• Can be used at home for 15-30 minutes daily 5
• Meta-analysis confirms superiority to placebo (P < .00001) 7

Common Pitfalls to Avoid

• Inadequate follow-up: Failure to assess treatment response regularly leads to suboptimal outcomes 1
• Premature discontinuation: Stopping treatment before 4 months prevents adequate assessment of efficacy 4
• Inconsistent application: Missing doses or applying less than twice daily reduces effectiveness 4
• Unrealistic expectations: Treatment efficacy decreases with severity and duration of alopecia 1
• Wrong formulation for gender: Women using 5% minoxidil instead of 2% formulation may experience unwanted facial hair growth 3, 4