What is the best protocol for treating androgenic alopecia in females?

Treatment Protocol for Female Androgenetic Alopecia

Start with topical minoxidil 5% applied twice daily as first-line therapy, and strongly consider adding platelet-rich plasma (PRP) therapy with three monthly sessions for superior outcomes, as this combination approach is significantly more effective than minoxidil alone. 1, 2

First-Line Medical Therapy

• Topical minoxidil 5% is the recommended first-line treatment, applied 1 mL twice daily to the affected scalp areas 1, 2
• The 5% foam formulation applied once daily is noninferior to 2% solution twice daily, with significantly better tolerability (less pruritus and dandruff) and superior aesthetic properties that don't interfere with hair styling 3
• Treatment must be continued indefinitely—discontinuation leads to complete reversal of hair growth benefits within months 1, 2
• Expect 17-70% improvement in hair growth with minoxidil monotherapy, though results vary by concentration and individual response 4

Advanced Combination Therapy (Recommended for Optimal Results)

The combination of topical minoxidil 5% with PRP injections produces 1.74 times greater hair density and 14.3 times greater hair diameter compared to baseline, making this the most effective evidence-based approach 2

PRP Treatment Protocol

Initial Treatment Phase:

• Perform 3-5 sessions spaced exactly 1 month apart 1, 2
• Use manual double-spin method for PRP preparation with platelet concentration of 1-1.5 million platelets per µL 1
• Do NOT activate PRP before injection—nonactivated PRP shows 31% greater improvement in hair density 5, 1
• Inject 5-7 mL of PRP per session at a rate of 0.05-0.1 mL/cm² 1
• Use 30G × 4mm needles at 90-degree angle, 2-4mm depth, with injections spaced 1 cm apart 1

Maintenance Phase:

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

Pre-procedure Requirements:

• Apply pharmaceutical-grade topical anesthetic cream before injection due to significant pain 5, 1
• Patient must shampoo and detangle hair before session with no hair products applied 1

Platelet-Rich Fibrin (PRF) as Alternative

• PRF may offer theoretical advantages over PRP including longer growth factor release and lower cost 2
• PRF is particularly effective in mild androgenetic alopecia cases 5, 2
• Use same protocol as PRP: 3-5 sessions at 1-month intervals, then maintenance every 6 months 1
• PRF functions as both scaffold and reservoir with prolonged growth factor release 2

Emerging Option: Topical Finasteride Combination

The combination of topical minoxidil 5% with topical finasteride 0.25% demonstrates significantly superior efficacy compared to either monotherapy, representing the most effective medical treatment when PRP is not feasible 2

Monitoring Treatment Response

Evaluate at regular intervals using multiple objective measures:

• Standardized before-and-after photographs taken at each visit 1, 2
• Trichoscopy to evaluate hair density and shaft diameter 1, 2
• Hair pull tests to assess hair fragility (83% of patients achieve negative pull test with PRP + minoxidil) 1
• Patient self-assessment questionnaires for satisfaction scores 1, 2

Key indicators of positive response:

• Increased hair density (expect 27.7-45.9 hairs/cm² increase with PRP) 2
• Increased hair shaft diameter 2
• Decreased proportion of telogen hairs 2
• Negative hair pull test after treatment 1

Timing of evaluation:

• Assess response after completing one year of combination therapy 1
• Maximum response with PRP typically achieved by 6 months 5
• A 25% improvement in hair density at 2 months predicts sustained response at 6 months 5

Critical Pitfalls to Avoid

• Inadequate follow-up leads to suboptimal outcomes—regular monitoring is essential 1
• Treatment efficacy decreases with severity and duration of alopecia, so initiate therapy early 1
• Stopping minoxidil results in complete loss of benefits—patients must understand the indefinite commitment 1, 2
• Using activated PRP reduces efficacy by 31% compared to nonactivated PRP 5
• Insufficient treatment duration—some patients require extended therapy beyond initial 6 months 5