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 (1 mL per application) as first-line therapy, and if response is inadequate after 6-12 months, add platelet-rich plasma (PRP) injections while continuing minoxidil indefinitely. 1, 2

First-Line Treatment: Topical Minoxidil

• Topical minoxidil is the only FDA-recognized first-line treatment for female androgenetic alopecia and must be continued indefinitely to maintain results. 1, 2
• Apply minoxidil 5% solution, 1 mL twice daily to the affected scalp areas. 1
• Discontinuation leads to complete reversal of hair growth benefits, making lifelong therapy necessary. 1, 2
• Meta-analysis demonstrates minoxidil is superior to placebo (P < .00001) for promoting hair growth in women with androgenetic alopecia. 3

Advanced Combination Therapy: Adding PRP

If minoxidil monotherapy produces suboptimal results after 6-12 months, add PRP injections while maintaining topical minoxidil. 2, 4

PRP Treatment Protocol

• Use nonactivated PRP only—activation reduces efficacy by 31% compared to nonactivated preparations. 1, 2
• Initial treatment phase: 3-5 sessions spaced exactly one month apart. 1, 2, 4
• 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 to 0.1 mL/cm². 1
• Injection technique: Use 30G × 4 mm needles at 90-degree angle, 2-4 mm depth, with injections spaced 1 cm apart. 1
• Target platelet concentration: 1 to 1.5 million platelets per µL using manual double-spin method. 1

Pain Management for PRP

• Apply pharmaceutical-grade topical anesthetic cream before injection due to significant pain associated with PRP therapy. 1, 4
• Patient must shampoo and detangle hair before session, with no hair products applied. 1

Expected Outcomes with Combination Therapy

• Combination PRP plus minoxidil is significantly more effective than minoxidil monotherapy, increasing hair density 1.74 times and hair diameter 14.3 times. 1, 4
• PRP increases hair density by 27.7-45.9 hairs/cm² compared to baseline. 4
• 83% of patients achieve a negative hair pull test after combination treatment, indicating reduced hair fragility. 1
• A 25% improvement in hair density at 2 months predicts sustained response at 6 months. 1, 2
• Maximum response is typically achieved by 6 months. 2

Emerging Alternative: Platelet-Rich Fibrin (PRF)

• PRF shows promise as a potentially superior alternative to PRP with theoretical advantages including lower cost, easier preparation, and prolonged growth factor release. 2, 4
• PRF functions as both scaffold and reservoir for growth factors with longer release duration than PRP. 4
• PRF is particularly effective in mild androgenetic alopecia cases. 5, 4
• Protocol: 3-5 sessions at 1-month intervals, followed by maintenance every 6 months. 1
• However, high-quality comparative studies between PRF and PRP are lacking. 4

Low-Level Laser Light Therapy (LLLT)

• LLLT is another FDA-cleared option with demonstrated efficacy in female androgenetic alopecia. 1
• Recommended usage: three times per week. 1
• Meta-analysis confirms LLLT is superior to placebo (P < .00001) for promoting hair growth. 3

Monitoring Treatment Response

Evaluate treatment efficacy at regular intervals using multiple objective and subjective methods. 1, 4

Assessment Tools

• Standardized before-and-after photographs taken at consistent intervals. 1, 4
• Trichoscopy to evaluate hair density and shaft diameter. 1, 4
• Hair pull tests to evaluate hair fragility. 1, 4
• Patient self-assessment questionnaires for satisfaction scores. 1, 4

Key Response Indicators

• Increased hair density and shaft diameter. 4
• Decreased proportion of telogen hairs. 4
• Improved patient satisfaction scores. 4
• Negative hair pull test after treatment. 1, 4

Critical Clinical Pitfalls to Avoid

• Never discontinue minoxidil once started—all gains will be lost upon cessation. 2
• Never activate PRP before injection—activation reduces efficacy by 31%. 2
• Never use PRP as monotherapy—always combine with topical minoxidil for optimal outcomes. 2
• Inadequate follow-up to assess treatment response leads to suboptimal outcomes. 1
• Insufficient treatment duration can lead to suboptimal results, with some patients requiring extended therapy beyond initial 6 months. 2
• Efficacy of treatments decreases with severity and duration of alopecia, emphasizing the importance of early intervention. 1

Treatment Algorithm Summary

1. Start all patients on topical minoxidil 5% twice daily as baseline therapy. 1, 2
2. Evaluate response at 6-12 months using standardized photographs, trichoscopy, and patient questionnaires. 1, 4
3. If response is suboptimal, add PRP injections (3-5 sessions monthly) while continuing minoxidil. 2, 4
4. After initial PRP phase, maintain with PRP every 6 months indefinitely. 1, 2
5. Never discontinue minoxidil at any point in treatment. 2