Treatment of Alopecia in Women
The treatment approach for alopecia in women depends critically on the type of alopecia: for female pattern baldness (androgenetic alopecia), topical minoxidil 5% once daily is first-line treatment, while for alopecia areata, intralesional corticosteroids for limited disease or contact immunotherapy with DPCP for extensive disease are recommended. 1, 2
Critical First Step: Determine the Type of Alopecia
The treatment algorithm diverges completely based on whether the patient has:
- Androgenetic alopecia (female pattern baldness): Diffuse thinning of the frontoparietal scalp with intact hair follicles 3
- Alopecia areata: Autoimmune-mediated patchy hair loss with potential for spontaneous regrowth 2
These conditions require entirely different therapeutic approaches, and misidentification leads to inappropriate treatment 1.
Treatment Algorithm for Female Pattern Baldness (Androgenetic Alopecia)
First-Line Treatment
Initiate topical minoxidil 5% applied once daily to the affected scalp areas. 1
- The 5% concentration is specifically recommended by the American College of Dermatology for women 1
- Treatment must continue indefinitely, as discontinuation reverses all hair growth benefits 1
- Expect hair growth ranging from 17% to 70% depending on concentration and individual response 4
- Clinical trials demonstrate mean increases of 23-33 nonvellus hairs in a 1-cm² area after 32 weeks 3, 5
Evaluation and Second-Line Options
Assess treatment response at 4-6 months using standardized photographs, trichoscopy, and patient self-assessment. 1, 6
Key indicators of positive response include:
If response is suboptimal after 4-6 months, add platelet-rich plasma (PRP) therapy. 1
- PRP protocol: 3-5 sessions at 1-month intervals, using 5-7 mL PRP, injecting 0.05-0.1 mL/cm² at 2-4 mm depth 6
- Maintenance phase: 1 session every 6 months after initial treatment 6
- Combination therapy with PRP and minoxidil shows superior efficacy compared to either treatment alone 1, 6
- Local anesthesia is strongly recommended to manage injection-related pain 6
Adjunctive Treatment
Low-level laser light therapy (LLLT) three times per week can be added as an additional option with demonstrated efficacy. 1
Critical Pitfall to Avoid
Do NOT use alopecia areata treatments (intralesional corticosteroids, contact immunotherapy with DPCP) for female pattern baldness—these are inappropriate and ineffective for this condition. 1
Treatment Algorithm for Alopecia Areata in Women
Initial Counseling
Provide thorough counseling about the autoimmune basis of alopecia areata, its unpredictable course, and the fact that no treatment alters the long-term disease trajectory. 2
- Assess psychological impact, as women with alopecia areata often experience significant quality of life impairment requiring psychological support 2
Treatment Based on Disease Extent
Limited Patchy Disease (Few Patches)
Intralesional triamcinolone acetonide injections are first-line treatment, with a 62% response rate. 2
- Inject 0.05-0.1 mL of triamcinolone acetonide 5-10 mg/mL just beneath the dermis in the upper subcutis 2
- Administer monthly injections 2
- Expected response duration is approximately 9 months if successful 2
- Main limitation is patient discomfort, which may be poorly tolerated 2
Extensive Patchy Disease or Alopecia Totalis/Universalis
Contact immunotherapy with DPCP is the best-documented treatment for extensive disease, with 50-60% overall response rates. 2
- Initial sensitization with 2% DPCP solution 2
- Weekly applications starting at 0.001% concentration, increasing until mild dermatitis is achieved 2
- Treatment duration may need to extend beyond 6 months—response increases from 30% at 6 months to 78% at 32 months 2
- Most patients develop occipital/cervical lymphadenopathy during treatment, which is usually temporary 7
- Severe dermatitis is the most common adverse effect but can be minimized by careful concentration titration 7
Alternative Options for Alopecia Areata
Topical minoxidil (1-3%) has limited efficacy in alopecia areata, with response rates of only 32-33% and less than 10% sustained benefit in severe cases. 7
Treatments to Avoid in Alopecia Areata
Avoid systemic corticosteroids due to inadequate evidence of efficacy and potentially serious side effects. 2
Use caution with PUVA therapy due to high relapse rates and potential for unacceptably high cumulative UVA doses. 2
Special Considerations for Elderly Women
- Regular monitoring is essential to prevent premature discontinuation due to perceived lack of efficacy 1
- Efficacy may decrease with severity and duration of alopecia, making early treatment initiation critical 1
- For female pattern baldness in elderly patients, the same minoxidil 5% once daily regimen applies 1