What are the treatment options for a patient experiencing hair loss?

Hair Loss Treatment

Start with topical minoxidil 5% applied once daily as first-line therapy for both men and women, and add platelet-rich plasma (PRP) injections for patients seeking enhanced results or showing suboptimal response after 4-6 months. 1

First-Line Treatment by Sex

For Men

• Oral finasteride 1 mg daily demonstrates superior efficacy compared to topical minoxidil in head-to-head trials and should be considered the preferred first-line option for male pattern hair loss. 2, 3
• Alternatively, topical minoxidil 5% twice daily can be used, though clinical cure rates are lower (52% vs 80% with finasteride). 3
• Both treatments require indefinite continuation—discontinuation results in complete reversal of all hair growth gains. 1, 4

For Women

• Topical minoxidil 5% once daily is the recommended first-line treatment, as higher concentrations show no additional benefit in women compared to 2% formulations. 1, 4
• Women should NOT use minoxidil 5% formulations designed for men, as studies show they work no better than 2% solutions and may cause facial hair growth. 4
• For women with androgenic alopecia, combining minoxidil with oral spironolactone 100 mg/day shows significantly better results than minoxidil with finasteride, particularly for male-pattern hair loss in women. 5

When to Escalate: Adding PRP Therapy

Indications for PRP

• Add PRP after 4-6 months if minoxidil alone produces suboptimal results. 1
• The combination of PRP with topical minoxidil 5% shows the highest increase in hair density in comparative studies. 1, 2
• PRP works by inducing dermal papilla cell proliferation, increasing perifollicular vascularization, and accelerating the telogen-to-anagen (resting-to-growth) phase transition. 1, 2

Precise PRP Protocol

• Perform 3-5 treatment sessions spaced exactly 1 month apart during the initial phase, using 5-7 mL of PRP per session at a concentration of 1-1.5 million platelets per microliter. 1, 2
• Use nonactivated PRP only—it shows 31% greater improvement in hair density compared to activated PRP. 1
• Injection technique: 0.05-0.1 mL/cm² at 90-degree angle, 2-4 mm depth, with injections spaced 1 cm apart using 30-gauge × 4 mm needles. 1, 2
• Apply pharmaceutical-grade topical anesthetic cream before injection due to significant pain. 1, 2
• After completing the initial series, maintain with 1 session every 6 months indefinitely. 1, 2

Predicting PRP Response

• A 25% improvement in hair density at 2 months predicts sustained response at 6 months. 1, 6
• Maximum response typically occurs by 6 months. 1, 6
• Higher platelet concentrations (1-1.5 million/µL) correlate with greater improvements in hair density, follicle diameter, and terminal hair density. 1, 2

Treatment Algorithm

1. Initiate first-line therapy:

   • Men: Oral finasteride 1 mg daily OR topical minoxidil 5% twice daily 2, 3
   • Women: Topical minoxidil 5% once daily 1

2. Evaluate response at 4-6 months using:

   • Standardized before-and-after photographs at consistent lighting and angles 1, 6
   • Trichoscopy to measure hair density per cm² and hair shaft diameter 1, 6
   • Hair pull tests to assess hair fragility 1
   • Patient self-assessment questionnaires 1, 6

3. If suboptimal response, add PRP therapy:

   • Continue background minoxidil (and finasteride in men) 2
   • Initiate PRP protocol as detailed above 1, 2
   • Reassess at 12 months with comprehensive evaluation 1

4. For women with inadequate response to minoxidil alone:

   • Add oral spironolactone 100 mg/day (superior to finasteride in women) 5

Monitoring Treatment Success

Objective Measures (Use Multiple, Not Just One)

• Increased hair density per cm² on trichoscopy 1, 6
• Increased hair shaft diameter 1, 6
• Decreased proportion of telogen (resting phase) hairs 1, 6
• Improved patient satisfaction scores 1, 6

Timeline Expectations

• Initial results with minoxidil may appear as early as 2 months, but most patients require 4 months to see results. 4
• Temporary increase in hair shedding during the first 2 weeks is expected and indicates old hairs are being replaced—this is normal. 4
• Initial regrowth appears as soft, downy, colorless hairs (like peach fuzz) that eventually match the color and thickness of existing scalp hair. 4

Critical Pitfalls to Avoid

Treatment Failures

• Low platelet concentration, inadequate injection volume, or insufficient treatment frequency causes PRP treatment failure. 1, 2
• Insufficient treatment duration leads to suboptimal outcomes—some patients require extended therapy beyond 6 months. 1
• Inadequate follow-up to assess treatment response results in missed opportunities to adjust therapy. 1

Patient Preparation Errors

• Patient must shampoo and detangle hair before each PRP session with no hair products applied. 1, 6
• Ensure laboratory testing excludes other causes if presentation is atypical: thyroid function, iron stores, vitamin D, and zinc levels. 1

Efficacy Decreases With Delay

• The efficacy of all treatments decreases with increasing severity and duration of alopecia, making early intervention essential. 1
• Minoxidil 5% is more likely to regrow hair in men with less extensive hair loss; if hair loss is more advanced than moderate vertex thinning, it may not work. 4

Special Populations and Contraindications

Alopecia Areata (Patchy Hair Loss)

• This is an autoimmune condition requiring different treatment than androgenetic alopecia. 7, 8
• Intralesional corticosteroid injections are first-line for limited patches. 8
• Contact immunotherapy with DPCP shows 50-60% response rates for extensive disease, though it requires specialized centers and careful handling. 7
• Systemic options include oral corticosteroids, methotrexate, and sulfasalazine for severe cases. 7

Tinea Capitis (Fungal Scalp Infection)

• Requires oral antifungal therapy, not topical treatments for androgenetic alopecia. 8

Traction Alopecia

• Treatment is decreasing tension on hair from tight hairstyles (cornrows, ponytails). 4, 8

Pregnancy and Breastfeeding

• Minoxidil 5% may be harmful during pregnancy or breastfeeding. 4
• Contact immunotherapy should not be used in pregnant women or women intending to become pregnant. 7

Additional Treatment Options

Low-Level Laser Light Therapy (LLLT)

• LLLT at 655 nm demonstrates efficacy when used 3 times per week and requires continuous use every 6 months to maintain effectiveness. 1

Finasteride Side Effects

• Loss of libido occurs in approximately 15% of men (6 of 40 patients in one study). 3
• Side effects disappear when treatment is stopped. 3
• Serum prostate-specific antigen decreases with finasteride use. 3