What are the treatment options for a patient with androgenic alopecia?

Treatment Options for Androgenic Alopecia

For male androgenic alopecia, initiate combination therapy with oral finasteride 1 mg daily and topical minoxidil 5% twice daily, as these are the only FDA-approved treatments proven to halt progression and stimulate regrowth. 1, 2

First-Line Pharmacological Treatment

For Men

• Oral finasteride 1 mg daily combined with topical minoxidil 5% applied twice daily represents the gold standard first-line therapy, working synergistically by inhibiting 5-alpha reductase (finasteride) and promoting hair growth through follicular stimulation (minoxidil). 1, 3
• Topical minoxidil 5% must be applied directly to the scalp (not the hair) twice daily and continued indefinitely, as discontinuation leads to reversal of all hair growth benefits within months. 4, 2
• Results typically appear at 2-4 months, though some patients may require up to 6 months to see meaningful improvement. 2
• A temporary increase in hair shedding during the first 2 weeks is expected and indicates the medication is working by eliminating old hairs to make room for new growth. 2

For Women

• Topical minoxidil 5% applied twice daily is the recommended first-line treatment, as it is the only FDA-approved option with robust evidence for female androgenic alopecia. 4, 5, 3
• Women should NOT use oral finasteride due to lack of efficacy and potential teratogenic effects. 2
• The same application protocol applies: 1 mL twice daily applied directly to the scalp, continued indefinitely. 4

Advanced Combination Therapy with Platelet-Rich Plasma (PRP)

When to Add PRP

• For patients seeking enhanced results beyond minoxidil monotherapy, add PRP injections to topical minoxidil, as this combination demonstrates significantly superior efficacy with 57% median increase in terminal hair density versus 48% with minoxidil alone at 32 weeks. 4, 5
• PRP combined with minoxidil increases hair density 1.74 times and hair diameter 14.3 times compared to baseline. 5
• 83% of patients achieve a negative hair pull test (indicating reduced hair fragility) with combination therapy. 4

PRP Protocol Specifications

• Use the manual double-spin method with nonactivated PRP at a platelet concentration of 1-1.5 million platelets per µL, as nonactivated PRP shows 31% greater improvement in hair density compared to activated PRP. 4, 1
• Initial phase: 3-5 treatment sessions spaced exactly 1 month apart, using 5-7 mL of PRP per session. 4, 5
• Injection technique: 90-degree angle, 2-4 mm depth, 0.05-0.1 mL/cm², with injections spaced 1 cm apart using 30G × 4 mm needles. 4, 1
• Maintenance phase: 1 session every 6 months after completing the initial treatment phase. 4, 5

Pain Management for PRP

• Apply pharmaceutical-grade topical anesthetic cream before every PRP injection, as the procedure causes significant pain without anesthesia. 4, 1
• Patients must shampoo and detangle hair before each session, with no hair products applied. 1

Alternative Advanced Therapy: Platelet-Rich Fibrin (PRF)

• PRF represents a promising alternative to PRP with theoretical advantages including longer growth factor release and potentially lower cost, though high-quality comparative studies are lacking. 5
• PRF shows particular efficacy in mild androgenic alopecia cases and functions as both scaffold and reservoir for prolonged growth factor release. 5
• Use the same protocol as PRP: 3-5 sessions at 1-month intervals, then maintenance every 6 months. 4

Monitoring Treatment Response

Evaluation Methods

• Assess treatment efficacy using multiple objective measures at regular intervals: standardized before-and-after photographs, trichoscopy to evaluate hair density and diameter, hair pull tests, and patient self-assessment questionnaires. 4, 5
• Key indicators of positive response include: increased hair density (27.7-45.9/cm² increase from baseline with PRP), increased hair shaft diameter, decreased proportion of telogen hairs, improved patient satisfaction scores, and negative hair pull test. 4, 5
• A 25% improvement in hair density at 2 months predicts sustained response at 6 months with PRP therapy. 1
• Maximum response with PRP is typically achieved by 6 months. 1

Critical Timing Considerations

• Evaluate minoxidil monotherapy response at 4 months; if no improvement is seen, stop and consider adding PRP or switching strategies. 2
• For combination PRP therapy, evaluate treatment response after one year. 1
• Monitor terminal versus vellus hair ratio as an indicator of treatment efficacy. 1

Important Clinical Pitfalls

Diagnosis Confirmation

• Confirm the diagnosis is truly androgenic alopecia (temporal, vertex, or mid-frontal scalp involvement in men; central region thinning with preserved frontal hairline in women) before initiating treatment. 6, 1
• Alopecia areata presents with patchy hair loss and requires entirely different treatment (intralesional corticosteroids, contact immunotherapy), not minoxidil or finasteride. 6, 1
• Unlike alopecia areata where 80% of limited patchy cases remit spontaneously within one year, spontaneous improvement in androgenic alopecia is rare. 1

Treatment Expectations

• Delaying effective treatment while trying unproven supplements may result in irreversible hair loss, as the condition is progressive and worsens with time. 1, 7
• Treatment efficacy decreases with the severity and duration of alopecia, making early intervention critical. 4
• Insufficient treatment duration leads to suboptimal outcomes; some patients require extended therapy beyond the initial 6 months. 1
• Inadequate follow-up to assess treatment response can lead to suboptimal outcomes. 4

Patient Selection

• Minoxidil 5% is more likely to regrow hair in patients with early-stage hair loss; those with extensive baldness may not respond. 2
• The response to treatment cannot be predicted and varies significantly between individuals. 2
• Patient-reported outcomes, including subjective assessment of hair thickness and ease of styling, are crucial in evaluating treatment response. 1