What are the treatment options for a male patient with androgenic alopecia (male pattern baldness)?

Male Androgenetic Alopecia Treatment

Start 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 in male pattern baldness. 1, 2

First-Line Pharmacological Treatment

Oral finasteride works by inhibiting 5-alpha reductase, preventing conversion of testosterone to dihydrotestosterone (DHT), the primary mediator of follicular miniaturization. 1, 3

• FDA-approved at 1 mg daily for male androgenetic alopecia 1
• Most effective when started early in the disease process 4, 5
• Results typically visible at 4 months, with continued improvement up to 12-24 months 2, 4
• Must be continued indefinitely to maintain benefits; hair loss resumes upon discontinuation 4, 5

Topical minoxidil 5% promotes hair growth through vasodilation and follicular stimulation. 1, 2

• FDA-approved for men; apply 1 mL twice daily directly to affected scalp areas 2
• Results may appear as early as 2 months, but 4 months minimum is often required 2
• Initial shedding for up to 2 weeks is expected and indicates the medication is working 2
• New hair initially appears as soft, downy, colorless growth before maturing 2
• Most effective for vertex hair loss; less effective for frontal/temporal recession 2

Combination Therapy Approach

Finasteride plus minoxidil together provides superior efficacy compared to either agent alone, addressing both the hormonal pathogenesis and direct follicular stimulation. 1, 4

• This combination arrests disease progression while promoting regrowth 4, 5
• Early treatment achieves optimal outcomes before extensive miniaturization occurs 4, 5

Adjunctive Treatment: Platelet-Rich Plasma (PRP)

PRP can be added for patients refractory to medical treatment or seeking enhanced results. 1, 4

• Protocol: 3-5 sessions at 1-month intervals initially, then maintenance every 6 months 1
• Inject 5-7 mL per session at 0.05-0.1 mL/cm² into affected scalp areas 6
• Clinical trials show improvement in hair count, though evidence quality is moderate 1, 4
• PRP combined with minoxidil produces the highest increase in hair density compared to either treatment alone 6

Treatment Monitoring and Expectations

Evaluate response at 3 months initially, with formal assessment at 12 months for combination therapy. 6, 1

Objective measures to track: 6

• Standardized photographs comparing baseline to follow-up
• Hair density per cm² via trichoscopy
• Hair shaft diameter measurements
• Patient satisfaction questionnaires

Key indicators of positive response: 6

• Increased hair density and shaft diameter
• Decreased proportion of telogen (resting phase) hairs
• Improved patient-reported outcomes

Common Pitfalls to Avoid

Do not stop treatment prematurely - meaningful changes may take 12-24 months, and discontinuation results in loss of all gains. 6, 4

Avoid delaying effective treatment while trying unproven supplements (e.g., saw palmetto), as this may result in irreversible hair loss. 1

Do not use minoxidil 5% in women - it works no better than 2% formulation and may cause facial hair growth. 2

Recognize that spontaneous improvement is rare in androgenetic alopecia, unlike alopecia areata where 80% of limited cases remit spontaneously. 1

Advanced Treatment Options

Hair transplantation should be considered for advanced cases resistant to medical treatment or after medical stabilization. 6, 7

Dutasteride 0.5 mg (off-label) may induce better responses than finasteride, especially in frontal areas, though it lacks FDA approval for this indication. 3

Oral minoxidil 2.5-5 mg daily (off-label) shows efficacy in clinical studies, with hypertrichosis as the main adverse effect. 3

Psychological Considerations

Address the psychological impact through counseling, as hair loss significantly affects self-esteem, confidence, and quality of life in affected men. 8, 6, 4

• Consider referral for psychological support for patients experiencing significant distress 8
• Discuss cosmetic camouflage options during the treatment response period 8

Pattern Recognition for Diagnosis

Male androgenetic alopecia presents with characteristic patterns: 9, 8

• Preferential involvement of temples, vertex, and mid-frontal scalp
• Use Hamilton-Norwood classification to document extent
• Preserved occipital and lateral scalp hair

If hair loss is patchy rather than patterned, consider alopecia areata, which requires entirely different treatment (intralesional corticosteroids, contact immunotherapy). 9, 1