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

First-Line Treatment for Hair Loss

For androgenetic alopecia (pattern hair loss), topical minoxidil 5% applied twice daily is the first-line treatment, with results expected at 2-4 months and requiring indefinite continuation to maintain benefits. 1

Initial Assessment and Diagnosis

Before initiating treatment, determine the specific type of hair loss:

• Androgenetic alopecia (AGA) presents with gradual thinning at the vertex (crown) in men or diffuse thinning over the crown in women, typically with family history 1
• Alopecia areata shows round or oval patches of complete hair loss with short broken hairs at margins, yellow dots on dermoscopy, and nail changes in 10% of cases 2
• Exclude secondary causes including thyroid disease, nutritional deficiencies (iron, vitamin A excess), medication-induced loss, or scarring conditions 1

First-Line Treatment Protocol for Androgenetic Alopecia

Topical Minoxidil 5%

Apply 1 mL of minoxidil 5% solution twice daily (morning and evening) directly to the affected scalp areas using the dropper applicator. 1

Key application instructions:

• Part hair to expose the scalp and apply directly to skin, not hair 1
• Allow 4 hours of contact time before washing 1
• Apply nighttime dose 2-4 hours before bed to allow drying 1
• Use mild shampoo if washing scalp before application 1

Expected timeline and outcomes:

• Initial results may appear at 2 months, but most patients require 4 months to see benefit 1
• Temporary increased shedding for up to 2 weeks is normal and indicates treatment is working 1
• Initial regrowth appears as fine, colorless "peach fuzz" that gradually becomes pigmented and thicker 1
• Treatment must continue indefinitely; discontinuation results in reversal of benefits within months 3

Important contraindications and precautions:

• Women should use 2% formulation, not 5%, as higher concentrations provide no additional benefit and increase facial hair growth risk 1
• Not indicated for frontal hairline recession or patchy hair loss 1
• Discontinue if no improvement after 4 months 1
• Common side effects include scalp itching and irritation; rare side effects include unwanted facial hair growth (reversible with discontinuation) 1

First-Line Treatment for Alopecia Areata

For Limited Patchy Disease (< 5 patches, < 3 cm diameter)

Intralesional triamcinolone acetonide 5-10 mg/mL injected monthly achieves 62% complete regrowth rates and is the first-line intervention when treatment is desired. 2

Treatment protocol:

• Inject 0.05-0.1 mL per site just below the dermis in upper subcutaneous tissue 4
• Each injection produces approximately 0.5 cm diameter tuft of hair growth 4
• Administer multiple injections spaced throughout affected areas 4
• Repeat monthly until satisfactory response obtained 2
• Skin atrophy at injection sites is the most consistent side effect 4

Alternative Approach for Limited Disease

Reassurance alone is legitimate for limited patchy hair loss of short duration, as spontaneous remission occurs in up to 80% of patients. 2

• Patients with less than 25% scalp involvement have 68% chance of being disease-free at long-term follow-up 2
• Hair follicles remain viable even in longstanding disease, maintaining potential for recovery 2

Second-Line and Adjunctive Treatments

Platelet-Rich Plasma (PRP) for Androgenetic Alopecia

For patients with suboptimal response to minoxidil monotherapy, add PRP injections using nonactivated preparation at 1-1.5 million platelets/µL, administered monthly for 3-5 sessions, then every 6 months for maintenance. 3

Technical specifications:

• Use manual double-spin method for preparation 3
• Inject 5-7 mL total volume at 0.05-0.1 mL/cm² 3
• Use 30G × 4mm needles at 90-degree angle, 2-4mm depth, 1 cm apart 3
• Apply pharmaceutical-grade topical anesthetic cream before injection due to significant pain 3
• Nonactivated PRP shows 31% greater improvement than activated PRP 3

Expected outcomes with combination therapy:

• 57% median increase in terminal hair density versus 48% with minoxidil alone at 32 weeks 3
• 83% of patients achieve negative hair pull test indicating reduced hair fragility 3
• Maximum response typically achieved by 6 months 3

Contact Immunotherapy for Extensive Alopecia Areata

For extensive alopecia areata (> 50% scalp involvement), diphenylcyclopropenone (DPCP) contact immunotherapy achieves 50-60% worthwhile response rates, though this is an unlicensed treatment requiring informed consent. 4

Protocol:

• Sensitize with 2% DPCP solution to small scalp area 4
• Two weeks later, begin weekly applications starting at 0.001% concentration 4
• Increase concentration weekly until mild dermatitis reaction obtained 4
• Treatment duration of 32 months may be required for optimal response (78% response rate versus 30% at 6 months) 4
• Patients with total/universal alopecia have only 17% response rate even with prolonged treatment 4

Critical Pitfalls to Avoid

• Inadequate application technique: Minoxidil must contact the scalp directly, not just hair, and requires 4 hours of contact time 1
• Premature discontinuation: Stopping treatment before 4 months prevents assessment of true efficacy 1
• Using 5% minoxidil in women: This concentration offers no benefit over 2% in women and increases facial hair growth risk 1
• Expecting complete hair restoration: Most patients achieve partial improvement, not complete regrowth 1
• Low PRP platelet concentration or inadequate injection volume: These technical errors lead to treatment failure 3
• Misdiagnosing hair loss type: Minoxidil does not work for scarring alopecias, medication-induced loss, or nutritional deficiencies 1