What are the treatment options for a male patient with male pattern baldness?

Male Pattern Baldness Treatment

First-Line Treatment: Topical Minoxidil 5%

For male pattern baldness (androgenetic alopecia), topical minoxidil 5% applied twice daily is the FDA-approved first-line treatment that should be initiated immediately, with the understanding that it must be continued indefinitely to maintain results. 1

Minoxidil Treatment Protocol

• Apply 1 mL of minoxidil 5% topical solution directly to the scalp twice daily, ensuring the medication reaches the scalp rather than just the hair 1
• Results typically appear at 2 months, though some men require at least 4 months of consistent use before seeing regrowth 1
• Initial hair loss may temporarily increase for up to 2 weeks when starting treatment—this is expected as old hairs are shed to make way for new growth 1
• New hair initially appears as soft, downy, colorless "peach fuzz" before developing into terminal hairs with normal color and thickness 1
• Discontinuation leads to reversal of all hair growth benefits, making lifelong treatment necessary 2

Evidence Supporting Minoxidil

• The 2% minoxidil formulation demonstrated statistically significant increases in non-vellus hair counts compared to placebo (mean increase of 58.2 hairs vs 4.0 hairs at 4 months, p=0.0001) 3
• The 5% formulation provides more hair regrowth than the 2% concentration and is specifically indicated for men 1
• European trials confirmed superiority over placebo with significant improvements in non-vellus hair counts (p=0.0084) and investigator-rated hair growth (p=0.019) at 24 weeks 4

Critical Limitations to Understand

• Minoxidil works best for vertex (crown) hair loss, not frontal baldness or receding hairline 1
• Men with extensive hair loss beyond the vertex pattern shown on FDA labeling are less likely to respond 1
• If no results are seen after 4 months of twice-daily use, discontinue treatment as further use is unlikely to help 1

Second-Line Treatment: Adding Platelet-Rich Plasma (PRP)

If minoxidil monotherapy produces suboptimal results after 4-6 months, add PRP injections to create combination therapy, which achieves 57% median increase in terminal hair density versus 48% with minoxidil alone. 2

PRP Treatment Protocol

• Use the manual double-spin method with target platelet concentration of 1 to 1.5 million platelets per µL 2
• Use nonactivated PRP, which shows 31% greater improvement in hair density compared to activated PRP 2
• Administer 5-7 mL of PRP at 0.05 to 0.1 mL/cm², injecting at 90-degree angle, 2-4 mm depth, with injections spaced 1 cm apart 2
• Initial phase: minimum of 3-5 sessions at 1-month intervals 2
• Maintenance phase: 1 session every 6 months after initial treatment 2
• Apply pharmaceutical-grade topical anesthetic cream before injection due to significant pain 2
• Use 30G × 4 mm needles to minimize discomfort 2

Expected Outcomes with Combination Therapy

• 83% of patients achieve a negative hair pull test (reduced hair fragility) with PRP plus minoxidil 2
• Maximum response typically achieved by 6 months 2
• A 25% improvement in hair density at 2 months predicts sustained response at 6 months 2

Monitoring Treatment Response

• Use standardized before-and-after photographs at each visit 2
• Perform trichoscopy to evaluate hair density and diameter 2
• Monitor terminal versus vellus hair ratio as key efficacy indicator 2
• Assess patient-reported outcomes including subjective hair thickness and ease of styling 2

Critical Pitfalls to Avoid

• Low platelet concentration, inadequate injection volume, or insufficient treatment frequency leads to PRP treatment failure 2
• Insufficient treatment duration—some patients require extended therapy beyond initial 6 months 2
• Inadequate follow-up to assess treatment response leads to suboptimal outcomes 2
• Treatment efficacy decreases with severity and duration of alopecia, so earlier intervention is preferable 2

Alternative and Emerging Options

• Low-level laser light therapy (LLLT) three times per week shows demonstrated efficacy 2
• Platelet-rich fibrin (PRF) has theoretical advantages over PRP including lower cost, easier preparation, and sustained growth factor release 2
• Oral finasteride 1 mg and dutasteride 0.5 mg are effective 5-alpha reductase inhibitors, with dutasteride inducing better responses especially in the frontal area 5
• Topical finasteride 0.25% daily provides efficacy with less systemic absorption than oral formulations 5
• Oral minoxidil 2.5-5 mg daily is an off-label option with proven efficacy, though hypertrichosis is the main adverse effect 5

Important Distinctions

This guidance applies specifically to male pattern baldness (androgenetic alopecia), NOT alopecia areata, which is an autoimmune condition requiring entirely different treatments such as intralesional corticosteroids or contact immunotherapy with DPCP. 6, 7