What is the best approach for treating androgenetic alopecia, particularly using Minoxidil?

Minoxidil for Androgenetic Alopecia

First-Line Treatment Recommendation

Start with topical minoxidil 5% applied 1 mL twice daily directly to the scalp, and if response is suboptimal after 4-6 months, add platelet-rich plasma (PRP) therapy rather than switching to oral minoxidil. 1, 2

Topical Minoxidil Protocol

Application Instructions

• Apply 1 mL twice daily (morning and evening) directly onto the scalp in the hair loss area 2
• Allow 2-4 hours to dry completely before bed to prevent staining of linens 2
• Do not exceed twice daily application—more frequent use does not improve results and may increase side effects 2
• Each bottle should last one month if used as directed 2

Expected Timeline for Results

• Initial results may appear as early as 2 months with twice daily use 2
• Some patients require at least 4 months before seeing results 2
• If no improvement after 4 months of topical monotherapy, discontinue or add PRP therapy 2, 1
• Temporary increase in hair shedding may occur in first 2 weeks—this is expected and indicates old hairs are being replaced 2

Monitoring Response

• Evaluate at 3,6, and 12 months using: 1
  • Standardized before-and-after photographs
  • Trichoscopy to assess hair density and diameter
  • Terminal versus vellus hair ratio 1
  • Patient self-assessment questionnaires
  • Hair pull tests to evaluate fragility

Combination Therapy with PRP

When to Add PRP

If topical minoxidil 5% alone produces suboptimal results after 4-6 months, add PRP injections rather than switching to oral minoxidil—this combination shows superior efficacy with 57% median increase in terminal hair density versus 48% with minoxidil alone at 32 weeks. 1

PRP Technical Protocol

• Preparation method: Manual double-spin method with target platelet concentration of 1-1.5 million platelets per µL 1
• Critical detail: Use nonactivated PRP—it shows 31% greater improvement in hair density compared to activated PRP 1
• Initial treatment phase: Minimum of 3-5 sessions at 1-month intervals 1
• Dosing: 5-7 mL PRP per session, using 0.05-0.1 mL/cm² 1
• Injection technique: 90-degree angle, 2-4 mm depth, injections 1 cm apart 1
• Needle size: 30G × 4 mm to minimize discomfort 1
• Maintenance phase: 1 session every 6 months after initial treatment 1

Pain Management for PRP

• Apply pharmaceutical-grade topical anesthetic cream before injection due to significant pain associated with the procedure 1
• Patient must shampoo and detangle hair before session with no hair products applied 1

Expected Outcomes with Combination Therapy

• 83% of patients achieve negative hair pull test (reduced hair fragility) 1
• Maximum response typically achieved by 6 months 1
• 25% improvement in hair density at 2 months predicts sustained response at 6 months 1

Oral Minoxidil (Off-Label Alternative)

When to Consider Oral Minoxidil

Oral minoxidil 1 mg daily may be considered for patients who fail or cannot tolerate topical therapy, though combination therapy with topical minoxidil 5% plus PRP shows greater efficacy than switching to oral monotherapy. 3, 1

Efficacy and Dosing

• Oral minoxidil 1 mg is as effective as topical 5% in treating androgenetic alopecia 3
• Response rates of 18-82.4% have been observed 3
• Women require lower starting doses due to increased risk of adverse effects 3
• Doses >5 mg are associated with increased adverse effects including hypertrichosis (17.5%) and tachycardia (3.5%) 3

Mandatory Cardiovascular Screening

All patients must undergo cardiovascular screening before initiating oral minoxidil—it is contraindicated in patients with pre-existing cardiovascular disease due to rare but serious adverse effects including pericardial effusion. 3

Monitoring for Oral Minoxidil

• Monitor for orthostatic symptoms, edema, and tachycardia 3
• Common side effects: hypertrichosis (17.5%), lower limb edema, orthostatic hypotension 3
• Overall adverse effect incidence: 14.9% at low doses 3
• Women have higher overall incidence of adverse effects compared to men 3

Contraindications for Oral Minoxidil

• Pre-existing cardiovascular disease 3
• Pregnancy or women planning to become pregnant (lack of safety data) 3

Critical Pitfalls to Avoid

Treatment Failures

• Low platelet concentration, inadequate injection volume, or insufficient treatment frequency leads to PRP treatment failure 1
• Insufficient treatment duration can lead to suboptimal outcomes—some patients require extended therapy beyond initial 6 months 1
• Inadequate follow-up to assess treatment response leads to suboptimal outcomes 1

Maintenance Requirements

Continuous use of minoxidil is mandatory to maintain hair regrowth—discontinuation leads to reversal of benefits within 3-4 months. 1, 2

Application Errors

• Applying minoxidil and washing hair within 4 hours reduces efficacy—allow at least 4 hours before washing 2
• Missing doses: do not make up for missed applications, simply continue with next scheduled dose 2

Compatibility with Hair Care

Styling Products and Treatments

• Hair sprays, gels, mousses, and conditioners may be used after minoxidil has soaked into scalp 2
• Hair coloring and perming are permitted with precautions: 2
  • Wash off all minoxidil before applying chemical treatments
  • Do not apply minoxidil on same day as chemical treatment
  • Wait 24 hours after chemical treatment before resuming minoxidil to ensure no scalp irritation

Shampoo Selection

• Use mild shampoo if washing scalp before minoxidil application 2

Side Effects and Safety

Common Side Effects (Topical)

• Itching and skin irritation of treated scalp area 2
• Alcohol content causes burning if it contacts eyes—rinse with large amounts of cool tap water if accidental contact occurs 2
• Unwanted facial hair growth is rare and reversible 2

When to Stop and Seek Medical Attention

Stop use immediately and consult a physician if: 2

• Chest pain, rapid heartbeat, faintness, or dizziness occurs
• Sudden unexplained weight gain
• Hand or foot swelling
• Persistent scalp irritation or redness
• Unwanted facial hair growth
• No hair regrowth after 4 months

Special Populations

Women

• Women should not use topical minoxidil 5% solution—studies show it works no better than 2% solution in women, and some women may develop facial hair 2
• For women, topical minoxidil 5% (likely foam formulation) or 2% solution is first-line, with oral minoxidil 1 mg as alternative for those who fail or cannot tolerate topical therapy 3
• Oral minoxidil may be harmful if used during pregnancy or breast-feeding 2, 3

Age Restrictions

• Do not use on babies or children under 18 years old 2

Contraindications for Topical Use

Do not use topical minoxidil if: 2

• Hair loss pattern differs from vertex thinning (not for frontal baldness or receding hairline)
• No family history of hair loss
• Hair loss is sudden and/or patchy
• Scalp is red, inflamed, infected, irritated, or painful
• Using other medicines on the scalp