What are the best treatment options for a male patient experiencing hair loss?

Treatment of Male Pattern Hair Loss

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

First-Line Pharmacological Treatment

Oral Finasteride

• Finasteride 1 mg daily is the gold standard oral treatment, working by inhibiting type II 5-alpha reductase to decrease scalp dihydrotestosterone (DHT), the androgen responsible for follicle miniaturization. 1, 3
• Clinical trials demonstrate finasteride increases hair count by 107-138 hairs (measured in 5.1 cm² area) compared to progressive loss with placebo over 1-2 years. 3
• Treatment must be continuous—stopping finasteride results in resumption of hair loss within months. 4
• Finasteride is only approved for men; it should not be used in women, especially those of childbearing potential. 1

Topical Minoxidil 5%

• Apply minoxidil 5% solution 1 mL twice daily directly to the dry scalp in areas of thinning, particularly the vertex (crown). 2
• Minoxidil promotes hair growth by prolonging the anagen (growth) phase and increasing perifollicular vascularization. 4
• Expect results at 2-4 months minimum—hair grows only 0.5-1 inch per month, so visible regrowth takes time. 2
• Initial increased shedding for up to 2 weeks is normal and indicates old hairs are being replaced; this should not prompt discontinuation. 2
• Like finasteride, minoxidil requires continuous use to maintain results. 4

Pattern Recognition and Diagnosis

Confirm Androgenetic Alopecia

• Look for characteristic pattern: temporal recession, vertex thinning, or mid-frontal scalp involvement with preserved occipital and lateral scalp hair. 1
• Use Hamilton-Norwood classification to document extent of hair loss. 1
• If hair loss is patchy rather than patterned, consider alopecia areata, which requires entirely different treatment (intralesional corticosteroids or contact immunotherapy). 5, 1

When to Order Laboratory Tests

• Laboratory testing is generally unnecessary when androgenetic alopecia is clinically evident with typical pattern. 4
• Check TSH and free T4 only if thyroid disease is suspected (fatigue, weight changes, cold intolerance). 4
• Check serum ferritin (optimal ≥60 ng/mL), vitamin D, and zinc only if nutritional deficiency is suspected or hair loss is diffuse rather than patterned. 4, 6
• Check total testosterone, free testosterone, and SHBG only if signs of androgen excess are present (acne, hirsutism). 4

Adjunctive Treatment: Platelet-Rich Plasma (PRP)

When to Consider PRP

• PRP injections can be added as adjunctive therapy for patients who want to maximize results or have suboptimal response to finasteride and minoxidil. 1, 4
• PRP works by inducing dermal papilla proliferation, increasing perifollicular vascularization, and accelerating telogen-to-anagen transition. 4

PRP Protocol

• Treatment phase: 3-5 sessions at 1-month intervals using 5-7 mL PRP (0.05-0.1 mL/cm²). 5
• Inject into scalp at 90-degree angle, 2-4 mm depth, with injections 1 cm apart in areas of hair loss. 5
• Use manual double-spin method for preparation; platelet concentration should be 1-1.5 million/µL. 5
• Maintenance phase: 1 session every 6 months after initial treatment series. 5, 4
• Apply topical numbing cream before procedure, as injections can be painful. 5

Monitoring Treatment Response

Timeline and Expectations

• Photograph the scalp at baseline and every 3-6 months using standardized lighting and angles to objectively track response. 1
• Counsel patients that no visible improvement should be expected before 3-4 months of consistent twice-daily treatment. 2
• At 4 months, if no response is seen, consider adding PRP or reassessing diagnosis. 2
• Early treatment achieves better outcomes—delaying effective therapy while trying unproven supplements may result in irreversible follicle miniaturization. 1

Patient Satisfaction

• Use patient satisfaction questionnaires to track subjective improvement in hair appearance and quality of life. 1
• Address psychological impact, as hair loss significantly affects self-esteem, confidence, and work productivity. 7

Common Pitfalls to Avoid

Diagnostic Errors

• Do not confuse androgenetic alopecia with alopecia areata—patchy loss with exclamation mark hairs indicates alopecia areata, requiring different treatment. 5, 4
• Do not order extensive autoimmune panels when androgenetic alopecia is clinically obvious. 4
• Consider trichotillomania (compulsive hair pulling) if hair loss pattern is bizarre or incomplete, with firmly anchored broken hairs. 4

Treatment Mistakes

• Do not recommend saw palmetto—it lacks robust evidence and delays effective treatment with finasteride and minoxidil. 1
• Do not use potent topical corticosteroids for androgenetic alopecia; they are ineffective and indicated only for alopecia areata. 5
• Avoid systemic corticosteroids or PUVA for hair loss due to serious side effects and inadequate efficacy. 5
• Minoxidil 5% is not FDA-approved for women—women should use minoxidil 2% solution, as 5% works no better and may cause unwanted facial hair growth. 2

Application Technique

• Ensure patients apply minoxidil to dry scalp, not wet hair—the medication must reach the scalp surface to be absorbed. 2
• Instruct patients to wash and detangle hair before PRP sessions, avoiding hair products like gel or spray. 5

Alternative Considerations

When Medical Treatment Fails

• Hair transplantation (follicular unit extraction) can be considered for patients with inadequate response to medical therapy, especially when combined with PRP pre-treatment and follicle soaking. 5
• Wigs provide immediate cosmetic benefit but are rarely natural-appearing for men. 5

Treatments to Avoid

• Oral zinc and isoprinosine are ineffective in controlled trials. 5
• PUVA therapy has high relapse rates and unacceptably high cumulative UVA doses. 5