What treatment options are available for an adult patient experiencing androgenetic alopecia (male/female pattern baldness) with symptoms of thinning hair strands and hair fall?

Treatment of Androgenetic Alopecia (Pattern Hair Loss)

For thinning hair strands and hair fall consistent with androgenetic alopecia, initiate combination therapy with topical minoxidil 5% twice daily and oral finasteride 1 mg daily, as these are the only FDA-approved treatments proven to halt progression and stimulate regrowth. 1, 2

Confirming the Diagnosis

Before starting treatment, confirm you are dealing with androgenetic alopecia and not alopecia areata, as these require completely different approaches:

• Androgenetic alopecia presents with patterned hair loss affecting temples, vertex (crown), and mid-frontal scalp, with preserved occipital and lateral scalp hair 1
• Alopecia areata presents with patchy hair loss and exclamation mark hairs, requiring intralesional corticosteroids or contact immunotherapy instead 3, 1
• If hair loss is patchy rather than patterned, this is likely alopecia areata, not androgenetic alopecia 1

First-Line Treatment Protocol

Start combination therapy immediately:

• Topical minoxidil 5%: Apply 1 mL twice daily directly to the scalp in areas of thinning 1, 2
• Oral finasteride 1 mg: Take once daily (for male patients) 1, 4

Critical Timeline Expectations

• Hair regrowth takes time—results may appear at 2 months but often require 4 months of consistent twice-daily use 2
• Initial shedding may occur in the first 2 weeks as old hairs are replaced; this is expected and indicates the treatment is working 2
• If no improvement after 4 months of minoxidil, the treatment is unlikely to work 2
• Treatment must continue indefinitely—stopping causes reversal of all hair growth benefits 5, 2

Important Caveat About Spontaneous Improvement

Unlike alopecia areata (where 80% of limited patchy cases remit spontaneously within one year), spontaneous improvement in androgenetic alopecia is rare 1. Delaying effective treatment with finasteride and minoxidil while trying unproven supplements may result in irreversible hair loss 1.

Monitoring Treatment Response

Evaluate response at 4-6 months using:

• Standardized photographs comparing baseline to follow-up 1, 5
• Patient satisfaction questionnaires as key indicators of positive response 1
• Hair pull test to evaluate hair fragility 5
• Trichoscopy to assess hair density and diameter changes 5

Key indicators of positive response include increased hair density, increased hair shaft diameter, decreased proportion of telogen hairs, and improved patient satisfaction scores 5.

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

If response to minoxidil and finasteride is suboptimal after 6 months, add PRP injections as adjunctive therapy 1, 5:

PRP Protocol Specifications

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

Pain Management for PRP

Apply pharmaceutical-grade topical anesthetic cream before injection due to significant pain associated with the procedure 5. Use 30G × 4 mm needles to minimize discomfort 5.

Expected Outcomes with Combination Therapy

Combination therapy of minoxidil 5% and PRP achieves a 57% median increase in terminal hair density versus 48% with minoxidil alone at 32 weeks 5. Additionally, 83% of patients achieve a negative hair pull test after treatment, indicating reduced hair fragility 5.

Common Pitfalls to Avoid

• Insufficient treatment duration: Some patients require extended therapy beyond initial 6 months; maximum response with PRP is typically achieved by 6 months 5
• Low platelet concentration, inadequate injection volume, or insufficient treatment frequency leads to PRP treatment failure 5
• Using topical corticosteroids: These are ineffective for androgenetic alopecia and indicated only for alopecia areata 3, 1
• Inadequate follow-up: Failing to assess treatment response leads to suboptimal outcomes 5

Alternative and Emerging Options

• Low-level laser light therapy (LLLT): FDA-cleared option with demonstrated efficacy, recommended usage three times per week 5, 6
• Platelet-rich fibrin (PRF): Shows promise as potentially superior alternative to PRP with theoretical advantages including sustained growth factor release 5
• Hair transplantation (follicular unit extraction): Consider for patients with inadequate response to medical therapy, especially when combined with PRP pre-treatment 1

Special Considerations

• For female patients: Finasteride is not recommended; use minoxidil as first-line treatment, with PRP as second-line 5
• Wigs: Provide immediate cosmetic benefit but are rarely natural-appearing for men; more effective solution for women with extensive hair loss 3
• Individual genetic factors significantly influence response to all treatments 5