What is the most effective treatment for androgenetic alopecia in an adult patient?

Management of Thinning Hair and Hair Fall

For androgenetic alopecia (pattern hair loss), start with topical minoxidil 5% twice daily as first-line therapy, and strongly consider adding platelet-rich plasma (PRP) injections for superior results, as combination therapy achieves 57% median increase in terminal hair density versus 48% with minoxidil alone. 1

First-Line Treatment Approach

Topical Minoxidil 5%:

• Apply 1 mL twice daily directly to the scalp 2
• Must be continued indefinitely to maintain results, as discontinuation leads to reversal of hair growth benefits 1
• Results may appear as early as 2 months, but most patients require at least 4 months of consistent use before seeing improvement 2
• Initial temporary increase in hair shedding for up to 2 weeks is expected and indicates the medication is working 2

Important caveat: Minoxidil 5% is FDA-approved for men only; women should use 2% formulation as 5% works no better in women and may cause unwanted facial hair growth 2

Enhanced Treatment: Adding PRP Therapy

When to add PRP:

• For patients seeking optimal results from the start 1
• For suboptimal response to minoxidil monotherapy after 4-6 months 1
• Combination therapy is significantly more effective than minoxidil alone 3, 1, 4

PRP Protocol (based on American Academy of Periodontology and Indian Association of Dermatologists recommendations):

Preparation specifications:

• Use manual double-spin method without activation (nonactivated PRP shows 31% greater improvement than activated) 1
• Target platelet concentration: 1 to 1.5 million platelets per µL 1, 5

Treatment phase:

• 3-5 sessions spaced exactly 1 month apart 1, 5
• Dose: 5-7 mL PRP per session 1
• Injection technique: 0.05 to 0.1 mL/cm², 90-degree angle, 2-4 mm depth, injections 1 cm apart 1
• Use 30G × 4mm needles to minimize discomfort 1

Maintenance phase:

• 1 session every 6 months after completing initial treatment series 1, 5

Pain management:

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

Expected Outcomes and Monitoring

Timeline for results:

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

Monitoring parameters:

• Standardized before-and-after photographs 1
• Trichoscopy to evaluate hair density and diameter 1
• Hair pull test to assess fragility 1
• Patient self-assessment questionnaires 1
• Terminal versus vellus hair ratio as indicator of treatment efficacy 1

Critical Pitfalls to Avoid

Treatment failure factors:

• Low platelet concentration in PRP (<1 million platelets/µL) 1, 5
• Inadequate injection volume or insufficient treatment frequency 1
• Stopping minoxidil prematurely (before 4 months) 2
• Insufficient treatment duration (some patients require therapy beyond initial 6 months) 1

Patient selection errors:

• This approach is for androgenetic alopecia (pattern hair loss) only 3
• Not appropriate for patchy hair loss (alopecia areata), which requires different treatment 3
• Not for hair loss from medications, nutritional deficiencies, thyroid disease, or scarring conditions 2
• If no family history of gradual hair loss or if hair loss is patchy, refer to dermatologist for evaluation 2

Alternative Considerations

For men specifically:

• Oral finasteride 1 mg daily demonstrates superior efficacy to minoxidil in head-to-head trials 5, 6
• Combination of topical finasteride 0.25% with minoxidil 5% shows significantly higher efficacy than either monotherapy 7

Low-level laser therapy (LLLT):

• 655-nm laser devices used 3 times per week 3
• Can be used as adjunctive therapy 3

Platelet-Rich Fibrin (PRF):

• Theoretical advantages over PRP including lower cost and sustained growth factor release 1
• However, evidence base remains more limited than for PRP 5