What is the recommended treatment for androgenetic alopecia in women?

Treatment for Androgenetic Alopecia in Women

Start with topical minoxidil 5% applied 1 mL twice daily to the affected scalp areas as first-line therapy, and if response is inadequate after 6-12 months, add monthly platelet-rich plasma (PRP) injections for enhanced efficacy. 1, 2, 3

First-Line Treatment: Topical Minoxidil

• Minoxidil 5% solution is the only FDA-approved treatment and the recommended first-line therapy by the American Academy of Dermatology for female androgenetic alopecia. 3

• Apply exactly 1 mL of minoxidil 5% solution twice daily directly to the affected scalp areas. 1, 3

• The 5% foam formulation applied once daily is noninferior to 2% solution twice daily and offers practical advantages including less scalp irritation, less pruritus, less dandruff, and better compatibility with hair styling. 4

• Treatment must continue indefinitely—stopping minoxidil reverses all hair growth benefits completely. 1, 3

• Expect to see objective improvement in nonvellus hair count (33-hair increase in target areas) and subjective improvement reported by 55% of women within 32 weeks. 5, 4

Common Pitfalls to Avoid

• Do not confuse androgenetic alopecia (diffuse frontoparietal thinning) with alopecia areata (patchy hair loss), which requires completely different treatment with intralesional corticosteroids. 6, 3

• Avoid routinely testing for iron deficiency—no published studies demonstrate treatment response to iron replacement in androgenetic alopecia. 3

• Do not use oral minoxidil as it causes dose-dependent hypertrichosis (unwanted body hair growth throughout the body). 3

Second-Line Treatment: Adding PRP Therapy

If minoxidil monotherapy produces inadequate results after 6-12 months, add PRP injections while continuing topical minoxidil. 1, 2, 3

• Combination therapy (PRP plus minoxidil 5%) achieves 57% median increase in terminal hair density versus 48% with minoxidil alone at 32 weeks. 1

• PRP combined with minoxidil increases hair density 1.74 times and hair diameter 14.3 times compared to baseline. 2

• 83% of patients achieve a negative hair pull test (indicating reduced hair fragility) with combination therapy. 1

PRP Treatment Protocol

Initial Phase:

• Perform 3-5 treatment sessions spaced exactly 1 month apart. 1, 2, 3

• Use 5-7 mL of PRP per session, injecting 0.05-0.1 mL/cm² at 1 cm intervals. 1, 3

• Inject at 90-degree angle, 2-4 mm depth, using 30G × 4 mm needles to minimize discomfort. 1

• Use nonactivated PRP prepared by manual double-spin method with target platelet concentration of 1-1.5 million platelets per µL—nonactivated PRP shows 31% greater improvement in hair density compared to activated PRP. 1

Maintenance Phase:

• After completing initial sessions, continue with 1 PRP session every 6 months indefinitely. 1, 2, 3

Pain Management:

• Apply pharmaceutical-grade topical anesthetic cream before every PRP injection—the procedure causes significant pain without anesthesia. 1, 3

• Patients must shampoo and detangle hair before each session with no hair products applied. 1

Critical Technical Factors for PRP Success

• Low platelet concentration, inadequate injection volume, or insufficient treatment frequency leads to PRP treatment failure. 1

• Maximum response with PRP typically occurs by 6 months, though some patients require extended therapy beyond initial 6 months. 1

• A 25% improvement in hair density at 2 months predicts sustained response at 6 months. 1

Alternative Advanced Option: Topical Finasteride Combination

• The combination of topical minoxidil 5% with topical finasteride 0.25% demonstrates significantly superior efficacy compared to either monotherapy and represents the most effective medical treatment approach. 2

Adjunctive Treatment Option

• Low-level laser therapy (LLLT) using 655-nm laser devices can be added as adjunctive therapy, applied 3 times per week continuously. 1, 3

Monitoring Treatment Response

Evaluate treatment efficacy using multiple objective measures at regular intervals:

• Standardized before-and-after photographs taken under identical lighting conditions. 1, 2, 3

• Trichoscopy to evaluate hair density, hair shaft diameter, and proportion of telogen versus anagen hairs. 1, 2, 3

• Hair pull test to assess hair fragility. 1, 2

• Patient self-assessment questionnaires for subjective satisfaction. 1, 2, 3

Key indicators of positive treatment response include:

• Increased hair density and shaft diameter. 1, 2
• Decreased proportion of telogen hairs. 1, 2
• Negative hair pull test. 1, 2
• Improved patient satisfaction scores. 1, 2
• Increased terminal versus vellus hair ratio. 1

Timing of Evaluation

• Evaluate treatment response after one year of combination therapy. 1, 3

• Inadequate follow-up leads to suboptimal outcomes—schedule regular monitoring appointments every 3-6 months. 3

Important Prognostic Factors

• Treatment efficacy decreases with increasing severity and duration of alopecia—early initiation is crucial for optimal results. 1, 3

• Individual genetic factors significantly influence response to all treatments. 1

Emerging Alternative: Platelet-Rich Fibrin (PRF)

• PRF represents a promising alternative to PRP with theoretical advantages including lower cost, easier preparation, more sustained growth factor release, and potentially superior efficacy in mild androgenetic alopecia. 1, 2

• Preliminary studies demonstrate PRF safety and efficacy comparable to PRP, though high-quality comparative studies are lacking. 1, 2