What are the recommended treatment options for androgenic alopecia in adult men and women?

Treatment of Androgenetic Alopecia

For male androgenetic alopecia, initiate combination therapy with oral finasteride 1 mg daily and topical minoxidil 5% twice daily, as these are the only FDA-approved treatments proven to halt progression and stimulate regrowth. 1, 2 For female androgenetic alopecia, topical minoxidil is the cornerstone first-line treatment and must be continued indefinitely to maintain benefits. 3, 4

Critical Diagnostic Distinction

Before initiating treatment, confirm the diagnosis is androgenetic alopecia and not alopecia areata, as these require completely different management approaches: 1

• Androgenetic alopecia presents with patterned hair loss (temples, vertex, mid-frontal scalp in men; diffuse thinning in women) 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 5, 1
• If hair loss is patchy rather than patterned, this is alopecia areata with 80% spontaneous remission in limited cases within one year, whereas androgenetic alopecia rarely improves spontaneously 1

Male Androgenetic Alopecia Treatment Algorithm

First-Line Therapy

Start combination therapy immediately: 1

• Oral finasteride 1 mg daily (inhibits 5-alpha reductase to block DHT production) 1, 6
• Topical minoxidil 5% solution, 1 mL applied twice daily directly to affected scalp areas 1, 2
• Both medications must be continued indefinitely, as discontinuation leads to reversal of all hair growth benefits within months 3, 2

Expected Timeline and Monitoring

• Hair regrowth may begin as early as 2 months, but most men require at least 4 months to see results 2
• Initial shedding for up to 2 weeks is expected and indicates the medication is working by replacing old hairs with new growth 2
• Document baseline with standardized photographs using the Hamilton-Norwood classification 1
• Schedule formal evaluation at 3 months initially, then at 12 months, as meaningful changes may take 12-24 months 4

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

For suboptimal response to finasteride and minoxidil after 4-6 months, add PRP injections: 3, 1

PRP Treatment Protocol: 3

• Preparation: Manual double-spin method, target platelet concentration 1-1.5 million platelets per µL, use nonactivated PRP (shows 31% greater improvement than activated) 3
• Initial phase: 3-5 sessions spaced exactly 1 month apart 3, 1
• Dose: 5-7 mL PRP per session, injected at 0.05-0.1 mL/cm² 3, 1
• Technique: 90-degree angle, 2-4 mm depth, injections 1 cm apart using 30G × 4 mm needles 3
• Maintenance: 1 session every 6 months after initial treatment phase 3, 1
• Pain management: Apply pharmaceutical-grade topical anesthetic cream before injection due to significant pain 3

Expected outcomes with PRP + minoxidil combination: 57% median increase in terminal hair density versus 48% with minoxidil alone at 32 weeks 3

Female Androgenetic Alopecia Treatment Algorithm

First-Line Therapy

Topical minoxidil is the cornerstone treatment: 3, 4

• Apply minoxidil 5% solution, 1 mL twice daily to affected scalp areas 3
• Must be continued indefinitely to maintain hair growth benefits 3, 4
• Discontinuation leads to reversal of all gains within months 4

Second-Line: Adding PRP for Enhanced Results

When resources permit or response to minoxidil alone is suboptimal, add PRP therapy using the identical protocol described above for men 3, 4

Combination therapy outcomes: 3

• 83% of patients achieve negative hair pull test (reduced hair fragility) 3
• Highest increase in hair density compared to either treatment alone 3, 4
• Maximum response typically achieved by 6 months 3

Monitoring Treatment Efficacy

Evaluate response using multiple objective measures: 3, 4

• Standardized before-and-after photographs 3, 4
• Trichoscopy to measure hair density and diameter 3, 4
• Hair pull tests to evaluate hair fragility 3, 4
• Patient self-assessment questionnaires 3, 4

Key indicators of positive response: 4

• Increased hair density per cm² 4
• Increased hair shaft diameter 4
• Decreased proportion of telogen hairs 4
• Improved patient satisfaction scores 4

Adjunctive Treatment Options

Low-Level Laser Therapy (LLLT)

• Use FDA-cleared 655 nm laser devices three times per week 3
• Requires continuous indefinite use to maintain regrowth, similar to minoxidil 3
• Abrupt cessation results in loss of hair-regrowth gains within months 3

Emerging Alternative: Platelet-Rich Fibrin (PRF)

• Preliminary studies show comparable safety and efficacy to PRP 3
• Theoretical advantages include lower cost, simpler preparation, and sustained growth factor release 3
• May serve as viable alternative to PRP, though more data needed 3

Critical Pitfalls to Avoid

Treatment failures commonly result from: 3, 4

• Low platelet concentration, inadequate injection volume, or insufficient treatment frequency leads to PRP failure 3
• Inadequate follow-up to assess treatment response 3, 4
• Stopping treatment prematurely before 4-6 months 4, 2
• Discontinuing successful therapy, causing reversal of all gains 3, 4
• Delaying effective treatment with unproven supplements (e.g., saw palmetto lacks robust data) may result in irreversible hair loss 1
• Using potent topical corticosteroids for androgenetic alopecia—these are ineffective and indicated only for alopecia areata 1

Advanced Options for Refractory Cases

For inadequate response to medical therapy: 1

• Hair transplantation (follicular unit extraction) can be considered, especially when combined with PRP pre-treatment and follicle soaking 1
• Address psychological impact through counseling and cosmetic camouflage options 4

What NOT to Use

Treatments lacking evidence for androgenetic alopecia: 1

• Saw palmetto (no robust high-quality data) 1
• Potent topical corticosteroids (ineffective for androgenetic alopecia, only for alopecia areata) 1
• Unproven supplements without documented deficiencies 4