Updated Management Protocol for Male and Female Pattern Hair Loss
For male pattern hair loss, initiate oral finasteride 1 mg daily or dutasteride 0.5 mg daily combined with topical minoxidil 5% twice daily; for female pattern hair loss, start topical minoxidil 2% twice daily as monotherapy, reserving oral antiandrogens for non-responders or those with hyperandrogenism. 1, 2
Initial Diagnostic Workup
Clinical Assessment
Examine the scalp pattern carefully: diffuse thinning at the crown with preserved frontal hairline indicates androgenetic alopecia, while discrete patches with exclamation-mark hairs suggest alopecia areata (a completely different condition requiring different treatment). 3, 4
Perform dermoscopy to differentiate androgenetic alopecia from other causes—look for hair shaft diameter variability and miniaturized follicles rather than yellow dots or exclamation-mark hairs. 3
Assess for signs of hyperandrogenism in women: acne, hirsutism, irregular menstrual cycles, which may indicate polycystic ovary syndrome and influence treatment selection. 3
Laboratory Testing (Targeted, Not Routine)
Check serum ferritin (optimal ≥60 ng/mL for hair growth), TSH and free T4 (to exclude thyroid disease), vitamin D (<20 ng/mL indicates deficiency), and zinc levels—but only when clinical presentation is atypical or nutritional deficiency is suspected. 3, 4
In women with hyperandrogenism signs, measure total testosterone, free testosterone, and sex hormone-binding globulin (SHBG); consider screening for PCOS with 2-hour oral glucose tolerance test and fasting lipid panel. 3
Do not order extensive autoimmune panels for straightforward androgenetic alopecia—this adds no value and the diagnosis is clinical. 3, 4
First-Line Treatment Protocols
Male Pattern Hair Loss
Combination therapy is superior to monotherapy and should be initiated immediately:
Oral finasteride 1 mg daily OR dutasteride 0.5 mg daily (both are first-line, equally recommended). 1, 2
Plus topical minoxidil 5% solution, 1 mL applied to dry scalp twice daily (morning and evening). 1, 5, 2
Treatment must be continuous indefinitely—discontinuation results in reversal of all gains within months. 1, 5
Set realistic expectations: visible results require 4–6 months minimum; hair regrowth is typically soft and downy initially, then gradually thickens. 5
Female Pattern Hair Loss
Topical minoxidil is the only FDA-approved treatment and should be started first:
Topical minoxidil 2% solution, 1 mL applied to dry scalp twice daily (the 5% formulation is not recommended for women as it works no better than 2% and may cause unwanted facial hair growth). 1, 5, 2
Oral finasteride and dutasteride are absolutely contraindicated in women of childbearing potential due to teratogenic risk. 2
Treatment must continue indefinitely to maintain results—stopping leads to complete reversal. 1
Expect 12–24 months before judging efficacy; use standardized photographs and patient self-assessment to monitor response. 1, 6
Second-Line and Adjunctive Therapies
For Suboptimal Response to Minoxidil Monotherapy
Platelet-rich plasma (PRP) therapy shows superior efficacy when combined with topical minoxidil:
Use the manual double-spin method to prepare PRP with target platelet concentration of 1.0–1.5 million platelets/µL; do not activate the PRP (nonactivated PRP shows 31% greater improvement in hair density). 1
Protocol: 3–5 treatment sessions spaced 1 month apart, using 5–7 mL PRP per session, injected at 0.05–0.1 mL/cm² at 2–4 mm depth with 1 cm spacing between injection sites. 1
Apply pharmaceutical-grade topical anesthetic cream 30–60 minutes before injection due to significant procedural pain. 1
Maintenance phase: 1 session every 6 months after initial treatment series to sustain benefits. 1
Combination therapy (PRP + minoxidil) achieves 57% median increase in terminal hair density versus 48% with minoxidil alone at 32 weeks, with 83% of patients achieving negative hair pull test. 1
Oral Antiandrogens for Women (When Minoxidil Fails or Hyperandrogenism Present)
Spironolactone 200 mg daily OR cyproterone acetate 50–100 mg daily (100 mg for 10 days per month if premenopausal) can be added for women who fail topical minoxidil or have clinical hyperandrogenism. 7, 6
88% of women receiving oral antiandrogens experience stabilization or improvement of hair loss, though complete regrowth is uncommon. 7
Higher midscalp clinical grade predicts better response to antiandrogen therapy; no other clinical or laboratory parameter reliably predicts outcome. 7
Contraception is mandatory in women of childbearing age due to feminization risk to male fetuses. 6
Low-Level Laser Therapy (LLLT)
655 nm laser devices used three times per week demonstrate efficacy as adjunctive therapy for both male and female pattern hair loss. 1
Continuous indefinite use is required to maintain regrowth, similar to minoxidil. 1
Use only FDA-cleared devices specifically marketed for hair regrowth. 1
Monitoring Treatment Response
Use standardized before-and-after photographs with consistent lighting and head positioning in a stereotactic device—this is the gold standard for objective assessment. 1, 7
Perform trichoscopy to evaluate hair density, shaft diameter, and terminal-to-vellus hair ratio as quantitative indicators of response. 1
Conduct hair pull tests to assess hair fragility and shedding—a negative pull test after treatment indicates reduced fragility and successful stabilization. 1
Administer patient self-assessment questionnaires to capture subjective improvement in hair thickness, ease of styling, and quality of life. 1
Reassess at 4–6 months minimum for men on finasteride/dutasteride plus minoxidil; 12–24 months for women on minoxidil monotherapy or antiandrogens. 5, 6
Critical Pitfalls to Avoid
Do not confuse androgenetic alopecia with alopecia areata—patchy loss with exclamation-mark hairs requires completely different treatment (intralesional corticosteroids or contact immunotherapy, not minoxidil or finasteride). 3, 4
Do not prescribe finasteride or dutasteride to women—these are teratogenic and contraindicated in females of childbearing potential. 2
Do not use minoxidil 5% in women—it offers no additional benefit over 2% and increases risk of unwanted facial hair growth. 5, 2
Do not stop treatment once regrowth occurs—all pharmacologic therapies require indefinite continuation or hair loss will resume within 3–6 months. 1, 5
Do not expect rapid results—counsel patients that visible improvement requires 4–6 months minimum, and peak response may take 12–24 months. 5, 6
Do not use activated PRP—nonactivated PRP produces 31% greater hair density improvement compared to activated preparations. 1
Do not order routine extensive laboratory panels—testing should be targeted only when clinical presentation is atypical or systemic disease is suspected. 3, 4
Do not overlook psychological impact—hair loss profoundly affects quality of life, self-esteem, and social functioning; consider mental health referral when patients show withdrawal, depression, or impaired work/social function. 4, 6
Safety Considerations
Finasteride/dutasteride side effects: decreased libido, erectile dysfunction, and ejaculatory dysfunction occur in <2% of men; these typically resolve with discontinuation. 2
Minoxidil side effects: scalp irritation, pruritus, and unwanted facial hair growth (especially with 5% formulation in women); rarely, systemic absorption may cause tachycardia or fluid retention. 5, 2
Spironolactone side effects: hyperkalemia (monitor potassium in elderly or those with renal impairment), menstrual irregularities, breast tenderness, and postural hypotension. 7, 6
PRP therapy risks: pain (mitigated by topical anesthesia), transient scalp tenderness, and rare infection risk; low platelet concentration or inadequate injection volume leads to treatment failure. 1
Pregnancy/breastfeeding: minoxidil is FDA Pregnancy Category C; finasteride and dutasteride are Category X (absolutely contraindicated); antiandrogens require effective contraception. 5, 2, 6