Treatment of Frontal and Temporal Androgenetic Alopecia in Adult Males
Start with combination therapy of topical minoxidil 5% twice daily plus oral finasteride 1 mg daily, as this provides superior efficacy compared to either agent alone, with finasteride demonstrating particular effectiveness in frontal scalp regions. 1, 2, 3
First-Line Combination Therapy
Oral finasteride 1 mg daily is essential for frontal and temporal hair loss, as dutasteride 0.5 mg has been proven to induce superior responses specifically in the frontal area compared to other treatments. 4, 3 However, since dutasteride is not FDA-approved for this indication, finasteride remains the standard oral agent. 1
Apply topical minoxidil 5% solution (1 mL) twice daily to affected frontal and temporal areas as baseline therapy. 1, 2
Add oral finasteride 1 mg daily from treatment initiation for faster and more complete results, particularly for frontal scalp involvement. 2, 5
The combination of finasteride plus minoxidil achieves 94.1% improvement rates versus 80.5% with finasteride alone and 59% with minoxidil alone at 12 months. 5
Never discontinue minoxidil once started—all hair regrowth gains will be lost within months of cessation. 1, 2
Alternative to Oral Finasteride
If systemic finasteride is not tolerated or desired, topical finasteride 0.25% spray applied once daily in the evening provides effective results with less systemic absorption. 4, 6
The combination of topical minoxidil 5% (morning application) plus topical finasteride 0.25% spray (evening application) produces significantly greater hair density increases (+81 hairs/cm² at 6 months) compared to either monotherapy. 6
This topical combination achieves a global photographic assessment score of 2.0 versus 0.6 with topical finasteride alone and 1.3 with minoxidil alone at 6 months. 6
Second-Line Therapy: Adding PRP
If response remains suboptimal after 6-12 months of combination medical therapy, add platelet-rich plasma (PRP) injections while continuing topical minoxidil. 1, 2
PRP Protocol Specifications
Use nonactivated PRP only—activation reduces efficacy by 31% compared to nonactivated preparations. 1, 2, 7
Target platelet concentration: 1.0 to 1.5 million platelets per µL using manual double-spin method. 7
Initial treatment phase: 3-5 sessions spaced exactly one month apart. 1, 7
Injection technique: 5-7 mL total volume, 0.05-0.1 mL/cm², 90-degree angle, 2-4 mm depth, injections 1 cm apart using 30G × 4 mm needles. 7
Apply pharmaceutical-grade topical anesthetic cream 30-60 minutes before injection due to significant procedural pain. 7
Maintenance phase: One session every 6 months after initial treatment series. 1, 7
Expected PRP Outcomes
Combination PRP plus minoxidil 5% produces 57% median increase in terminal hair density versus 48% with minoxidil alone at 32 weeks. 7
Initial improvements visible at 2-3 months, with 25% improvement at 2 months predicting sustained response at 6 months. 2, 7
83% of patients achieve negative hair pull test after PRP plus minoxidil, indicating reduced hair fragility. 7
Never use PRP as monotherapy—always combine with continued topical minoxidil for optimal outcomes. 1, 2
Monitoring Treatment Response
Evaluate efficacy at 3-month intervals using multiple objective measures: 2, 7
- Standardized before-and-after photographs with identical lighting and positioning
- Trichoscopy to measure hair density (hairs/cm²) and terminal versus vellus hair ratio
- Hair pull test to assess hair fragility and treatment response
- Patient self-assessment questionnaires for subjective improvement
Emerging Alternative: Platelet-Rich Fibrin (PRF)
PRF shows promise as a potentially superior alternative to PRP with theoretical advantages including lower cost, easier preparation, and sustained growth factor release. 1, 7 However, no head-to-head randomized controlled trials comparing PRF to PRP exist as of 2023. 8
Critical Pitfalls to Avoid
Low platelet concentration (<1 million/µL), inadequate injection volume, or insufficient treatment frequency leads to PRP treatment failure. 7
Activating PRP before injection reduces efficacy by 31%—use nonactivated preparations only. 1, 2
Insufficient treatment duration leads to suboptimal outcomes—some patients require extended therapy beyond initial 6 months before adding PRP. 2, 7
Individual genetic factors significantly influence response to all treatments, explaining variable outcomes between patients. 8, 7
Treatment Algorithm Summary
Months 0-6: Topical minoxidil 5% twice daily + oral finasteride 1 mg daily (or topical finasteride 0.25% once daily if oral not tolerated) 1, 2, 6
Month 6-12: Continue combination therapy and assess response using objective measures 2, 7
Month 12+: If suboptimal response, add PRP injections (3-5 sessions monthly) while continuing minoxidil indefinitely 1, 2
Maintenance: PRP every 6 months + continuous minoxidil 5% twice daily + continuous finasteride 1, 7