Evaluation and Management of Female Androgenic Hair Loss

Diagnostic Evaluation

The American College of Dermatology recommends looking for the characteristic pattern of central scalp thinning with preserved frontal hairline (Ludwig pattern) or frontal accentuation (Christmas tree pattern) to distinguish female androgenic alopecia from diffuse alopecia areata or telogen effluvium 2
Examination for miniaturized hairs using dermoscopy is a hallmark of androgenic alopecia, with a normal scalp appearance without inflammatory scaling 2
The scalp should appear normal without inflammatory scaling; if scaling is present, consider seborrheic dermatitis as a separate condition 2

Endocrine evaluation is mandatory in all patients with female pattern hair loss to assess for androgen excess, including measurement of free and total testosterone 2
DHEA-S (dehydroepiandrosterone sulfate) should be measured as part of the endocrine evaluation 3
Androstenedione should be measured as part of the endocrine evaluation 2
Additional recommended testing includes TSH and free T4 to rule out thyroid disease, serum ferritin, vitamin D and zinc levels, and prolactin if menstrual irregularities are present 2, 3

The American Academy of Dermatology recommends starting with topical minoxidil 5% twice daily for women without hyperandrogenism 1
Consider adding platelet-rich plasma (PRP) for optimal results, with an initial phase of 3-5 treatment sessions spaced exactly 1 month apart and a maintenance phase of 1 session every 6 months 1
PRP combined with minoxidil produces the highest increase in hair density compared to either treatment alone 1

Schedule formal evaluation at specific intervals, including 3 months initially for minoxidil alone and 12 months for PRP combination therapy 1
Use objective measures to assess response, including standardized before-and-after photographs, trichoscopy to measure hair density and diameter, hair pull tests, and patient self-assessment questionnaires 1
Positive response indicators include increased hair density per cm², increased hair shaft diameter, decreased proportion of telogen hairs, and improved patient satisfaction scores 1

Never stop treatment prematurely, as hair loss will return to pretreatment status if therapy is discontinued 1
Do not use unproven supplements without documented deficiencies 1
Avoid inadequate follow-up, as patients need regular monitoring to assess response 1
Do not overlook the psychological impact of hair loss, and consider counseling and cosmetic camouflage options 1