Androgenetic Alopecia Treatment Guidelines

Introduction to Treatment Options

• The American Academy of Dermatology recommends topical minoxidil as the first-line treatment for androgenetic alopecia (AGA), with 5% solution applied twice daily being the gold standard for men and 2% solution for women 1
• The American College of Dermatology recommends topical minoxidil 5% as the first-line treatment for female pattern hair loss, with visible results expected after 6-12 months of treatment 2

Efficacy of Topical Minoxidil

• Topical minoxidil 5% demonstrates 45% more hair regrowth than 2% formulation at 48 weeks, with clinical studies showing significant increases in hair density and response rates of approximately 80% 1
• Topical minoxidil may cause localized side effects, such as pruritus, burning, and irritation, although these are typically mild and well-tolerated 2

Combination Therapies

• The combination of minoxidil and topical finasteride produces higher hair density increases (+81 hairs/cm² after 6 months) and 79% of patients achieved significant visible improvement versus 41% with minoxidil alone 1
• Platelet-rich plasma (PRP) therapy combined with daily topical minoxidil application shows higher efficacy than minoxidil alone, particularly beneficial for poor responders to conventional therapy 1
• Low-dose oral combination therapy, such as minoxidil 0.25 mg + spironolactone 25 mg once daily, may be considered as an alternative treatment option, although its efficacy is not well-established 2, 1

Emerging Therapies

• Acellular dermal matrix (ADM) shows promise in limited case studies, with a theoretical advantage of longer release of growth factors compared to PRP, although evidence is limited and no randomized controlled trials are available yet 1
• Nutrafol may be considered as an adjunctive therapy for established androgenetic alopecia, or as a reasonable option for early or mild hair thinning, particularly for patients seeking a "natural" approach, although the evidence is not as robust as for FDA-approved treatments, as noted by the British Association of Dermatologists 3

Treatment Protocols

• The treatment protocol typically involves intradermal PRP injections combined with daily topical minoxidil application, with multiple controlled studies supporting this combination 1
• For inadequate response after 4-6 months, consider adding topical finasteride or PRP therapy, and for treatment-resistant cases, consider oral options (finasteride 1mg for men) or combination with PRP 1
• Oral finasteride 1mg daily is recommended as a first-line treatment for androgenetic alopecia, with proven efficacy in promoting hair regrowth and preventing further hair loss, although it may cause sexual dysfunction and gynecomastia in some patients, as suggested by the American Academy of Dermatology 4, 2

Patient Evaluation and Follow-up

• Baseline photos should be taken before starting treatment, with evaluation at 3 months for initial response, critical evaluation at 6 months, and comprehensive assessment at 12 months to determine continuation 1
• Initial assessment should be performed at 3 months, with critical evaluation at 6 months, and comprehensive evaluation at 12 months to decide on continuing or modifying treatment, as reported by the Journal of Clinical Oncology and the American Academy of Dermatology 5, 1
• A thorough medical history, including duration and progression of hair loss, family history, recent stressors, medication use, and hormonal changes, should be taken to identify potential underlying causes of hair loss, as recommended by the British Association of Dermatologists 3
• Laboratory testing, including complete blood count, ferritin and iron studies, thyroid function tests, vitamin D levels, zinc levels, and hormonal panel, is recommended based on clinical suspicion to determine the underlying cause of hair loss, as suggested by the American Academy of Dermatology 3

Important Considerations

• Patients should understand that maintenance of existing hair and modest regrowth is a successful outcome, and complete hair restoration is unlikely, with results taking time - visible improvement typically begins at 2-4 months 1
• Women who are pregnant or breastfeeding should avoid minoxidil and finasteride, and it is not recommended for individuals under 18 years of age, with caution in patients with scalp conditions that may increase absorption 1
• Finasteride is contraindicated in pregnancy due to known teratogenicity, and women of childbearing potential must use reliable contraception while taking finasteride, as recommended by the Journal of Urology 2
• Potential side effects of finasteride include sexual dysfunction and endocrine effects, as reported by the Journal of Clinical Oncology 5

Lifestyle Modifications and Nutritional Considerations

• Implementing lifestyle modifications, such as a weight loss program, which can improve PCOS symptoms even with a 5% weight reduction, is recommended as part of the initial assessment and treatment approach for female pattern hair loss (FPHL) in patients with PCOS, as suggested by the American Academy of Family Physicians 6
• Using sulfate-free shampoos and conditioners, and choosing hydrating formulas with ingredients like natural oils, hydrolyzed proteins, and ceramides can help fragile hair, as suggested by the British Journal of Dermatology 7
• Reducing thermal damage by limiting the use of heat styling tools, using thermal protectants, and air-drying when possible can help prevent further hair damage, as suggested by the British Journal of Dermatology 7
• Protecting the hair from environmental factors, such as using UV protection and covering the hair in extreme weather conditions, is also recommended, as suggested by the British Journal of Dermatology 7
• Evaluating for nutritional deficiencies that may contribute to hair loss is essential, including iron, zinc, vitamin D, and thyroid function, with targeted supplementation recommended before considering comprehensive supplements like Nutrafol, as suggested by the American Journal of Clinical Dermatology 8
• Zinc deficiency is associated with fragile hair, and levels below 70 μg/dL may require supplementation, as suggested by the American Journal of Clinical Dermatology 8
• Vitamin D is essential for normal hair follicle function, and maintaining levels of at least 30 ng/mL (75 nmol/L) is recommended, as suggested by the British Journal of Dermatology 7