Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

men who opt for conservative management

1st line – cosmetic aids or no treatment

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ONGOING
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men who opt for conservative management
1st line – 

cosmetic aids or no treatment

Many men may decide to do nothing. For these, a watch-and-wait approach may be appropriate.

For others, cosmetic aids such as tinted cosmetics, hair lightening, and creative hair styling may help to camouflage the defect. Hairpieces or hair extensions may also cover the scalp.[15]​​[29]

men who opt for medical management

1st line – topical minoxidil

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ONGOING
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men who opt for medical management
1st line – 

topical minoxidil

Topical minoxidil is a first-line treatment.[11][15]​​[32]​​​ May be an increased risk of absorption if skin barrier is damaged. Should be used for at least 1 year for best results. Hair loss resumes when treatment is stopped.

Primary options

minoxidil topical: (2%-5% solution) apply 1 mL to the affected area(s) twice daily; (5% foam) apply half a capful to the affected area(s) twice daily

Consider – oral finasteride

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ONGOING
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men who opt for medical management
Consider – 

oral finasteride

Additional treatment recommended for SOME patients in selected patient group

The combination of topical minoxidil and oral finasteride appears to act synergistically and be superior compared with monotherapy.​[11][15]​ If monotherapy is started, the effects should be monitored for at least 6 to 12 months before a second treatment choice is added in those who show an initial poor response.

Men who wish to change treatments should continue using the original medicine in addition to the new agent for at least 6 months before discontinuing it and switching treatment.

Primary options

finasteride: 1 mg orally once daily

Consider – cosmetic aids

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ONGOING
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men who opt for medical management
Consider – 

cosmetic aids

Additional treatment recommended for SOME patients in selected patient group

Cosmetic aids such as tinted cosmetics, hair lightening, and creative hair styling may help to camouflage the defect. Hairpieces or hair extensions may also cover the scalp.[15]​​[29]

1st line – oral finasteride

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ONGOING
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men who opt for medical management
1st line – 

oral finasteride

Finasteride should be used for at least 1 year for best results.​[11][15]​ It significantly increases hair counts, improves scalp coverage, and increases the length, diameter, and pigment of hair.[11][27][38]​​​

Finasteride reduces prostate-specific antigen (PSA) levels in older men.[27][38] Results of PSA test values in older men should be taken at baseline and during treatment to compensate for this effect of the drug.

Sexually related side effects, such as decreased libido or erectile dysfunction, may occur, but may be completely reversible after discontinuation of the drug.[27][38][39]

Primary options

finasteride: 1 mg orally once daily

Consider – topical minoxidil

Back
ONGOING
|
men who opt for medical management
Consider – 

topical minoxidil

Additional treatment recommended for SOME patients in selected patient group

The combination of topical minoxidil and oral finasteride appears to act synergistically and be superior compared with monotherapy.​[11][15]​ If monotherapy is started, the effects should be monitored for at least 6 to 12 months before a second treatment choice is added in those who show an initial poor response.

Men who wish to change treatments should continue using the original medicine in addition to the new agent for at least 6 months before discontinuing it and switching treatment.

Primary options

minoxidil topical: (2-5% solution) apply 1 mL to the affected area(s) twice daily; (5% foam) apply half a capful to the affected area(s) twice daily

Consider – cosmetic aids

Back
ONGOING
|
men who opt for medical management
Consider – 

cosmetic aids

Additional treatment recommended for SOME patients in selected patient group

Cosmetic aids such as tinted cosmetics, hair lightening, and creative hair styling may help to camouflage the defect. Hairpieces or hair extensions may also cover the scalp.[15]​​[29]

women who opt for conservative management

1st line – cosmetic aids or no treatment

Back
ONGOING
|
women who opt for conservative management
1st line – 

cosmetic aids or no treatment

Some women may decide to do nothing. For these, a watch-and-wait approach may be appropriate.

Cosmetic aids such as tinted cosmetics, hair lightening, and creative hair styling may help to camouflage the defect. Hairpieces or hair extensions may also cover the scalp.[15]​​[29]

women who opt for medical management

1st line – topical minoxidil

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ONGOING
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women who opt for medical management
1st line – 

topical minoxidil

The 2% solution and 5% foam are approved for use in women with female-pattern hair loss with or without hyperandrogenism.[7][11][15]​​​​[32]​​​​ It is important to note that the 5% foam is only recommended once daily in women (the recommended dose in men is twice daily).

May have increased risk of absorption if skin barrier is damaged.

Primary options

minoxidil topical: (2% solution) apply 1 mL to the affected area(s) twice daily; (5% foam) apply half a capful to the affected area(s) once daily

Consider – cosmetic aids

Back
ONGOING
|
women who opt for medical management
Consider – 

cosmetic aids

Additional treatment recommended for SOME patients in selected patient group

Cosmetic aids such as tinted cosmetics, hair lightening, and creative hair styling may help to camouflage the defect. Hairpieces or hair extensions may also cover the scalp.[15]​​[29]

Plus – anti-androgen therapy

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ONGOING
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women who opt for medical management
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with hyperandrogenism
Plus – 

anti-androgen therapy

Treatment recommended for ALL patients in selected patient group

Antiandrogen therapies such as spironolactone, cyproterone, flutamide, and bicalutamide have been studied in a limited fashion in women with and without hyperandrogenism and female pattern hair loss. The benefit is limited in these studies, but women with concomitant hyperandrogenism (<40% of cases) may benefit more from antiandrogen therapy.[29][46][15][34]​ Cyproterone is not available in the US, but is available in Europe and many other countries.

All women on anti-androgens should use effective means of contraception while taking these drugs.[11][15]​​ This protects against the risk of pregnancy and feminisation of male fetuses. A combined contraceptive pill with a progestin of low androgenic activity such as norgestimate is recommended.

Oral contraceptives alone also reduce the production of androgens and increase sex hormone-binding globulin, resulting in a decrease of free testosterone levels.[49] Oral contraceptives containing a progestin with anti-androgenic activity (e.g., drospirenone/ethinylestradiol) are recommended.

Primary options

spironolactone: 200 mg orally once daily for at least 12 months

or

cyproterone acetate: consult specialist for guidance on dose

or

flutamide: consult specialist for guidance on dose

or

bicalutamide: consult specialist for guidance on dose

-- AND --

norgestimate/ethinylestradiol: consult product literature for guidance on dosage

Secondary options

drospirenone/ethinylestradiol: consult product literature for guidance on dosage

failed medical treatment

1st line – hair transplant

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ONGOING
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failed medical treatment
1st line – 

hair transplant

Men and women with pattern hair loss who desire greater hair density than medical management will provide may be appropriate candidates for hair transplantation. Modern hair transplant surgery consists solely of follicular unit transplantation using grafts produced from traditional strip harvesting or follicular unit extraction.[50]

Ideal male candidates should be over 25 years of age with high-density donor hair and just frontal and mid-frontal hair-loss.

Ideal female candidates should have high-density donor hair and extensive hair loss or thinning of the frontal scalp.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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