Approach

Patients with androgenetic alopecia have four management options:

  • No treatment

  • Medical treatment

  • Surgical treatment such as hair transplants

  • Cosmetic aids such as camouflage and/or hairpieces.

The majority of men may decide to do nothing. Most women, however, are severely distressed by hair loss and seek medical advice. The aim of pharmacologic treatment, which is different for men and women, is to reverse or stabilize the miniaturization of hair follicles and stimulate hair regrowth.

Men who opt for conservative management

Many men with mild androgenetic alopecia will decide not to use treatment. For these men, a watch-and-wait policy may be appropriate. Tinted cosmetics, hair lightening, and creative hair styling may help to camouflage the defect. Hairpieces or hair extensions may also cover the scalp.​[15][31]

Men who opt for medical management

Currently, only topical minoxidil (2% and 5%) and oral finasteride are approved for the medical management of male-pattern baldness.[11][15]​ Both medications can slow down hair loss, and to a lesser extent produce regrowth of lost hair; however, complete reversal of hair loss is never achieved. Oral dutaseride is another option. However, while it is approved for this indication in some countries, male pattern hair loss is an unlicensed use in the US and Europe. Low-dose oral minoxidil has become more popular for hair loss, but is an off-label use. Based on a meta-analysis, dutasteride is more efficacious than finasteride, which is in turn more efficacious than minoxidil (oral and topical).[32]

Usually, the most appropriate option is to start with a single treatment and monitor response for at least 6 to 12 months, before a decision is made about efficacy and before a second treatment is tried or a combination of minoxidil and finasteride is used. All therapies may need to be used indefinitely to maintain their effect. If treatment is discontinued, benefit is lost over time, and the hair density will regress to baseline.

Topical minoxidil

  • Initially introduced as an antihypertensive drug, minoxidil (used topically for this indication) is approved for androgenetic alopecia in men.[11][33][34]​​ It is a potassium-channel opener and potent vasodilator, but its mechanism of action for hair regrowth is unknown. The drug appears to increase the duration of the anagen phase and reverses miniaturization of hair follicles through angiogenic effects.[35] The 5% solution is associated with more robust hair growth compared with the 2% solution in men.[36][37][38] The 5% foam formulation may cause less irritation than the 5% solution due to the absence of propylene glycol.[39] It may also be more cosmetically pleasing to use.

Finasteride

  • Originally developed for the treatment of benign prostate hyperplasia, finasteride is approved for adult men with androgenetic alopecia.[11][27][34]​​ It irreversibly binds to the type II 5-alpha-reductase isoenzyme and inhibits the conversion of testosterone to dihydrotestosterone (DHT). Clinical studies have shown that target area hair counts are significantly increased in men after 12 months of therapy.[11][40]​ Sexually related adverse effects, such as decreased libido or erectile dysfunction, may occur, but may be reversible after discontinuation of the drug.[27][40][41]​ There are reports of so-called "post-finasteride syndrome" consisting of persistent sexual adverse effects along with depression, anxiety, suicidal ideation and cognitive impairment.[42]​ The true incidence of this and its relationship to finasteride use is unclear.[11]

Treatment switch

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

Combination treatment

  • Based on a few studies in humans and animals, the combination of topical minoxidil and oral finasteride appears to act synergistically and be superior compared with monotherapy.[11][15] The degree of hair loss-associated distress in the patient should guide the decision regarding beginning minoxidil or finasteride as monotherapy initially, or beginning both simultaneously to maximize early treatment benefits. If monotherapy is chosen, 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.

Women who opt for conservative management

Some women with mild pattern hair loss may decide not to use treatment. For these women, a watch-and-wait policy may be appropriate. Tinted cosmetics, hair lightening, and creative hair styling may help to camouflage the defect. Hairpieces or hair extensions may also cover the scalp.​[15][31]

Women who opt for medical management

Currently, minoxidil topical 2% solution and 5% foam are the only treatments approved for pattern hair loss in women in the US.[7][11][15][34]​​ Oral finasteride and other antiandrogens are sometimes used off-label. Similarly to in men, treatments slow hair loss, with a lower likelihood of improving hair growth. Minoxidil is contraindicated in pregnancy and lactation. Oral finasteride and antiandrogens are contraindicated in pregnant women due to the risk of feminizing a male fetus.

Topical minoxidil

  • Minoxidil topical 5% foam has been shown to be noninferior to the 2% solution. The foam tends to be more tolerable than the solution and may be more cosmetically acceptable.[43] Although not approved for women in the US, minoxidil topical 5% solution has also been shown to be significantly more effective than placebo both by target hair counts and subject assessment.[44] The 5% minoxidil topical solution appears to be safe in women with the only additional risks of the 5% over the 2% solution being a higher incidence of facial hypertrichosis and scalp irritation.[11][15]​​​​ However, the 5% foam does not cause as much of an increase in facial hypertrichosis as compared to the 2% solution.[43] Anecdotally, preference for solution versus foam varies greatly based on the individual patient.

Finasteride

  • Uncontrolled studies suggest a benefit of finasteride in normoandrogenic women after 12 months of treatment.[11][45][46] However, a controlled study in postmenopausal women with pattern hair loss showed no difference in finasteride (at a lower dose) as compared to placebo.[11][47]

Antiandrogen therapy

  • 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.[31][48]​​ 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 feminization of male fetuses. A combined contraceptive pill with a progestin of low androgenic activity such as norgestimate is recommended. Bicalutamide is a selective androgen receptor antagonist with a higher affinity and better safety profile as compared to flutamide.[49][50]

  • Oral contraceptives alone also reduce the production of androgens and increase sex hormone-binding globulin, resulting in a decrease of free testosterone levels.[51] Oral contraceptives containing a progestin with antiandrogenic activity (e.g., drospirenone/ethinyl estradiol) are recommended.

Hair transplant surgery for failed medical treatment

Few patients will enjoy robust regrowth of hair with medical therapy. Those who desire restoration of greater density of hair than medications will provide may be appropriate candidates for hair transplantation.[11][15]​​ 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.

Modern hair transplant surgery consists solely of follicular unit transplantation using grafts produced from traditional strip harvesting or follicular unit extraction or excision. Older techniques including punch grafts, mini-grafts, micro-grafts, slit grafts, and strip grafts are outmoded and will not produce acceptable results.[52] Follicular-unit transplantation gives the most natural-appearing results. Possible complications of hair transplants include infection, scarring around the grafts, poor growth of grafts, keloid formation, persistent scalp pain, telogen effluvium, and arteriovenous fistula formation, although all these complications are extremely rare in experienced hands.

Adjunctive use of finasteride and/or topical minoxidil may stabilize underlying hair loss, which will allow the patient to maintain a more natural appearance over time.[11][15]​​

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