Androgenetic Alopecia

Androgenetic alopecia
Straight to the point of care
Last updated: Sep 01, 2020

Table of Contents
Overview 3
Summary 3
Definition 3
Theory 4
Epidemiology 4
Aetiology 5
Pathophysiology 5
Classification 5
Case history 7
Diagnosis 10
Approach 10
History and exam 14
Risk factors 14
Investigations 16
Differentials 18
Management 21
Approach 21
Treatment algorithm overview 23
Treatment algorithm 25
Emerging 31
Patient discussions 31
Follow up 33
Monitoring 33
Complications 33
Prognosis 33
Guidelines 34
Diagnostic guidelines 34
Treatment guidelines 34
Online resources 36
References 37
Images 43
Disclaimer 47
Androgenetic alopecia Overview
Summary
Also known as pattern hair loss, androgenetic alopecia is a genetically determined, patterned, progressive
loss of hair from the scalp and occurs in both men and women. Both androgens and genetics play a role in
OVERVIEW
its pathogenesis.
The term androgenetic alopecia is best used only when referring to male-pattern hair loss, as most females
likely do not share the androgenic pathway. A more appropriate term for women is female-pattern hair loss.
The term pattern hair loss will be used when referring to hair loss affecting both sexes.
Men present with hair thinning in the temporal areas that advances to the crown (vertex) area as the alopecia
progresses. Women usually have more diffuse thinning on the crown area, and less commonly present with a
male-type pattern.
Diagnosis is clinical and is based on recognising the pattern of hair loss.
Possible treatments are oral finasteride and/or topical minoxidil solution or foam for men, and topical
minoxidil solution or foam for women.
For women with female-pattern hair loss and concomitant hyperandrogenism (<40% of cases), additional
androgen-suppressive therapy may be considered.
Definition
A genetically determined, patterned, progressive loss of hair from the scalp. In men, hair loss is caused by
androgen-mediated follicular miniaturisation that leads to fine, short, non-pigmented, vellus hair formation.
The pathogenesis of female-pattern hair loss has not been well characterised, and androgens are not
believed to play a major role for most women. Historically, the incidence of male and female-pattern hair loss
has been significantly underestimated by the exclusion of the early stages of hair loss. If all stages of hair
loss are included, the incidence of pattern hair loss may be as high as 98% in men, and 86% in women.[1]
Men present with gradual thinning in the temporal areas, producing a characteristic M shape with gradual
extension to the crown (vertex) area. Women usually present with diffuse thinning on the crown area while
maintaining a frontal hairline.
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 01, 2020.
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Androgenetic alopecia Theory
Epidemiology
The prevalence of pattern hair loss may be as high as 98% and as low as 40%, depending on the study
definitions.[2] [4] [5] [6] In men, the age of onset usually is between 20 and 25 years, and prevalence and
THEORY
severity of disease increase with age. In general, 30% of white people are affected by age 30 years, 50%
by age 50 years, and 80% by age 70 years. The global incidence varies among ethnic groups with the
greatest incidence in white people, followed by Asians, African Americans, and Native Americans.[5] [6] [7] In
women, the onset of hair loss is usually before 40 years, and over 10% of premenopausal women have some
evidence of pattern hair loss.[3] [8] [9] [10]
Female-pattern androgenetic alopecia

From the collection of Robert Haber, MD
However, the incidence increases in women around the time of the menopause and may affect up to 56% of
women over the age of 70 years.[8]
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 01, 2020.
Aetiology
The condition was previously considered to be a dominantly inherited disorder with variable penetrance and
expressivity. However, it is now clear that androgenetic alopecia is of multifactorial or polygenic inheritance,
THEORY
in which clinical expression represents a threshold effect.[11] [12] In women, a link to polycystic ovary
syndrome has been found, but polygenic inheritance is also likely.[13] [14]
Many genetic studies have been performed, identifying at least 12 genetic regions that associate with
androgenetic alopecia in men with candidate genes that include the androgen receptor (AR), histone-
deacetylases (HDAC) 4 and 9, and the WNT molecule WNT10A.[12] In women, only a weak association
has been found with the androgen receptor (AR) locus, and no association has been found with the other 11
candidate regions found in men.[15]
Pathophysiology
Androgenetic alopecia is characterised by progressive shortening of the anagen growth phase with each
hair cycle associated with increased telogen and catagen hair transformation.[16] This process leads to
follicular miniaturisation with conversion of long, terminal hairs to short and fine vellus hairs. Several factors
have been suggested to play a role in hair growth, but only stem cell factor (SCF) and insulin-like growth
factor 1 (IGF1), which is known to induce 5-alpha-reductase, have been found to be altered in response to
androgens.[17]
In men, the hair loss is known to be dependent on dihydrotestosterone (DHT), which is irreversibly converted
from testosterone by the enzyme 5-alpha-reductase. Of the two isoenzymes of 5-alpha-reductase, type
I and type II, a predominance of type II is found within hair follicles in the human scalp.[18] In addition,
there is over-expression of androgen receptors in balding compared with non-balding scalps.[19] Recently,
prostaglandins have been implicated in the pathogenesis of male androgenetic alopecia. The enzyme
PGD(2)-synthase and its product PGD(2) are elevated in balding scalp skin and PGD(2) has an inhibitory
effect on hair growth in animal and in vitro experiments.[12] PGD(2) may stimulate expression of the
androgen receptor.[20] In women, the role of androgens and androgen receptors in pattern hair loss has not
been completely elucidated.
Classification
Male-pat tern baldness (Norwood-Hamilton classification)[2]
• Type I: minimal bitemporal recession of hair
• Type II: extension of type I
• Type III: hair loss in tonsure area and recession of hair from the forehead
• Type IV-VI: extension of type III
• Type VII: most severe pattern of hair loss, with a confluence of the balding areas; hair preserved only
around the back and the sides of the head
5
THEORY Androgenetic alopecia Theory
The pattern of androgenetic alopecia in men (after Hamilton and Norwood)

Female-pat tern baldness (Ludwig classification)[3]

• Type I: mild (hair loss on the front and top of the scalp with relative preservation of the frontal hairline)
• Type II: moderate
• Type III: severe
THEORY
The pattern of pattern hair loss in women (after Ludwig classification)
Case history
Case history #1
A 25-year-old man presents with progressive hair loss at the vertex area with hair thinning at both
temporal areas for the last 3 years. He is otherwise healthy and does not take any medications. On
physical examination, there is diffuse hair loss over the central scalp, with frontal and bitemporal
recession. He is estimated as type IV according to the Norwood-Hamilton classification. There is no
clinical evidence of inflammation or fibrosis. Hair-pull test is negative.
7
THEORY Androgenetic alopecia Theory
Hair-pull test
From the collection of Paradi Mirmirani MD; used with permission
Case history #2
A 43-year-old woman presents with a 9-month history of increased hair shedding with a reduction in hair
volume over the mid-frontal scalp. She is otherwise healthy and does not take any medications, including
oral contraceptives. On physical examination the central-scalp density is estimated as type II according to
the Ludwig classification for female-pattern baldness, with moderate thinning and preserved frontal hair
line. No temporal recession is noted. The hair-pull test is negative.
THEORY
Hair-pull test
No other causes of hair loss are identified.
9
Androgenetic alopecia Diagnosis
Approach
Pattern hair loss is characterised by progressive, patterned hair loss from the scalp. There is gradual
conversion of terminal hair (long, thick, and pigmented) into vellus hair (short, fine, and unpigmented). The
condition affects both men and women.
General history and examination

Patients typically present with gradual thinning of hair. History should include onset, duration, and location
of hair loss, family history of alopecia, nutrition history, and drug history. There should be no clinical
evidence of scarring or inflammation and no signs of tenderness or pruritus. Follicular ostia should be
preserved. Past medical history of an autoimmune or inflammatory disorder should be ruled out.
A 'hair-pull' test should be conducted. This is used to measure the telogen hair density.
DIAGNOSIS
Hair-pull test
In pattern hair loss, the hair-pull test is usually negative (≤3 hairs being pulled). Approximately 50 to 100
hairs are grasped between the thumb and the middle and index fingers and then firmly pulled. More
than 3 hairs pulled is a positive result. The test should be performed on the frontal and occipital area for
comparison.
Early onset of hair loss in the vertex area appears to be a marker for early onset of coronary heart
disease in men with hypertension and/or dyslipidaemia,[7] so additional cardiovascular-related
questioning and examination may be appropriate in some patients.
Clinical features in men

A symmetric, progressive, patterned hair loss characterised by bitemporal recession and thinning
at the crown (vertex) is seen. The Norwood-Hamilton classification is commonly used to document
severity of baldness (types I-VII, based on pattern and severity).[2] The condition can occur at any age
following puberty, when androgen hormone levels rise. The first indication is a recession of hairline in the
bitemporal areas.
Clinical features in women

The hair loss is more diffuse and less patterned, and female patients typically present with gradual
thinning of the central scalp hair, usually over several years.[8]
DIAGNOSIS
11
DIAGNOSIS Androgenetic alopecia Diagnosis
Female-pattern androgenetic alopecia

Physical examination shows a widening of the central parting, with diffuse reduction of hair follicles on the
frontal and central scalp. The frontal and temporal hairlines are generally retained, but a small number
of women do develop recession of bitemporal hairlines as seen in male-pattern baldness.[8] The Ludwig
classification is commonly used to classify severity (types I-III, based on severity).[3] The central part
width can also be compared with the occipital part width. Early onset in women suggests pathological
hyperandrogenism.[10]
Tests
It is important to exclude other causes of hair loss.
Hair-pull test
DIAGNOSIS
Hair-pull test
• The hair-pull test is a rapid assessment of telogen hair density and is usually negative in
androgenetic alopecia. Approximately 50 to 100 hairs are grasped between the thumb and the
middle and index fingers and then firmly pulled. More than 3 hairs pulled is a positive result.
Laboratory investigations
• A history suspicious for autoimmune disease, infection, or anaemia in men and women should
direct any laboratory testing. This would include FBC with differential, comprehensive metabolic
panel, antinuclear antibodies, rapid plasma reagin, and serum ferritin estimation.
• In otherwise healthy women, TSH and serum ferritin should be checked.
• Women with signs of hyperandrogenism, such as hirsutism on other parts of the body, irregular
periods, or severe acne vulgaris, require laboratory analysis of serum dehydroepiandrosterone
(DHEA)-sulfate, total and free testosterone levels, and sex hormone-binding globulin.[8] The most
13
common disorder of androgen excess is polycystic ovary syndrome (PCOS). Other causes are
adrenal tumours, adrenal hyperplasia, or hyperprolactinaemia.[10]
Dermatoscopy (epiluminescence microscopy)
• Usually not required but can be used to examine stage of development of scalp and hairs and to
distinguish from other non-scarring forms of alopecia.
Skin biopsy
• Usually not required but may be helpful to distinguish from other non-scarring forms of alopecia.[16]
Horizontal sections from a scalp biopsy provide important information on the ratio of terminal to
vellus hairs and the ratio of hairs in telogen phase (i.e., resting) to anagen phase (i.e., actively
growing). There are no significant findings of inflammation. Fibrous streamers, however, can be
found around miniaturised hair follicles.
History and exam

Key diagnostic factors
presence of risk factors (common)
• Key risk factors are advancing age, prostate cancer, polycystic ovary syndrome, and insulin resistance
disorders.
family history of baldness (common)

• The risk of androgenetic alopecia increases with a positive family history in the father, mother, and/or
maternal grandfather.[5] [6] [7]
gradual receding of frontal hairline, central, and crown (vertex) (common)

• Typical pattern in men.[5] [6] [16]
DIAGNOSIS
diffuse thinning of the central scalp with preservation of frontotemporal

hairline (common)
• More common among women than men.[5] [6] [7] [8] [16]
Other diagnostic factors

white ethnicity (common)
• Pattern hair loss is 4 times more prevalent in white people compared with African Americans, where
prevalence is similar to that of Indian and Asian men.[6] [7]
Risk factors
Strong
advancing age
• Pattern hair loss is an age-dependent disorder. Based on the prevalence of data available, about 30%
of men by the age of 30 years will be affected. This will rise to about 50% by the age of 50 years and
to about 80% by the age of 70 years.[4] [5] [6] The incidence of pattern hair loss increases in women
around the time of the menopause and may affect up to 56% of women over the age of 70 years.[8]
polycystic ovary syndrome in women

• In women, pattern hair loss is associated with an increased risk of polycystic ovary syndrome
(PCOS).[8] A study of 89 women of mixed ethnic origin with pattern hair loss reported a 67%
prevalence of PCOS.[15]
Weak
insulin resistance disorders
• Men 19 to 50 years of age who have early onset of hair loss have an increased incidence of
hyperinsulinaemia and disorders associated with insulin resistance such as obesity, hypertension, and
dyslipidaemia.[21]
prostate cancer
• There is an association between the vertex baldness and prostate cancer, most likely related to shared
androgen pathways.[22]
DIAGNOSIS
15
Investigations
1st test to order
Test Result
hair-pull test ≤3 hairs pulled
• Used to measure the telogen hair density.
DIAGNOSIS
Hair-pull test
In pattern hair loss, the hair-pull test is usually negative.

Approximately 50 to 100 hairs are grasped between the thumb and
the middle and index fingers and then firmly pulled. More than 3 hairs
pulled is a positive result.
• The test should be performed on the frontal and occipital area for
comparison.
thyroid function test normal
• Important to exclude thyroid dysfunction in men and women with
diffuse hair loss.[10] [23]
serum ferritin normal levels
Test Result
• Important to exclude iron deficiency in both men and women.
Other tests to consider
Test Result
FBC with differential normal
• Excludes anaemia and infection as cause of hair loss.
comprehensive metabolic panel normal
• Excludes hepatic disease as cause of hair loss.
antinuclear antibodies normal
• Evaluates for autoimmune disease as cause of hair loss.
rapid plasma reagin negative
• Excludes syphilis as a cause of hair loss.
free testosterone normal to increased
in women with
• Required if signs of hirsutism on other parts of body, irregular
hyperandrogenism
menstruation, and/or severe acne are present, to rule out Cushing's
disease, adrenal hyperplasia, ovarian tumour, or polycystic ovary
syndrome (PCOS).
serum dehydroepiandrosterone (DHEA)-sulfate normal to increased
in women with
hyperandrogenism
menstruation, and/or severe acne are present, to rule out adrenal
source of excess androgens.
sex hormone-binding globulin normal to reduced
in women with
hyperandrogenism
menstruation, and/or severe acne.
dermatoscopy miniaturised hair follicles
DIAGNOSIS
and follicular ostia
• Usually not necessary but may be used as a diagnostic tool to
scalp biopsy increased vellus hairs
and miniaturised hair
• Usually not necessary but may be used as a diagnostic tool to
follicles; increased
telogen hairs
17
Differentials
Condition Differentiating signs / Differentiating tests

symptoms
Diffuse alopecia areata • This is a non-scarring, • Histopathology of a scalp
autoimmune, inflammatory biopsy is characterised
hair loss, which is by an increased number
typically characterised of catagen and telogen
by circumscribed and follicles, and the presence of
asymmetrical areas of lymphocytic and eosinophilic
baldness. infiltrates in the peribulbar
• The scalp is the most region.
common site affected.
• Diagnosis is suggested by
findings of short broken-off
(exclamation-point) hairs,
pitted nails, and a history of
periodic regrowth of hair.[24]
Acute telogen effluvium • An increased shedding of • Hair-pull test is usually

normal hairs. positive.
• Alopecia is diffuse.
• There is a history of physical
stressor (high fever, surgery,
pregnancy, rapid weight
loss, nutritional deficiencies,
haemorrhage, or hormonal
dysfunction such as thyroid
dysfunction) or offending
medication use beginning
approximately 3 to 5 months
prior to onset of shedding.
• Diffuse hair loss on the
scalp with sometimes short
DIAGNOSIS
regrowing frontal hair,

although overall hair density
appears normal to minimally Hair-pull test
decreased. From the collection of
Paradi Mirmirani MD;
used with permission
• Scalp biopsy does not show
miniaturised hair follicles
and may appear almost
normal except for a variable
increase in the proportion of
telogen follicles.
Chronic telogen effluvium • This is an idiopathic, abrupt • Hair-pull test is positive

onset of generalised diffuse only in the active early hair
shedding of telogen hairs loss phases, but negative
from the scalp that may in long-standing hair loss.
persist up to several years. Histopathological evaluation
• Occurs more commonly in of a scalp biopsy shows a
women. normal-appearing scalp skin.

symptoms
• May be distinguished from
acute telogen effluvium by its
long fluctuating course.
• Frontoparietal hair loss
or widening of the central
part is not present, but
the disease may be
accompanied by bitemporal
recession.
• Women typically present
without visible reduction in
scalp hair density.
• The hair loss appears to be
self-limiting and does not
cause baldness.
Anagen effluvium • Anagen hair loss is • Hair-pull test will be positive.

associated with any damage • Predominantly anagen hairs
to the hair follicle that present on microscopic
impairs its mitotic activity. examination of biopsy
Usually occurs after specimen.
exposure to antineoplastic
chemotherapeutic agents
that cause immediate
interference with hair-shaft
formation and shedding
of already formed anagen
hairs.[24]
Polycystic ovary • Patients may present • Standard diagnostic tests

syndrome (PCOS) with weight gain, irregular are pelvic ultrasound,
menstruation, infertility, and/ although not all women
or hirsutism. Associated have ovarian cysts, and
DIAGNOSIS
symptoms or features are an androgen profile (total
acne and androgenetic and free testosterone,
alopecia. dehydroepiandrosterone
[DHEA]-sulfate, and sex
hormone-binding globulin).
Cushing's syndrome • Patients may complain • Standard screening tests

of weight gain presenting show elevated 24-hour
as moon face, truncal urine free cortisol levels,
obesity, and buffalo hump. late-night salivary cortisol,
Associated findings are or lack of suppression on
hirsutism, facial flushing, overnight dexamethasone
haematomas, and striae test. High- and low-dose
distensae. dexamethasone suppression
may further identify ACTH-
dependent or -independent
Cushing's syndrome.
Hyperprolactinaemia • Women may present • Screening test shows

with oligomenorrhoea elevated serum prolactin
or amenorrhoea. Men levels.
may present with sexual
dysfunction, headache,
19

symptoms
and/or visual field defects.
Galactorrhoea may be an
associated finding in both
men and women.
Thyroid dysfunction • Patients with hypothyroidism • Serum test for TSH shows
may present with cold elevated levels in patients
intolerance, fatigue, with primary hypothyroidism
weight gain, constipation, and low or suppressed levels
goitre, and/or depression. in patients with primary
Associated findings are dry hyperthyroidism.
coarse hair and skin.
• Patients with
hyperthyroidism may present
with weight loss, increased
appetite, heat intolerance,
irritability, fatigue, and/or
cardiac symptoms such as
palpitations.
• Patients with autoimmune
disorder may also present
with pretibial myxoedema
and/or exophthalmus.
Iron deficiency • Symptoms may include • Standard screening tests

progressive fatigue, pallor, reveal microcytic anaemia,
dyspnoea, and pica. low serum iron and ferritin
Associated findings are hair levels, and high iron-binding
loss and brittle nails. capacity.
DIAGNOSIS
Androgenetic alopecia Management
Approach
Patients with androgenetic alopecia have 4 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 pharmacological treatment, which is different for men and women, is to
reverse or stabilise the miniaturisation 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.[12] [16] [25]
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.[12] [16] 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
dutasteride 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.
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.[12] [26] 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 miniaturisation of hair follicles through angiogenic
effects.[27] The 5% solution is associated with more robust hair growth compared with the 2%
solution in men.[28] [29] [30] The 5% foam formulation may cause less irritation than the 5%
solution due to the absence of propylene glycol.[31] It may also be more cosmetically pleasing to
use.
Finasteride
MANAGEMENT
• Originally developed for the treatment of benign prostate hyperplasia, finasteride is approved
for adult men with androgenetic alopecia.[12] [23] 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.[12] [32] Sexually related adverse effects, such as decreased libido or erectile
21
dysfunction, may occur, but may be reversible after discontinuation of the drug.[23] [32] [33] There
are reports of so-called 'post-finasteride syndrome' consisting of persistent sexual adverse effects
along with suicidal ideation and cognitive impairment. The true incidence of this and its relationship
to finasteride use is unclear.[12]
Treatment switch
• 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.
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.[12] [16] 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 maximise 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.[12] [16] [25]
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.[8] [12] [16] 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 feminising a male fetus.
Topical minoxidil.
• Minoxidil topical 5% foam has been shown to be noninferior to the 2% solution. This foam tends
to be more tolerable than the solution and may be more cosmetically acceptable.[34] Although not
approved for use in women, minoxidil topical 5% solution has also been shown to be significantly
more effective than placebo both by target hair counts and subject assessment.[35] 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.[16] [12]
However, the 5% foam does not cause as much of an increase in facial hypertrichosis as compared
to the 2% solution.[34] Anecdotally, preference for solution versus foam varies greatly based on the
individual patient.
Finasteride
MANAGEMENT
• Uncontrolled studies suggest a benefit of finasteride in normoandrogenic women after 12 months

of treatment.[12] [36] [37] However, a controlled study in postmenopausal women with pattern hair
loss showed no difference in finasteride (at a lower dose) as compared to placebo.[12] [38]
Antiandrogen therapy
• Antiandrogen therapies such as spironolactone, cyproterone, and flutamide 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.[25] [39] Cyproterone is not available in the
US, but is available in Europe and many other countries. All women on antiandrogens should use
effective means of contraception while taking these drugs.[16] [12] 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.[40] Oral contraceptives
containing a progestin with antiandrogenic activity (e.g., drospirenone/ethinylestradiol) are
recommended.
Hair transplant surgery for failed medical treatment

Few patients will enjoy robust regrowth of hair with medical therapy. Those who desire the restoration
of greater density of hair than medications will provide may be appropriate candidates for hair
transplantation.[16] [12] 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.[41] 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 stabilise underlying hair loss, which will allow
the patient to maintain a more natural appearance over time.[16] [12]
Treatment algorithm overview

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 MANAGEMENT
23
Ongoing ( summary )
men who opt for conservative
management
1st cosmetic aids or no treatment
men who opt for medical

management
1st topical minoxidil
adjunct oral finasteride
adjunct cosmetic aids
1st oral finasteride
adjunct topical minoxidil
women who opt for conservative

management
women who opt for medical

management
with hyperandrogenism plus anti-androgen therapy
failed medical treatment
1st hair transplant

MANAGEMENT
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
MANAGEMENT
25
Ongoing
men who opt for conservative
management
» 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.[16] [12] [25]
men who opt for medical
management

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
» Topical minoxidil is a first-line treatment.[16]

[12] 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.
adjunct oral finasteride
Treatment recommended for SOME patients in
selected patient group
Primary options
» finasteride: 1 mg orally once daily
» The combination of topical minoxidil and oral

finasteride appears to act synergistically and be
superior compared with monotherapy.[16] [12]
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.
MANAGEMENT

Ongoing
» 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.[16] [12]
[25]
1st oral finasteride
Primary options
» finasteride: 1 mg orally once daily
» Finasteride should be used for at least 1 year

for best results.[16] [12] It significantly increases
hair counts, improves scalp coverage, and
increases the length, diameter, and pigment of
hair.[23] [32] [23] [12]
» Finasteride reduces prostate-specific antigen

(PSA) levels in older men.[23] [32] 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.[23] [32] [33]
adjunct topical minoxidil
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
» The combination of topical minoxidil and oral

finasteride appears to act synergistically and be
superior compared with monotherapy.[16] [12]
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.
MANAGEMENT

27
Ongoing
[25]
women who opt for conservative
management
» Some women may decide to do nothing.

For these, a watch-and-wait approach may be
appropriate.

[25]
women who opt for medical
management

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
» The 2% solution and 5% foam are approved

for use in women with female-pattern hair
loss with or without hyperandrogenism.[8] [16]
[12] 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.
[25]
with hyperandrogenism plus anti-androgen therapy
Treatment recommended for ALL patients in
MANAGEMENT
Primary options
» spironolactone: 200 mg orally once daily for

at least 12 months
-or-
Ongoing
» cyproterone acetate: consult specialist for
guidance on dose
-or-
» flutamide: 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
» Antiandrogen therapies such as

spironolactone, cyproterone, and flutamide 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.[25] [39] [16]
[28] 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.[16] [12] 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.[21] Oral
contraceptives containing a progestin with
anti-androgenic activity (e.g., drospirenone/
ethinylestradiol) are recommended.
failed medical treatment
1st 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
MANAGEMENT
extraction.[41]
» Ideal male candidates should be over 25 years

of age with high-density donor hair and just
frontal and mid-frontal hair-loss.
29
Ongoing
» Ideal female candidates should have high-
density donor hair and extensive hair loss or
thinning of the frontal scalp.
MANAGEMENT
Emerging
Oral minoxidil
Oral minoxidil specifically for androgenetic alopecia in men has not been studied extensively, however one
study has shown that it may only be marginally more effective than topical minoxidil.[12] [42] Low-dose
oral minoxidil has also been explored in women with female pattern hair loss and may be of benefit.[43]
Adverse effects may include postural hypotension, hypertrichosis, oedema, and/or electrocardiogram
abnormalities.[12] [43]
Dutasteride
Dutasteride is a more potent 5-alpha reductase inhibitor that binds to type I and type II 5-alpha reductase.
While it is only approved for benign prostatic hyperplasia in the US and Europe, it is approved for male
pattern hair loss in some other countries. Clinical studies have shown significant increase in hair counts
and global hair assessment after 6 months of therapy as compared to placebo and finasteride.[12] [44] [45]
Dutasteride, like finasteride, may also be associated with sexual adverse effects.[33]
Low-level laser treatment

There is growing interest in the use of low-level laser devices to help grow hair. Currently, several units have
been granted FDA clearance as hair growth devices. Scepticism as to the validity of low-level laser treatment
(LLLT) has decreased among both practitioners and consumers. This is due to additional scientific studies
appearing in the literature that demonstrate efficacy and safety, and also due to greater understanding being
gained of the putative mechanisms of action.[46] [47]
Platelet-rich plasma therapy

Platelet-rich therapy (PRP) is an autologous preparation of plasma with a supraphysiologic concentration of
platelets thought to promote wound healing and hair growth through the release of various growth factors
from activated platelets.[12] Whole blood is drawn from the patient and after processing, the platelet-rich
plasma is injected intradermally into the scalp. A variety of protocols and systems are available to accomplish
this process which makes it difficult to establish efficacy. The majority of clinical studies available range
from weekly to monthly treatments, with three or more treatments. Improvement in hair counts, density, and
patient satisfaction has been reported.[12] [48] Adverse effects appear to be limited to transient oedema,
erythema, pain, and/or headache.
Microneedling
With microneedling, fine needles are applied to the scalp via a roller or pen and microwounds are induced
which activate wound healing and the generation of various growth factors.[14] Few studies exist and are of
limited quality, but microneedling is sometimes used in conjunction with other treatments including topical
minoxidil and/or platelet-rich therapy. It may improve the penetration of topical treatments.
Patient discussions
Patients should be informed that the effects of treatment will last as long as they continue with therapy.
Once treatment is discontinued, hair loss pattern will return to baseline level or the level which would have
occurred without treatment. [British Association of Dermatology: Patient information leaflets on hair loss]
(https://www.bad.org.uk/for-the-public/patient-information-leaflets) [American Hair Research Society]
(https://www.americanhairresearchsociety.org) [National Institutes of Health Genetics Home Reference:
MANAGEMENT
androgenetic alopecia] (http://ghr.nlm.nih.gov/condition=androgeneticalopecia)
All potential side effects from treatment will also disappear once treatment is discontinued.
Women with female-pattern baldness should be informed that complete hair loss on the central scalp is
rare, in contrast to male-pattern baldness.
31
MANAGEMENT Androgenetic alopecia Management
Androgenetic alopecia Follow up
Monitoring
Monitoring
FOLLOW UP
• Patients should be followed by a dermatologist to monitor efficacy of therapy.
• There are no laboratory tests indicated in men who are using topical minoxidil or finasteride.
• For safety purposes, women taking spironolactone should have potassium levels checked prior to
therapy.
• Women with concomitant hyperandrogenism who are treated with antiandrogens or are on oral
contraceptives must have levels of free testosterone and dehydroepiandrosterone (DHEA)-sulfate
measured 3 to 4 months after onset of therapy.
Complications
Complications Timeframe Likelihood

minoxidil-related contact dermatitis or skin irritation short term low
Most likely caused by propylene glycol. Treatment may be replaced with 5% minoxidil foam, which is
without propylene glycol.[26]
finasteride-related sexual dysfunction short term low
Occurs in 1.3% to 1.8% of men treated with finasteride. May resolve during long-term treatment or after
discontinuation of drug.[32] [49]
Prognosis
Men
Androgenetic alopecia in men aged between 18 and 60 years can be effectively treated with topical minoxidil
or oral finasteride. Treatment is continued indefinitely, although peak hair growth with topical minoxidil
solution is achieved after 4 months and with oral finasteride after 2 years. There is a 66% maximum increase
in hair growth with finasteride.[32] If treatment is discontinued, any positive hair growth effect will be lost
within 6 to 12 months.[16] [32]
Women
Treatment produces moderate efficacy. Treatment is recommended to be continued indefinitely to maintain
effects.[25] [39]
33
Androgenetic alopecia Guidelines
Diagnostic guidelines
Europe
EEMCO guidance for the assessment of hair shedding and alopecia (ht tp://
www.karger.com/Journal/Issue/229877)
Published by: European Expert Group on Efficacy Measurement of Last published: 2004
Cosmetics and other Topical Products
North America
Medical guidelines for clinical practice for diagnosis and treatment

of hyperandrogenic disorders (ht tps://www.aace.com/resources?
keys=&field_disease_state_content_t_value%5BGuidelines%5D=Guidelines)
Published by: American Association of Clinical Endocrinologists Last published: 2001
GUIDELINES
Guidelines for the care of androgenetic alopecia (ht tp://

www.ncbi.nlm.nih.gov/pubmed/8784287)
Published by: American Academy of Dermatology Last published: 1996
Treatment guidelines
Europe
Evidence-based (S3) guideline for the treatment of androgenetic alopecia in

women and in men (ht tps://www.edf.one/home/Guidelines/Guidelines.html)
Published by: European Dermatology Forum Last published: 2017
North America
Medical guidelines for clinical practice for diagnosis and treatment

of hyperandrogenic disorders (ht tps://www.aace.com/resources?
keys=&field_disease_state_content_t_value%5BGuidelines%5D=Guidelines)
Published by: American Association of Clinical Endocrinologists Last published: 2001
Androgenetic alopecia Guidelines
Asia
Hair transplantation: standard guidelines of care (ht tp://www.ijdvl.com/

text.asp?2008/74/7/46/42287)
Published by: Indian Association of Dermatologists, Venereologists and Last published: 2008
Leprologists
Guidelines for the diagnosis and treatment of male-pat tern and

female-pat tern hair loss (ht tps://onlinelibrary.wiley.com/doi/
epdf/10.1111/1346-8138.14470)
Published by: Japanese Dermatological Association Last published: 2017
GUIDELINES
35
Androgenetic alopecia Online resources
Online resources
1. British Association of Dermatology: Patient information leaflets on hair loss (https://www.bad.org.uk/for-
the-public/patient-information-leaflets) (external link)
2. American Hair Research Society (https://www.americanhairresearchsociety.org) (external link)
3. National Institutes of Health Genetics Home Reference: androgenetic alopecia (http://ghr.nlm.nih.gov/

condition=androgeneticalopecia) (external link)
ONLINE RESOURCES
Androgenetic alopecia References
Key articles
• Starace M, Orlando G, Alessandrini A, et al. Female androgenetic alopecia: an update on diagnosis
REFERENCES
and management. Am J Clin Dermatol. 2020 Feb;21(1):69-84. Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/31677111?tool=bestpractice.bmj.com)
• Kanti V, Messenger A, Dobos G, et al. Evidence-based (S3) guideline for the treatment of
androgenetic alopecia in women and in men - short version. J Eur Acad Dermatol Venereol.
2018 Jan;32(1):11-22. Full text (https://www.doi.org/10.1111/jdv.14624) Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/29178529?tool=bestpractice.bmj.com)
• Olsen EA, Messenger AG, Shapiro J, et al. Evaluation and treatment of male and female pattern
hair loss. J Am Acad Dermatol. 2005 Feb;52(2):301-11. Abstract (http://www.ncbi.nlm.nih.gov/
• Olsen EA, Whiting D, Bergfeld W, et al. A multicenter, randomized, placebo-controlled, double-

blind clinical trial of a novel formulation of 5% minoxidil topical foam versus placebo in the treatment
of androgenetic alopecia in men. J Am Acad Dermatol. 2007 Nov;57(5):767-74. Abstract (http://
• Kaufman KD, Olsen EA, Whiting D, et al. Finasteride in the treatment of men with androgenetic
alopecia. Finasteride Male Pattern Hair Loss Study Group. J Am Acad Dermatol. 1998 Oct;39(4 Pt
1):578-89. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/9777765?tool=bestpractice.bmj.com)
• Lucky AW, Piacquadio DJ, Ditre CM, et al. A randomized, placebo-controlled trial of 5%
and 2% topical minoxidil solutions in the treatment of female pattern hair loss. J Am Acad
Dermatol. 2004 Apr;50(4):541-53. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/15034503?
tool=bestpractice.bmj.com)
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www.doi.org/10.1055/s-0038-1660845) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/29954021?
49. Drake L, Hordinsky M, Fiedler V, et al. The effects of finasteride on scalp skin and serum androgen
levels in men with androgenetic alopecia. J Am Acad Dermatol. 1999 Oct;41(4):550-4. Abstract (http://
Androgenetic alopecia Images
Images
IMAGES
Figure 1: The pattern of androgenetic alopecia in men (after Hamilton and Norwood)
43
Figure 2: The pattern of pattern hair loss in women (after Ludwig classification)
IMAGES
IMAGES
Figure 3: Hair-pull test
45
IMAGES Androgenetic alopecia Images
Figure 4: Female-pattern androgenetic alopecia

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DISCLAIMER
Contributors:
// Authors:
Carolyn Goh, MD
Associate Clinical Professor
Department of Medicine, Division of Dermatology, UCLA Medical Center, Los Angeles, CA
DISCLOSURES: CG has spoken for the International Society of Hair Restoration Surgeons, the American
Academy of Dermatology, the Pacific Dermatologic Association, and has had manuscripts published in a
variety of journals.
// Acknowledgements:
Dr Carolyn Goh would like to gratefully acknowledge Dr Robert Haber, Dr Christiane Querfeld, and Dr
Christopher R. Shea, previous contributors to this topic. RH has an ownership interest in a company that
manufactures light-based hair growth devices and receives royalties for the sales of a surgical device used
in hair restoration surgery. CQ and CRS declare that they have no competing interests.
// Peer Reviewers:
Marcelo G. Horenstein, MD
Director of Dermatopathology
The Dermatology Group, Verona, NJ
DISCLOSURES: MGH declares that he has no competing interests.
Alvin R. Solomon, MD
Professor of Dermatology
Emory University School of Medicine, Atlanta, GA
DISCLOSURES: ARS declares that he has no competing interests.
David Whiting, MD, FACP

Medical Director
The Baylor Hair and Skin Research and Treatment Center, Dallas, TX
DISCLOSURES: DW is an author of a number of references cited in this topic. We have since been made
aware that Dr David Whiting is deceased.

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Androgenetic alopecia

Straight to the point of care

Last updated: Sep 01, 2020

Diagnosis is clinical and is based on recognising the pattern of hair loss.

Female-pattern androgenetic alopecia

The pattern of androgenetic alopecia in men (after Hamilton and Norwood)

Female-pat tern baldness (Ludwig classification)[3]

No other causes of hair loss are identified.

General history and examination

Clinical features in men

Clinical features in women

Female-pattern androgenetic alopecia

History and exam

family history of baldness (common)

gradual receding of frontal hairline, central, and crown (vertex) (common)

diffuse thinning of the central scalp with preservation of frontotemporal

Other diagnostic factors

polycystic ovary syndrome in women

In pattern hair loss, the hair-pull test is usually negative.

Other tests to consider

Condition Differentiating signs / Differentiating tests

Acute telogen effluvium • An increased shedding of • Hair-pull test is usually

regrowing frontal hair,

Chronic telogen effluvium • This is an idiopathic, abrupt • Hair-pull test is positive

Condition Differentiating signs / Differentiating tests

Anagen effluvium • Anagen hair loss is • Hair-pull test will be positive.

Polycystic ovary • Patients may present • Standard diagnostic tests

Cushing's syndrome • Patients may complain • Standard screening tests

Hyperprolactinaemia • Women may present • Screening test shows

Condition Differentiating signs / Differentiating tests

Iron deficiency • Symptoms may include • Standard screening tests

Men who opt for conservative management

Men who opt for medical management

Women who opt for conservative management

Women who opt for medical management

• Uncontrolled studies suggest a benefit of finasteride in normoandrogenic women after 12 months

Hair transplant surgery for failed medical treatment

Treatment algorithm overview

1st cosmetic aids or no treatment

men who opt for medical

1st topical minoxidil

adjunct oral finasteride

adjunct cosmetic aids

1st oral finasteride

adjunct topical minoxidil

adjunct cosmetic aids

women who opt for conservative

1st cosmetic aids or no treatment

women who opt for medical

1st topical minoxidil

adjunct cosmetic aids

with hyperandrogenism plus anti-androgen therapy

failed medical treatment

1st hair transplant

1st cosmetic aids or no treatment

» Many men may decide to do nothing. For

» For others, cosmetic aids such as tinted

1st topical minoxidil

» minoxidil topical: (2%-5% solution) apply

» Topical minoxidil is a first-line treatment.[16]

» finasteride: 1 mg orally once daily

» The combination of topical minoxidil and oral

» Men who wish to change treatments should

adjunct cosmetic aids