Version May 2024
INTRODUCTION — Male pattern hair loss (MPHL; also known as androgenetic alopecia in males and male balding) is a common, progressive form of hair loss distinguished by the reduction of terminal hairs on the scalp in a characteristic distribution (picture 1A-D and figure 1). The typical sites of involvement are the anterior scalp, mid-scalp, temporal scalp, and vertex of the scalp. Hair loss occurs over the course of years.
MPHL can be distressing, prompting some patients to seek treatment to minimize additional hair loss and induce hair regrowth. Treatment options for MPHL include various topical agents, systemic agents, and procedural interventions. Topical minoxidil and oral 5-alpha reductase inhibitors remain mainstays of treatment.
The treatment of MPHL in adults will be reviewed here. The clinical features and diagnosis of MPHL are reviewed separately. Female pattern hair loss and the general approach to the evaluation of hair loss are also reviewed separately.
●(See "Female pattern hair loss (androgenetic alopecia in females): Management".)
●(See "Evaluation and diagnosis of hair loss".)
APPROACH TO TREATMENT — We aim to treat MPHL as early as feasible, as responses to therapies for MPHL are often incomplete. The major treatment modalities for MPHL include topical and oral minoxidil, 5-alpha reductase inhibitors (finasteride or dutasteride), photobiomodulation (also known as low-level laser therapy [LLLT]), platelet-rich plasma (PRP), hair transplantation, and camouflage techniques.
The approach to the treatment of MPHL involves consideration of multiple factors, such as the clinical presentation, treatment efficacy, treatment adverse effects, patient preference, and treatment availability.
Our approach — Topical minoxidil and oral finasteride are the therapeutic agents that have been most extensively studied for MPHL. However, challenges with daily application of topical minoxidil, a desire to avoid potential adverse effects of oral finasteride, or a history of poor response to these therapies can prompt the use of other interventions.
●Initial therapy for patients who prefer to avoid oral 5-alpha reductase inhibitor therapy – Despite the demonstrated efficacy of oral finasteride for MPHL and data that suggest superiority over topical minoxidil, our experience is that many patients have concerns about potential sexual and other adverse effects of finasteride, prompting a desire for a different approach to treatment. For these patients, we generally encourage the inclusion of topical minoxidil or low-dose oral minoxidil in the treatment regimen.
Topical minoxidil is a preferred initial therapy for MPHL based on randomized trials that support efficacy, safety, and tolerability of this treatment. Despite the more limited data on oral minoxidil, some clinicians, including ourselves, consider oral minoxidil a reasonable alternative to topical minoxidil for initial therapy. The available data suggest benefit and relatively good tolerability, and the drug provides an alternative for patients who prefer oral therapy.
●Initial therapy for patients who prefer oral 5-alpha reductase inhibitor therapy – For patients who prefer treatment with an oral 5-alpha reductase inhibitor, we typically incorporate oral finasteride in the initial treatment regimen.
In our experience, patients who prefer treatment with oral finasteride place a high value on demonstrated efficacy from clinical trials, are comfortable with (or prefer) use of an oral agent for long-term therapy, and are tolerant of the risk for potential adverse effects with this therapy.
We also encourage adjunctive use of topical minoxidil based upon data that suggest greater efficacy of combination therapy.
We generally reserve oral dutasteride (another 5-alpha reductase inhibitor) for patients who have insufficient responses to oral finasteride because dutasteride has been less extensively studied for MPHL. However, other experts suggest that initial treatment with dutasteride is a reasonable alternative based on data that support superior efficacy and a similar adverse effect profile [1]. (See 'Oral dutasteride' below.)
●Incorporation of other therapies – Patient preference and outcomes from prior treatment often inform the use of other therapies (eg, photobiomodulation, PRP, topical finasteride, oral dutasteride, hair transplantation). Examples of scenarios that often prompt us to incorporate other treatments include:
•Continued hair loss despite initial therapy with oral finasteride, topical minoxidil, or low-dose oral minoxidil
•Poor tolerance of the treatments above or a preference to avoid these treatments
•A desire for more aggressive treatment (eg, a patient's concern for unsatisfactory hair regrowth despite successful stabilization of hair loss) (see 'Role of combination therapy' below)
Our typical next step after an unsatisfactory response to oral finasteride and/or topical minoxidil is to start low-dose oral minoxidil; however, selection of subsequent therapy is heavily influenced by patient preference (after discussion of the mode and frequency of administration, adverse effects, cost, etc) and treatment availability. Photobiomodulation, PRP, or compounded topical finasteride are reasonable alternatives for patients who prefer skin-directed treatments over systemic treatment. We typically use photobiomodulation and PRP as adjuncts to pharmacologic treatment. Switching from oral finasteride to oral dutasteride is another alternative for patients who prefer systemic treatment. (See 'Alternative and adjunctive therapies' below and 'Role of combination therapy' below.)
Surgical hair transplantation, which involves the transfer of hair follicles from sites resistant to MPHL to the affected areas, can provide permanent improvement in scalp terminal hair growth. Given that long-term medical therapy for MPHL is indicated to maintain the best results of hair transplantation, we tend to use hair transplantation for patients who cannot achieve satisfactory results with medical therapy alone. The cost of hair transplantation can be prohibitive for some patients. (See 'Hair transplantation' below.)
A variety of camouflaging techniques can be helpful for minimizing the appearance of hair loss and can be employed as adjuncts or alternatives to medical or procedural therapy. (See 'Camouflaging agents' below.)
Role of combination therapy — Combination therapy for MPHL is common and based upon the theory that the use of therapies with different mechanisms of action may augment the response to therapy.
However, limitations of the available data (eg, study size, study heterogeneity) preclude definitive conclusions on the superiority of combination therapy [2]. Examples of trials that suggest benefit of combination therapy include trials reporting greater benefit of combination therapy with topical minoxidil and oral finasteride over topical minoxidil or oral finasteride alone [3,4], combination therapy with topical finasteride and topical minoxidil over topical minoxidil alone [5], combination therapy with topical minoxidil and PRP over topical minoxidil or PRP alone [6,7], combination therapy with topical minoxidil and photobiomodulation over minoxidil alone [2,8], and topical minoxidil and microneedling over topical minoxidil or microneedling alone [2].
PATIENT COUNSELING — Providing clear guidance on treatment options, regimens, and outcomes is an important component of therapy. Key points we typically discuss include:
●Potential treatment outcomes – We aim to understand the patient's desired final outcome and discuss the variable outcomes of MPHL therapy. Potential levels of response to individual treatments include absent response, reduction in the progression of hair loss, and variable regrowth of hair. (See 'Assessing response' below.)
●Proper treatment administration – Patients starting self-administered treatments, such as topical therapies or photobiomodulation devices, may benefit from clear instructions for treatment administration to optimize benefit and minimize risk for adverse effects. (See 'Topical minoxidil' below.)
●Expected time to response – Response to treatments for MPHL are delayed, with noticeable responses often requiring at least several months of treatment. We generally advise at least six months of treatment before assessing the response to therapy. Informing patients of the expected time to response may prevent premature discontinuation of treatment. (See 'Assessing response' below.)
●Long-term continuation of therapy – No treatments for MPHL are curative. Because of the progressive nature of MPHL, long-term continuation of pharmacologic therapy is necessary to maintain benefit. (See "Male pattern hair loss (androgenetic alopecia in males): Pathogenesis, clinical features, and diagnosis", section on 'Pattern and course'.)
ASSESSING RESPONSE
●Definition – The definition of a satisfactory response to treatment may vary across patients. In general, a satisfactory response can be considered cessation of the progression of hair loss and improvement in hair coverage that is satisfactory for the patient.
●Timing – Assessing for treatment benefit at an appropriate time point is critical. Treatments for MPHL often require at least six months to demonstrate clinically significant improvement.
●Techniques – In the clinical setting, the response to treatment is generally assessed through physical examination. Serial clinical photographs are helpful for documenting baseline status and for recognizing improvement and progression of MPHL.
Examples of other methods of assessing response include measurements of hair density or hair diameter. These methods are primarily reserved for clinical studies or specialized hair clinics.
PRIMARY THERAPIES — Topical minoxidil and oral 5-alpha reductase inhibitors (eg, oral finasteride and oral dutasteride) are the mainstays of treatment for MPHL. (See 'Approach to treatment' above.)
Topical minoxidil — Topical minoxidil promotes hair growth by increasing the duration of anagen, shortening telogen, and enlarging miniaturized follicles [9].
The pathophysiologic mechanism through which minoxidil influences follicular structure and follicular cycling is not fully understood. Minoxidil is a vasodilator, and the induction of vascular endothelial growth factor (VEGF) may be a mechanism by which minoxidil helps to maintain the vascularity and size of dermal papillae (collections of mesenchymal tissue beneath follicles that contribute to follicular development) [10,11]. Since the volume of a dermal papilla correlates with the size of the emerging hair follicle, minoxidil-induced support of the dermal papilla may be relevant. In addition, minoxidil is a regulator of potassium ion channels. This function may also contribute to the drug's beneficial effects [9,12].
Benefit from topical minoxidil is dependent on conversion of the drug to its active form, minoxidil sulfate [13]. At the hair follicle, phenol sulfotransferase (SULT1A1) converts minoxidil to minoxidil sulfate.
Administration — The standard regimen for topical minoxidil therapy is twice-daily application of 1 mL of minoxidil 5% solution or one-half capful of minoxidil 5% foam to the affected area. Minoxidil 2% solution is not typically used because of lower efficacy compared with the 5% solution. (See 'Efficacy' below.)
Selection of the solution or foam vehicle is based upon patient preference. Unlike minoxidil solution, the foam formulation is free of propylene glycol, a common cause of allergic contact dermatitis [14]. Fragrance-free formulations of minoxidil are also available. (See "Common allergens in allergic contact dermatitis".)
Patients should be instructed to target application of minoxidil to the scalp rather than the hair. In addition, patients should be counseled that hair shedding may occur early in the course of treatment; hair shedding is postulated to result from the stimulation of telogen follicles to reenter the anagen phase [15]. The increased hair loss usually resolves within two months. Discussing the potential for hair shedding may help to reduce premature discontinuation of treatment.
Treatment should continue for at least six months prior to assessing for benefit of therapy [16]. Continued treatment is necessary to maintain the response. If treatment is stopped, regrowth will be lost, often over the course of several months [17].
Efficacy — Randomized trials support the efficacy of topical minoxidil [14,17,18].
●Minoxidil 5% solution versus minoxidil 2% solution versus placebo – The largest randomized trial that compared minoxidil 5% solution with minoxidil 2% solution found minoxidil 5% solution the most effective regimen. In the trial, 393 adult males with MPHL were randomly assigned to minoxidil 5% solution, minoxidil 2% solution, or placebo [18]. After 48 weeks, minoxidil 5% solution was more effective than minoxidil 2% solution or placebo in terms of change from baseline in nonvellus hair count (increase in count of 18.6, 12.7, and 3.9 per cm2, respectively), patient ratings of scalp coverage and treatment benefit, and investigator rating of scalp coverage. Treatment with 5% minoxidil was also associated with an earlier therapeutic response and an improvement in the patients' psychologic perceptions of hair loss. However, pruritus and local skin irritation were more frequent in patients treated with the 5% concentration than in patients treated with the 2% concentration.
●Minoxidil 5% foam – No randomized trials have directly compared the efficacy of minoxidil 5% foam with minoxidil 5% solution. In a 16-week randomized trial (n = 352), compared with placebo, minoxidil 5% foam was associated with greater improvements in target area terminal hair counts (mean change in terminal hair counts of 20.9 versus 4.7), as well as in scores from patient self-assessments and an investigator global photographic review [14].
●Versus oral finasteride – Small studies comparing topical minoxidil with oral finasteride suggest greater efficacy of oral finasteride. (See 'Oral finasteride' below.)
Topical minoxidil has also been evaluated as a component of combination therapy. (See 'Oral finasteride' below.)
Additional study is necessary to confirm whether incorporation of SULT1A1 enzyme boosters to promote conversion of minoxidil to its active form improves treatment outcomes [13].
Adverse effects — Topical minoxidil is generally well tolerated. The most common side effects are allergic contact dermatitis and irritant contact dermatitis [19]. When given systemically, minoxidil has dose-dependent antihypertensive properties, but neither 5% nor 2% minoxidil solution alters systolic or diastolic blood pressure, pulse rate, or body weight when applied topically [20]. Nevertheless, due to the potential for systemic absorption when the scalp skin barrier is not intact, caution is prudent for patients with cardiac disease.
Oral finasteride — Finasteride is an inhibitor of dihydrotestosterone (DHT) production. Finasteride competitively inhibits the 5-alpha reductase type 2 enzyme and thereby inhibits conversion of testosterone to DHT [21]. At a dose of 1 mg per day, oral finasteride lowers serum and scalp DHT levels by more than 60 percent [22]. The drug has no affinity for the androgen receptor and does not interfere with testosterone action [21]. (See "Male pattern hair loss (androgenetic alopecia in males): Pathogenesis, clinical features, and diagnosis", section on 'Pathogenesis'.)
Administration — Standard adult dosing for oral finasteride for MPHL in adult males is 1 mg per day.
Treatment should continue for at least six months to assess the efficacy of oral finasteride, and some patients may require up to 12 months of treatment to determine benefit [16]. Oral finasteride must be continued to maintain benefit.
Caution is indicated for patients with hepatic impairment, diminished urinary flow, prostate cancer, and mood disorders. In addition, oral finasteride may reduce prostate-specific antigen (PSA) levels, requiring appropriate interpretation of PSA test results. (See "Measurement of prostate-specific antigen", section on 'Medications'.)
Efficacy — Data from randomized trials support efficacy of oral finasteride for MPHL.
●Oral finasteride versus placebo – A meta-analysis of placebo-controlled randomized trials (total of 3927 patients) identified moderate-quality evidence in support of the use of oral finasteride (at a dose of 1 or 5 mg per day) for MPHL in adults [23]. After 6 or 12 months of treatment, the mean percentage change in hair count was approximately 9 percent higher among patients treated with oral finasteride compared with patients who were given placebo (mean difference 9.42 percent, 95% CI 7.9-10.9 percent). After 48 months of therapy, the mean percentage change in hair count was approximately 24 percent higher in patients treated with oral finasteride (mean difference 24.3 percent, 95% CI 17.92-30.60 percent). Patients treated with finasteride were also more likely to report improvement with finasteride on self-assessment (risk ratio 1.81, 95% CI 1.42-2.32).
In addition to improved hair counts, other factors, such as increases in hair thickness, pigmentation, and length, may contribute to the perception of improved scalp coverage during therapy [22]. In a randomized trial that followed patients with MPHL treated with finasteride (at a dose of 1 mg per day) for up to 192 weeks, net improvements in hair weight were greater than improvements in hair count [24,25].
●Oral finasteride versus topical minoxidil – Data from small randomized trials suggest that oral finasteride (at a dose of 1 mg per day) may be more effective than topical minoxidil 5% solution.
•In an open trial, 65 males with MPHL (ages 18 to 50 years) were randomly assigned to oral finasteride (at a dose of 1 mg per day) or twice-daily application of minoxidil 5% solution [26]. At 12 months, a higher proportion of patients treated with oral finasteride exhibited minimal to dense hair growth (based upon investigator review of clinical photographs) than patients treated with minoxidil solution (80 versus 52 percent).
•In a trial that randomly assigned 99 males with MPHL (ages 18 to 45 years) to oral finasteride (at a dose of 1 mg per day) or twice-daily application of a lower concertation of minoxidil (the 2% solution), there was a smaller increase in hair count with topical minoxidil at 12 months compared with oral finasteride (9.6±0.9 hairs versus 17.7±2 hairs) [27]. However, there was not a statistically significant difference in visible improvement (based upon investigator photographic global assessment of the clinical response).
●Combination therapy – Trials assessing combination therapy with oral finasteride and topical minoxidil are limited but suggest greater benefit of combination therapy.
•An open randomized trial with 450 males (ages 18 to 50 years) with MPHL compared outcomes from oral finasteride (at a dose of 1 mg per day) alone, topical minoxidil 5% alone, and combined therapy [4]. Based upon blinded investigator assessment of photographs from 428 patients who completed the study, slight to great improvement was present after 12 months in 81 percent of patients treated with oral finasteride, 59 percent of patients treated with topical minoxidil, and 94 percent of patients treated with combination therapy.
•A open randomized trial of 100 males (ages 18 to 35 years) with MPHL evaluated the efficacies of oral finasteride (at a dose of 1 mg per day) alone (n = 30), minoxidil 2% solution (twice daily) alone (n = 24), oral finasteride and minoxidil 2% solution in combination (n = 36), and oral finasteride (at a dose of 1 mg per day) plus ketoconazole 2% shampoo (thrice weekly, n = 10) [3]. Visible improvement in hair growth based upon physician photographic assessment was detected at one year in all four groups (87, 42, 100, and 100 percent of patients, respectively). On statistical analysis, patients who received oral finasteride alone or in combination with topical minoxidil or ketoconazole had greater improvement on physician photographic assessment than patients who received only topical minoxidil. Combination therapy with oral finasteride and topical minoxidil was also superior to oral finasteride alone.
Adverse effects — Examples of potential adverse effects of oral finasteride include sexual dysfunction, gynecomastia, and teratogenicity. Oral finasteride therapy may also impact prostate cancer detection and risk. The relationship between oral finasteride and adverse psychologic outcomes is uncertain.
●Sexual dysfunction – Oral finasteride may be associated with deleterious effects on sexual function, such as erectile dysfunction, decreased libido, and ejaculatory dysfunction. A systematic review of nine trials with a total of 3570 patients found an overall absolute increase in sexual dysfunction of 1.5 percent [23]. A subsequent systematic review and meta-analysis of placebo-controlled randomized trials also detected an increased risk for sexual adverse effects among patients taking oral finasteride for MPHL [28].
Sexual side effects related to oral finasteride usually resolve after discontinuation of the medication [29]. However, persistent sexual dysfunction after the discontinuation of finasteride has been reported. (See "Medical treatment of benign prostatic hyperplasia", section on 'Sexual dysfunction'.)
Reductions in sperm count also may occur during treatment with finasteride [30,31]. This effect reverses after drug discontinuation.
●Gynecomastia – Gynecomastia, a benign proliferation of the glandular tissue of the breast, may occur in male patients treated with oral finasteride. (See "Epidemiology, pathophysiology, and causes of gynecomastia".)
●Teratogenicity – Oral finasteride is contraindicated for pregnant individuals. Finasteride may increase risk for abnormal fetal development of the male genital tract. Impregnating another individual while taking oral finasteride is not considered a risk to the fetus.
●Prostate cancer detection and risk – Finasteride may impact measurement of serum PSA. The PSA can decline significantly in males taking finasteride, resulting in the need to interpret test results accordingly [32]. (See "Measurement of prostate-specific antigen", section on 'Medications'.)
Although oral finasteride therapy decreases risk for prostate cancer, the drug may increase the risk for high-grade prostate cancer lesions. The relationship between finasteride treatment and prostate cancer is discussed in detail separately. (See "Chemoprevention strategies in prostate cancer", section on 'Finasteride: PCPT'.)
●Psychiatric outcomes – Whether oral finasteride therapy is a risk factor for suicidality and other adverse psychologic events (eg, depression, anxiety) in patients treated for MPHL is unclear [33,34]. Studies exploring this association are limited.
A pharmacovigilance study designed to identify disproportional signals of adverse reactions in a global database of drug safety reports suggests either an association between finasteride therapy and risk for suicidality and psychologic adverse events in younger adults treated with finasteride or disproportional signal detection related to stimulated reporting of adverse events [34]. The study identified 356 reports of suicidality (ideation, attempt, or completed suicide) and 2926 reports of psychologic adverse events (depression or anxiety) in users of finasteride; 99 percent of all reports occurred in males, and 71 percent occurred in individuals between the ages of 18 and 44 years. There were significant disproportionality signals for both suicidality (reporting odds ratio [ROR] 1.63, 95% CI 1.47-1.81, with the disproportionality signal driven by suicidal ideation reports) and psychologic adverse events (ROR 4.33, 95% CI 4.17-4.49) for finasteride when compared with reports for other drugs. In addition, when stratified by age and indication, younger patients (ROR 3.47, 95% CI 2.90-4.15) and patients with alopecia (ROR 2.06, 95% CI 1.81-2.34) had significant disproportionality signals for suicidality that were not present in older patients or patients with benign prostatic hyperplasia.
●Other – A relationship between finasteride therapy and male breast cancer has not been confirmed [35,36]. (See "Breast cancer in men".)
Oral dutasteride — Dutasteride is an inhibitor of both type 1 and type 2 5-alpha reductase. Compared with finasteride, dutasteride is a more potent inhibitor of 5-alpha reductase [37].
Administration — Standard dosing for oral dutasteride for MPHL in adult males is 0.5 mg per day. As with oral finasteride, treatment should continue for at least six months to assess the efficacy of oral dutasteride; some patients may require up to 12 months of treatment to determine benefit. Oral dutasteride must be continued to maintain benefit.
Caution is indicated for patients with hepatic impairment, diminished urinary flow, prostate cancer, or taking potent cytochrome P450 3A4 (CYP3A4) inhibitors (see "Dutasteride: Drug information"). For additional information on drug interactions, refer to the Lexicomp drug information monograph for dutasteride included within UpToDate.
In addition, dutasteride may reduce PSA levels, requiring appropriate interpretation of PSA test results. (See "Measurement of prostate-specific antigen", section on 'Medications'.)
Efficacy — Oral dutasteride (at a dose of 0.5 mg per day) is effective for MPHL and may be more effective than oral finasteride (at a dose of 1 mg per day) [38-40]. In comparison with finasteride, fewer studies have evaluated dutasteride for MPHL, and long-term efficacy data are more limited [38]. Examples of trials in support of the efficacy of dutasteride include:
●In a randomized trial, 917 males with MPHL (ages 20 to 50 years) were randomly assigned to one of three dose regimens of oral dutasteride (at doses of 0.5, 0.1, or 0.02 mg per day), oral finasteride (at a dose of 1 mg per day), or placebo [40]. At week 24, all dutasteride and finasteride regimens were superior to placebo for increasing baseline hair count and hair width. Only the dutasteride 0.5 mg regimen was superior to finasteride for these outcomes. Overall rates of adverse events were low and similar among the groups. Sexual adverse events were more frequent in the dutasteride and finasteride groups than in the placebo group but occurred at similar rates among the active treatment groups. A network meta-analysis provides additional support for greater efficacy of dutasteride (at a dose of 0.5 mg per day) compared with finasteride (at a dose of 1 mg per day) [38].
●In a randomized trial (n = 153), dutasteride (at a dose of 0.5 mg/day) was superior to placebo for the treatment of MPHL; the mean increase in hair counts in patients treated with dutasteride was 12.2/cm2 compared with 4.7/cm2 in patients treated with placebo [39]. There was no significant difference in the number of adverse effects reported in both groups. The most common drug-related adverse effect was sexual dysfunction, which was noted in 4 percent of study participants in the dutasteride group and 3 percent of those in the control group.
●Efficacy and safety of a higher 2.5 mg dose of dutasteride have been assessed in other studies. In a randomized trial (n = 416) that compared four different doses of dutasteride (ranging from 0.5 to 2.5 mg per day), finasteride (at a dose of 5 mg per day), and placebo, all doses of dutasteride and finasteride were more effective for increasing hair count at week 24 than placebo, and dutasteride 2.5 mg per day was more effective than finasteride 5 mg [41]. Decreased libido occurred in 13 percent of patients in the dutasteride 2.5 mg group compared with 1 to 4 percent of patients in the other groups.
Adverse effects — The adverse effects of dutasteride are similar to those of finasteride [42]. A 2019 systematic review and meta-analysis of randomized trials that assessed dutasteride or finasteride therapy for MPHL did not identify statistically significant differences in sexual side effects (eg, alteration of libido, erectile dysfunction, or ejaculatory disorders) between the two drugs [43]. (See 'Adverse effects' above.)
Examples of potential adverse effects include sexual dysfunction, gynecomastia, teratogenicity, and alteration of serum PSA levels. In addition, increased rates of high-grade prostate cancer have been reported with 5-alpha reductase inhibitor therapy, though the relevance of this finding is unclear. (See 'Oral finasteride' above and "Chemoprevention strategies in prostate cancer", section on '5-Alpha reductase inhibitors'.)
ALTERNATIVE AND ADJUNCTIVE THERAPIES — Multiple other interventions have been utilized for MPHL alone or in conjunction with other treatments. High-quality data on the efficacy of these treatments are more limited.
Oral minoxidil — Limited data suggest benefit of oral minoxidil for MPHL.
●Administration – Optimal dosing for oral minoxidil in MPHL has not been established, and approaches to treatment vary.
Prior to treatment, we obtain a baseline blood pressure measurement and body weight and inquire about pre-existing cardiovascular disease to identify patients who may benefit from cardiovascular consultation prior to the initiation of therapy. We generally begin minoxidil at a dose of 2.5 mg per day and subsequently increase to 5 mg per day if the response is inadequate after four to six months and the patient is tolerating therapy. Other experts opt for a lower starting and maximum dose, beginning at 1.25 mg per day and subsequently increasing to 2.5 mg per day.
We typically discontinue topical minoxidil when patients begin oral minoxidil therapy. Some clinicians opt to overlap these treatments for a few weeks in an attempt to offset the initial period of oral minoxidil-induced hair shedding.
●Efficacy – Data from small uncontrolled studies suggest benefit of oral minoxidil (at a dose of 2.5 or 5 mg per day) for MPHL.
•In a prospective uncontrolled study, 30 males with MPHL (ages 24 to 59 years) received oral minoxidil (at a dose of 5 mg per day) [44]. At week 24, the mean change in total hair counts and the mean hair diameter were increased compared with baseline. The dermatologist photographic assessment also demonstrated improvement in all patients, with 43 percent of patients designated as having excellent improvement.
•In a retrospective study of 41 males with MPHL treated with minoxidil (at a dose of 2.5 or 5 mg per day for at least six months) alone or in combination with other therapies, 37 (90 percent) had clinical improvement based upon dermatologist review of clinical images [45]. Of the 16 patients who received minoxidil alone, all had clinical improvement, including 6 (38 percent) assessed to have marked improvement. Reported adverse effects included hypertrichosis (10 patients), lower limb edema (2 patients), and hair shedding (1 patient) and primarily occurred in patients receiving 5 mg per day of minoxidil.
In contrast, a retrospective study of 25 males with MPHL treated with a lower dose of oral minoxidil (at 0.25 mg per day) did not find statistically significant improvements in hair density or new hairs after 24 weeks of treatment [46]. Reported adverse effects included hypertrichosis (five patients), hair shedding (four patients), and pedal edema (one patient).
The findings of a retrospective study suggest that combining oral minoxidil and topical minoxidil may not be more beneficial than low-dose oral minoxidil alone in nonscarring alopecia [47].
Additional study is necessary to determine the efficacy of sublingual minoxidil for MPHL. Sublingual minoxidil has been proposed as a method to improve bioavailability of the active form of minoxidil through bypassing hepatic first-pass metabolism of minoxidil [48].
●Adverse effects – Examples of potential adverse effects of oral minoxidil include hypertrichosis, pedal edema, periorbital swelling, tachycardia, rare electrocardiogram (EKG) changes, and postural hypotension/dizziness [49-51]. In addition, a temporary period of increased hair shedding may occur during the first three to six weeks of treatment [49].
Photobiomodulation — Photobiomodulation (also known as low-level laser therapy [LLLT]) involves use of a specialized comb, helmet, or other device to deliver red to infrared light to the scalp. The mechanism of action is not fully understood but may involve stimulation of hair growth through increased adenosine triphosphate production, modulation of reactive oxygen species, induction of transcription factors involved in cell proliferation and migration, and/or anti-inflammatory effects [52].
Treatment regimens and the types of light sources used for photobiomodulation vary. Often, patients use the selected device to administer treatment three to four times per week for the manufacturer-suggested time period (often 10 to 20 minutes) [52]. Treatment benefit is generally assessed after six months, but the optimal time course for assessment is unclear.
Photobiomodulation appears beneficial for MPHL, but questions remain about the duration of response. A systematic review and meta-analysis that included three randomized trials that compared photobiomodulation with placebo supports benefit of photobiomodulation (mean difference in hair count of 17.66, 95% CI 12.85-22.47) [53]. Individual randomized trials assessing specific devices (eg, HairMax LaserComb, TOPHAT655 helmet, Oaze helmet, RAMACAP helmet, iRestore ID-520 helmet) have also demonstrated greater increases in terminal hair density or hair count after treatment with photobiomodulation devices for 16 to 26 weeks than after sham treatments [54-59].
Photobiomodulation is generally well tolerated. The most commonly reported adverse events in clinical studies include headaches, skin pain and burning sensation, pruritus, erythema, acne, and mild paresthesia [60].
Platelet-rich plasma — Platelet-rich plasma (PRP) therapy is based upon the concept that growth factors released from platelets may modulate hair cycle signaling pathways that contribute to regrowth of hair [61].
Procedures for PRP therapy vary. In general, the procedure involves centrifugation of the patient's own blood to obtain PRP, preparation of the PRP with or without the addition of other agents (eg, calcium chloride or calcium gluconate) to induce activation, and subcutaneous injection of the prepared PRP into the scalp. Treatment begins with PRP sessions every four to six weeks for three to six months [62].
Data are insufficient to determine the best approach to subsequent management although lifelong treatment is necessary to maintain the response (similar to other treatments). For patients who appear to have benefited from treatment when reassessed after six months, continuation of treatment is reasonable (eg, a single treatment session performed every three to six months). Periodic repetition of a series of treatments may also be reasonable.
There is uncertainty regarding the efficacy and preferred regimen for PRP therapy [63-65]. Studies assessing PRP have generally been small and have utilized varying protocols and techniques. While some studies support benefit [66], others have not found PRP effective [61,63]. Examples of studies assessing PRP include:
●A meta-analysis that incorporated 10 controlled or uncontrolled studies with a total of 165 patients (with MPHL [most patients] or female pattern hair loss [FPHL]) that assessed hair density changes with PRP monotherapy supports benefit of PRP. The overall standardized mean difference (SMD) in hair density compared with baseline was 0.58 (95% CI 0.35-0.80) [66]. An analysis limited to data from the six placebo-controlled studies (n = 99) also favored efficacy of PRP (SMD 0.51, 95% CI 0.23-0.80).
●A split-head trial in which 35 patients with MPHL or FPHL received a series of three once-monthly treatments with PRP or placebo to one randomly assigned side of the scalp and the alternative treatment on the other side of the scalp found increases in hair density and hair diameter with both treatments three months after the completion of treatment [61]. However, there was not a statistically significant difference in hair density change between sites treated with PRP and sites treated with placebo.
PRP therapy is generally well tolerated. Pain during injection is the most common adverse effect.
Topical finasteride — Topical finasteride therapy has been used for MPHL, with the intent of achieving benefits of 5-alpha reductase inhibition while reducing systemic absorption of finasteride [67,68]. In the United States, topical finasteride is not commercially available; the drug is obtained through compounding pharmacies. Various formulations (from 0.005% to 1%) and regimens for topical finasteride have been utilized [68]. At least six months of treatment should elapse prior to an assessment of the response.
Multiple studies suggest benefit of topical finasteride, although more high-quality studies are necessary to clarify efficacy, preferred concentration and regimen, and safety [67,68]. Topical finasteride has not been proven more effective than oral finasteride (at a dose of 1 mg per day).
●In one of the largest trials to assess topical finasteride, 458 males (ages 18 to 40 years) with MPHL were randomly assigned to treatment with topical finasteride 0.25% spray solution applied once daily, placebo, or oral finasteride (at a dose of 1 mg per day) in a 2:2:1 ratio [69]. Approximately 30 percent of patients in each group discontinued the study prior to completion, and assessment of the effect on hair count was limited to 250 patients for whom macrophotographs were evaluable. At week 24, the adjusted mean change from baseline for the target area hair count was higher in the topical finasteride group than in the placebo group (20.2 versus 6.7 hairs), and the investigator-assessed response was also better in the topical finasteride group than in the placebo group. Statistically significant differences in these outcomes were not detected between the topical and oral finasteride groups. Statistically significant changes in hair width were not detected in any of the groups.
Treatment with topical finasteride was generally well tolerated in the trial [69]. Plasma finasteride concentrations and reductions in serum dihydrotestosterone (DHT) concentrations at week 24 were lower in the topical finasteride group than the oral finasteride group. Treatment-related sexual adverse events were reported in 2.8, 3.3, and 4.8 percent of patients in the topical finasteride, placebo, and oral finasteride groups.
Camouflaging agents — Camouflage techniques are an additional approach to restoring the appearance of dense hair growth.
A variety of topical camouflaging products are available. Examples include keratin fibers, which are sprinkled onto the hair, and a variety of scalp colorants (eg, sprays, lotions, powder cakes). Keratin fibers adhere to existing hairs and the scalp, augmenting the appearance of hair fullness. By minimizing the contrast between the color of the scalp and hair, scalp colorants reduce the appearance of hair loss. Wigs, toupees, and hairpieces are also effective camouflaging agents.
HAIR TRANSPLANTATION — Improvement in MPHL can be attained through surgery. Hair transplantation using follicular units (histologically identifiable groups of hair follicles that usually contain one to four terminal hairs) is the mainstay of surgical treatment [70]. Procedures that aim to reorient large areas of hair-bearing skin, such as scalp reduction and flaps, are less commonly performed.
●Candidates – The ideal candidates for hair transplantation are patients with stable or medically controlled MPHL who desire permanent improvement in hair loss and have an adequate reservoir of hair for transplantation. Patients with moderate degrees of baldness (Hamilton-Norwood III to V (figure 1)) are most often considered for the procedure. Patients with lesser degrees of hair loss may achieve satisfactory improvement with nonsurgical therapy alone. Patients with more severe hair loss may benefit from hair transplantation but require careful counseling regarding the number of surgical sessions that may be required and the expected cosmetic outcome [70].
Caution may also be indicated for patients who present early in the course of MPHL but whose clinical presentation suggests a high likelihood for progression to much more severe hair loss (eg, young patients with a rapid rate of hair loss) [70]. In such patients, insufficiently controlled MPHL may lead to new areas of balding and a less satisfactory long-term cosmetic outcome. For this reason, it is not common to offer hair transplantation to males under 25.
●Mechanism of benefit – The basic principle governing hair transplantation is that of "donor dominance." Hair follicles removed from nonbalding occipital scalp and transplanted into areas affected by MPHL will maintain the characteristics of the occipital scalp donor site. Because occipital hair is relatively resistant to MPHL, transplanted hairs will remain large caliber hairs. Growth of transplanted hair usually becomes evident 3 to 6 months after the procedure, with optimal results evident 9 to 18 months after the procedure [71].
●Overview of technique – Modern hair transplant techniques rely on the use of "follicular units," which are the natural groupings of one to four hair follicles that occur in the scalp. There are two fundamental ways that a hair transplant can be performed: follicular unit transplantation (FUT) and follicular unit extraction (FUE).
•Follicular unit transplantation – With FUT, a strip of tissue 8 to 15 mm wide and 20 to 30 cm long is surgically excised from the occipital scalp under local anesthesia. Follicular units are carefully dissected from the tissue strip with the aid of microscopes and then transplanted into areas of hair loss. The procedure leaves a thin, linear scar in the occipital scalp.
•Follicular unit extraction – FUE is more commonly performed and involves the removal of individual follicular units from a wide area of the occipital scalp. This can be performed manually or though motorized or robotic devices [71,72]. Although not truly a "scarless" technique, FUE does not leave a linear scar and has advantages for people who want to wear their hair very short.
The procedure is usually performed with local anesthesia with or without an oral anxiolytic [73]. It takes five to eight hours to perform a standard hair transplant session, with FUE taking longer to perform than FUT. A small hair transplant session may involve the transplantation of 800 to 1000 follicular units. A large session (megasession) would involve 3000 to 6000 grafts of follicular units.
●Safety – Potential complications of hair transplantation include pruritus, folliculitis, cyst formation, numbness or paresthesia, and excessive scarring [73]. Infection, skin necrosis, keloids, arteriovenous fistulas, and hiccups are rare complications. Poor surgical technique may result in an undesirable cosmetic outcome [73].
●Postoperative care – Patients can continue to lose nontransplanted hairs within susceptible areas following hair transplantation, resulting in diminishing satisfaction with the results. The continuation of medical treatment with topical minoxidil or an oral 5-alpha reductase inhibitor following a hair transplant procedure may help to limit further loss of pre-existing scalp hair [70]. In a randomized trial of 79 patients with MPHL who underwent hair transplantation, those treated with oral finasteride (at a dose of 1 mg per day) for 4 weeks prior to the transplant and for 48 weeks after the transplant achieved better results [74].
OTHER THERAPIES
Microneedling — Microneedling involves using a roller, specialized pen, or other device to insert numerous small (usually 0.5 to 1.5 mm long) needles into skin to create numerous small wounds. Microneedling may be a treatment option for MPHL. However, protocols for microneedling are not standardized, and additional study is necessary to clarify the role of microneedling in MPHL [75-77].
Microneedling is postulated to improve MPHL through induction of Wnt proteins that regulate dermal papilla signaling to hair follicle stem cells and stimulation of vascularization [75]. Microneedling may also increase absorption of topical treatments and may augment the activation of topical minoxidil [75].
Other — Examples of additional therapies with reports of benefit in MPHL include topical dutasteride [78,79], topical cetirizine [80], topical flutamide plus topical minoxidil [81], topical spironolactone [82], topical latanoprost [83], ketoconazole shampoo [84], topical rosemary oil [85], oral pumpkin seed oil [86], and various topical natural products and nutritional supplements [87]. Examples of procedural interventions with potential benefit include insertion of polydioxanone threads [88], botulinum toxin injections [89], mesotherapy [90], dutasteride injections [91], and stem cell therapy [92]. Additional study is necessary to clarify the role of these therapies in the treatment of MPHL.
MANAGEMENT OF COMORBIDITIES — MPHL may be associated with increased risk for other disorders. Patients with signs of associated diseases should receive appropriate management. (See "Male pattern hair loss (androgenetic alopecia in males): Pathogenesis, clinical features, and diagnosis", section on 'Associated disorders'.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Hair loss (The Basics)")
●Beyond the Basics topic (see "Patient education: Androgenetic alopecia in men and women (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Disease overview – Male pattern hair loss (MPHL; androgenetic alopecia in males, male balding) is a common form of nonscarring hair loss that presents with the loss of terminal hairs in characteristic areas of the scalp (picture 1A-D). The primary reason for treatment of MPHL is the development of negative psychosocial effects. (See 'Introduction' above and "Male pattern hair loss (androgenetic alopecia in males): Pathogenesis, clinical features, and diagnosis", section on 'Psychosocial effects'.)
●Patient counseling – Patients who desire treatment of MPHL should be carefully counseled. Successful treatment of MPHL generally requires long-term adherence to treatment. Thorough discussions with patients about treatment options and adverse effects, potential treatment outcomes, and proper treatment administration may help with appropriate treatment selection and may reduce risk for premature discontinuation of treatment. (See 'Patient counseling' above.)
●Assessing treatment response – Visible responses to MPHL therapies are usually delayed; therefore, the timing of the response assessment is important. In the clinical setting, the response to treatment is generally assessed through physical examination. In our experience, serial clinical photographs are helpful. (See 'Assessing response' above.)
The definition of an acceptable treatment response can vary. In general, a satisfactory response can be considered cessation of the progression of hair loss and improvement in hair coverage that is satisfactory for the patient. (See 'Assessing response' above.)
●Approach to treatment – The major treatment modalities for MPHL in adult males include topical or low-dose oral minoxidil, 5-alpha reductase inhibitors (finasteride and dutasteride), photobiomodulation (also known as low-level laser therapy [LLLT]), platelet-rich plasma (PRP), and hair transplantation. Topical minoxidil and oral finasteride are the therapies that have been most extensively studied for MPHL. Camouflaging agents (eg, keratin fibers, hairpieces, etc) are an additional option for patients who have insufficient responses to treatment or who prefer to avoid medical or procedural therapies. (See 'Approach to treatment' above.)
•Initial treatment
-Patients who prefer to avoid oral 5-alpha reductase inhibitor therapy – For adults with MPHL who prefer to avoid treatment with an oral 5-alpha reductase inhibitor, we suggest initial treatment with topical minoxidil 5% solution or foam rather than other therapies (Grade 2C). Reasons for deferring oral 5-alpha reductase inhibitor therapy may include concern for potential adverse effects and a preference for topical treatment.
Treatment with low-dose oral minoxidil is an alternative to topical minoxidil for patients who prefer an oral mode of therapy. However, efficacy data for oral minoxidil are more limited.
-Patients who prefer oral 5-alpha reductase inhibitor therapy – For adults with MPHL who desire oral 5-alpha reductase inhibitor therapy, we suggest initial treatment with oral finasteride and topical minoxidil 5% solution or foam rather than either agent alone (Grade 2C). Oral 5-alpha reductase inhibitors may be more effective than topical minoxidil, and combination therapy may be more effective than treatment with either agent alone.
In our experience, patients who prefer treatment with an oral 5-alpha reductase inhibitor place a high value on demonstrated efficacy from clinical trials, are comfortable with (or prefer) use of an oral agent for long-term therapy, and are tolerant of the risk for potential adverse effects with this therapy.
•Insufficient response to initial treatment – For adults with an insufficient response to oral finasteride or topical minoxidil, we suggest low-dose oral minoxidil for next-line treatment rather than other therapies (Grade 2C). For patients with a history of a poor response to oral finasteride, switching to oral dutasteride is a reasonable alternative. Oral dutasteride may be more effective than oral finasteride for MPHL.
Additional options include incorporating other therapies, such as photobiomodulation, PRP, or topical finasteride.
•Unsatisfactory response to nonsurgical treatment – Hair transplantation is an option for patients who cannot achieve satisfactory results with nonsurgical treatment. The ideal candidates are patients with stable or medically controlled MPHL who desire permanent improvement in hair loss and have an adequate reservoir of hair for transplantation. Candidates for hair transplantation should be carefully assessed and fully informed of expected outcomes and the need to continue medical therapy to maintain optimal results. (See 'Hair transplantation' above.)
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
