Baldness i.e. Androgenic alopecia (AGA) is a common form of hair loss which can occur in both men and women. In men, this condition is also known as male-pattern baldness and in women, this condition is known as female-pattern baldness. Here, we take a look at the various scientifically proven AGA/baldness treatments available.
Baldness Treatment
Currently, only 2 medicines have US Food and Drug Administration (FDA) approval for the treatment of androgenic alopecia:
Minoxidil: This medicine appears to lengthen the duration of the anagen phase (the active growth phase of hair follicles), and it may increase the blood supply to the follicles. Regrowth is better at the top of the head than in the front areas and is not noted for at least 3-4 months. It is usually used as a 2% solution for women or a 5% solution for men which is to be rubbed into the scalp. However, if the treatment is stopped, the baldness returns. It works better in patients who have just started having AGA and who have small areas of hair loss.
Finasteride: It is used in men and is better for balding at the top of the head. Again, if the treatment is stopped the baldness returns. It cannot be used in women who are still able to have children because it can result in defects in babies. The doses are about 1 mg daily by mouth.
Every patient is unique and only the doctor can evaluate and determine the best baldness treatment. Some drugs that are not approved by the FDA but may be helpful in certain situations are:
- Spironalactone: In women with AGA.
- Oral contraceptives: In women.
- Dutasteride: Similar and more potent than finasteride.
- Latanoprost: This solution is currently used to treat glaucoma and using it results in an increase of eyelashes. Some studies have shown that this medication could be useful for stimulating hair follicle activity and baldness treatment.
- Follistatin: It is a human cell-derived medication which is being studied.
- Low-level laser light therapy: A red light hairbrush–like device has been used by some doctors with good results but more studies are required.
- Surgical treatment: This gives good cosmetic results in AGA. The main problem is covering the bald area with donor plugs (or follicles) in a sufficient number to be effective. Micrografting produces a more natural appearance than the old technique of transplanting plugs.
5AR Inhibitors
Finasteride is a 5 Alpha Reductase Inhibitor (5AR) that is approved by the FDA for AGA. The drug works by inhibiting the conversion of testosterone to a hormone known as dihydrotestosterone (DHT) by blocking type II 5AR. Dosing, side effects, and counselling points are given in the table below.
Some studies have been conducted comparing finasteride topical solution with oral finasteride 1 mg. The studies were small, but they found a similar improvement in hair growth with fewer side effects compared with the oral therapy group.
Dutasteride is also used off-label for the treatment of AGA and is an inhibitor of both type I and type II 5AR. In addition, dutasteride is a more potent inhibitor of both of these isoenzymes compared with finasteride. In several studies, Dutasteride 0.5 mg was found to be superior to finasteride 1 mg at the end of 3 and 6 months in increasing hair count and hair width.
Minoxidil
Minoxidil was the first drug approved by the FDA for the treatment of AGA topically. It is available in various formulations but the commonly used ones are 2% and 5% solution. There are several mechanisms by which minoxidil may promote hair growth; however, the exact mechanism of action is unclear. In addition, topical minoxidil may oppose calcium entry into the cells, which may increase epidermal growth factors to allow hair growth. In approximately 50% of men, hair loss is stopped, and for some, there was hair regrowth. The drug must be continued even after desired results are achieved or hair growth will subside. Dosing, side effects, and counselling points are included in the table below.
| Drug | Dose | Side Effects | Key Points |
| Minoxidil (2%) | 1 ml once or twice daily | Redness, Itching | Hair colour or texture may change. Must continue it for sustained results. Usually, 2% is preferred in women. |
| Minoxidil (5%) | 1 ml twice daily | Redness, Itching, Change in hair texture, Headache | Hair colour or texture may change. Must continue it for sustained results. Usually, 5% is preferred in men for baldness treatment. |
| Finasteride | 1 mg daily | Orthostatic hypotension (9%), dizziness (7%), erectile dysfunction (5%-19%), ejaculatory dysfunction (1%-7%), decreased libido (2%-10%) | May take 3 months or longer to see the benefits. Must continue product to maintain results. Side effects may decrease over time. Pregnant females or those of childbearing age should avoid it. |
| Dutasteride | 0.5 mg daily | Decreased libido (<3%), Gynecomastia (<1%) Other side effects as finasteride. | Same as Finasteride. But it is more potent for baldness treatment. |
Ketoconazole, Spironolactone, and Prostaglandin F2 Analogues
Ketoconazole shampoo has been considered as an agent to aid in the treatment of AGA as combination therapy with oral finasteride. The mechanism is unclear; however, ketoconazole inhibits the DHT pathway, because of its antiandrogenic properties. In addition, it may reduce inflammation in the skin and help with baldness treatment.
Spironolactone is a potassium-sparing diuretic that has antiandrogenic properties; it blocks androgen receptors and decreases testosterone levels. Most of the clinical data using 50 to 200 mg/day of spironolactone have been in women with Female Pattern Hair Loss. It is especially effective if the woman with PCOS.
Prostaglandin F2 analogue latanoprost has been used in patients to treat glaucoma and the patients experienced the side effect of elongation of eyelashes and eyebrows. Studies have been done on latanoprost 0.1% daily to evaluate scalp hair growth. The 24-week study resulted in a significant increase in hair density from baseline when compared with placebo. Additional studies need to be conducted in a larger patient population for a longer period of time to determine the efficacy and safety of the therapy.
Low-level Laser Therapy
Low-level laser therapy has also been used for the treatment of AGA. It appears that these lasers can stimulate hair growth at certain wavelengths; however, the mechanism for this action has not been determined. There are several laser therapy devices, including a comb, a hood, and a helmet that fits on the head. More information is needed to determine the effectiveness as a baldness treatment.
Microneedling
Microneedling (with dermaroller or dermapen) has gained popularity and has been found to be beneficial in stimulating hair regrowth in alopecia. In micro-needling, multiple fine needles are used to create tiny punctures in the skin that stimulate the formation of new blood vessels, release growth factors, and promote the expression of certain proteins. Hair growth is a result of the release of certain growth factors and activation of the hair bulge, and Wnt proteins have been found to stimulate dermal papillae stem cells, leading to hair growth. Microneedling is generally used in conjunction with topical therapy such as minoxidil and it has been used with PRP.
Hair Transplantation
Hair transplantation is a commonly used treatment option for AGA. In hair transplantation, hair follicles are taken from areas of the scalp that are resistant to androgen and transplanted into areas that are androgen-dependent. Results are generally evident within 6 to 8 months after the transplant, and the use of pharmacologic agents such as minoxidil may be required to prevent progression of the condition.
Emerging Therapies
Several new therapies are emerging or being studied as treatment options for AGA, including PRP injections and JAK inhibitors.
Injecting autologous PRP into the scalp is a new therapy for the treatment of AGA. The platelets are gathered through a blood draw and then separated, concentrated, and prepared through several methods utilizing commercially available kits. Platelets release growth factors that are involved in the stimulation of endothelial and stem cells. Usually, it involves monthly sittings and may require 3-4 sittings to see the results. After 6-8 monthly sittings, patients can go for maintenance sittings every 6-12 months.
JAK inhibitors are under investigation as new drugs to treat alopecia areata; however, there is limited information about their use in AGA.
Conclusion
Over the past 30 years, there has been very little advancement in the treatment of AGA. As skin specialists consider options for treating this condition, pharmacologic products such as finasteride, minoxidil, and dutasteride, which have been widely studied and have provided positive outcomes, are available and should be considered as first-line therapies. In addition, PRP and microneedling are less common options that provide promising outcomes.
Healthcare providers should discuss options with patients and prescribe therapy based on actual outcomes in conjunction with patient preference while taking into consideration dosing schedules and cost.
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