Treatment of pattern hair loss (androgenetic alopecia)

What it is

It is diagnosed by the pattern and by trichoscopy, and treated medically over a long period — topical or low-dose oral minoxidil is the backbone, and the rest of the plan is decided by the examination, the blood work, and whether a woman is pregnant or breastfeeding. Scalp injections and low-level laser caps sit alongside that medical treatment rather than in place of it.

What this page covers

• Female pattern hair loss and widening of the part
• Male pattern hair loss and a receding frontal hairline
• Topical minoxidil and low-dose oral minoxidil
• Screening for coexisting telogen effluvium, iron deficiency and PCOS
• Low-level laser caps, helmets and combs as an adjunct
• Scalp PRP, mesotherapy and polynucleotide injections within the plan
• Hair transplant candidacy, donor area assessment and the question of timing

Who it suits

• Someone whose thinning came on gradually and follows the pattern — a part that has widened, or a front and crown that have receded — rather than a sudden heavy shed that began after an illness, a delivery, rapid weight loss or a weight-loss injection.
• Someone coming early, while there is still hair to hold on to. This treatment holds what is there far more than it brings back what has gone, and that is truer the earlier it starts.
• Someone who can accept a long treatment with review appointments and blood work, and with blood pressure and pulse checks if a tablet is part of the plan. Those checks are the treatment, not an extra on top of it. And long means long: stopping usually brings the shedding back and takes with it what was held on to, so this is a decision to keep going rather than a course to finish.
• Someone willing to be told the shedding has more than one cause. Pattern loss often overlaps with iron deficiency, a thyroid problem, polycystic ovary syndrome or a shed that followed weight-loss surgery, and treating only one of them leaves the complaint standing exactly where it was.
• Not you if what you want is the density of your twenties by a date — a wedding, a trip, a photograph. We would rather say so before anything is prescribed than after months of it.

When we advise delaying or not treating

• Pregnancy and breastfeeding. Minoxidil is not used in either, as a topical or as a tablet. If you are planning a pregnancy, say so at the first visit — it changes what is prescribed, and a review appointment is a late place to learn it.
• Heart disease that is not stable, heart failure, or fluid already collecting in the ankles or the chest. The oral form is not started there. Blood pressure and pulse are measured before it is considered — a blood pressure that runs low, or a history of fainting, weighs against it, and anything you already take for the heart or for blood pressure changes the picture, so tell us what those are.
• A woman who could become pregnant. Finasteride and dutasteride are not given to her at all — reliable contraception does not open that door. Spironolactone is the different case: it can be considered, and then only with reliable contraception in place, because of the risk to a male fetus. Read the possible effects below either way — they are set out here whether or not a tablet turns out to be part of your plan.
• Shedding that has not been worked up: iron and ferritin, thyroid, vitamin D, with protein, zinc and B12 added after weight-loss surgery or a weight-loss injection. No spray compensates for a deficiency nobody has looked for.
• A scalp that is inflamed, scaling or sore, or where the follicular openings have gone. That is a different diagnosis; trichoscopy is what separates it from pattern loss, and where trichoscopy cannot settle it a scalp biopsy does. Either way it is done before treatment is chosen rather than after.
• Hairline laser hair removal, hairline shaping or forehead reduction, or a hair transplant — over any hairline that is receding, whether or not the follicular openings still look present to you. Early scarring alopecia can leave them looking intact, so the decline stands until the scalp has been examined and a scarring alopecia excluded; in that condition specifically these procedures speed up the very loss you came about.
• A request to be handed the tablets by name, with no examination and no blood work, because a relative recommended them or a video did. We decline that, and would rather explain why than write the prescription.
• A request for scalp injections or a laser cap in place of medical treatment. These sit alongside a plan; on their own they are months passing without one.

Possible effects

These are stated in full, because a decision to begin a long medical treatment is not a sound one without them. Most of what follows is manageable and much of it eases on stopping — but none of it should reach you as a surprise months in.

• More shedding in the first weeks, with minoxidil as a topical or as a tablet. It is expected, it is not the treatment failing, and it is a common reason people stop just before the treatment begins to show. Tell us rather than stopping.
• Scalp irritation from the topical — itch, redness, flaking, sometimes a rash. The alcohol-based solution irritates more than the foam. Hair can also grow where the liquid runs, along the sides of the face and on the forehead.
• Facial and body hair on the oral form. This is not a footnote: it is a common reason a woman stops the tablet, it shows on the cheeks, the upper lip and the forearms, and it is something to agree to before the first tablet rather than to discover afterward. It eases after stopping, slowly.
• Fluid retention. Ankles that puff by the evening, a ring or a shoe that tightens, weight up over days. Report it — it is a reason to review the plan, not to push on through.
• Lightheadedness on standing, and palpitations. A fast or thumping heartbeat, or feeling close to fainting when you get up. Minoxidil in tablet form is a blood pressure medicine, used here at a low dose for hair, and these are its effects on the circulation showing through — which is why blood pressure and pulse are checked before starting and during treatment, and why any other doctor, dentist or surgeon who asks what you take should be told about it.
• Harm to an unborn child — the antiandrogen tablets. Finasteride and dutasteride block an enzyme a male fetus needs for its genitals to form normally, so they are not given to a woman who could become pregnant, and she should not handle a broken or crushed tablet, because the drug can be absorbed through the skin. A man taking either does not donate blood, and tells the blood bank he takes one, because that blood could reach a pregnant woman. Spironolactone carries its own concern for a male fetus, which is why reliable contraception is a condition of taking it rather than a suggestion.
• Finasteride and dutasteride in men — the possible effects on sexual function are reduced desire, difficulty with erections and a smaller volume of semen, and they are gone through and written down before a prescription rather than after it. Mood belongs on that same list: depressive symptoms, and thoughts of self-harm, appear in the safety warnings for these medicines, so if mood drops after starting, stop the tablet and be seen rather than pushing on. They also lower the PSA blood test, so any doctor who orders a PSA — not only a urologist — must be told the man is taking one, because a reading that looks reassuring may not be.
• Spironolactone raises potassium in the blood, so potassium and blood pressure are monitored, and more closely with kidney disease. Tell us everything else you take, because common things push potassium the same way — blood pressure tablets of the ACE inhibitor and ARB families, potassium supplements, anti-inflammatory painkillers, and the low-sodium salt substitutes sold as a healthier salt. Potassium high enough to matter shows as muscle weakness, or a heartbeat that feels slow or irregular; do not wait for the next appointment, that needs a potassium test the same day, and the nearest emergency department if it is the heartbeat itself that has changed. Irregular periods and breast tenderness are common reasons women stop it.
• Scalp injections and needling — soreness, bruising and small bleeding points, and in deeper skin tones a temporary darkening at the entry points.

The largest practical risk on this page is none of the above: it is time. Months spent on a spray, a cap and injections while a scarring alopecia goes unnamed, or while an iron or thyroid problem sits untreated underneath. That is why the examination and the blood work come first.

A note on darker skin

Pattern hair loss occurs at every skin tone, and nothing in the medical treatment for it depends on pigment. What changes is what the examination has to see: redness around the follicle is far less obvious in deeper skin tones, so the diagnosis rests instead on scale, loss of the follicular openings and a difference in hair caliber — which is why the scalp is read under magnification rather than by eye. Two conditions are named here in particular. Central centrifugal cicatricial alopecia, a scarring loss that begins at the crown and widens outward, is common in coarse, tightly curled hair and is repeatedly managed for years as ordinary thinning, so chemical relaxing, heat and tight braiding are asked about directly rather than skirted. And traction from a tightly fastened head covering and its pins, from heavy extensions and from a tight ponytail recovers with a change of styling if it is caught early, and scars the frontal margin if the pull continues, so the treatment there is a change in how the hair is secured, not a product. Where a procedure is added — scalp injections or needling, or a biopsy to settle a scarring diagnosis — deeper skin tones darken more readily at the entry points, and the biopsy site is chosen inside the hair with the risk of pigmentation or a keloid at that site discussed beforehand.

Afterwards

• Use the topical exactly as it was prescribed to you, on the scalp itself rather than on the hair, and let it dry before you cover your head or lie down.
• Expect more hair in the brush early on. Do not stop over it — tell us, so we look rather than guess.
• If a tablet is part of the plan, keep to the blood pressure and pulse checks and the blood tests that go with it. They are part of the plan, not an addition to it.
• Report, without waiting for the next appointment: swelling of the ankles or fingers, a shoe or a ring tightening, lightheadedness on standing, a racing heartbeat, new hair on the face, chest pain or breathlessness — and, on spironolactone, muscle weakness or a heartbeat that feels slow or irregular; and, on finasteride or dutasteride, a drop in mood.
• Photograph the same parting in the same light every few months, keep the photographs and bring them. Hair changes too slowly to be judged from memory, and memory is what makes people abandon a treatment that is working.
• Tell us before a pregnancy is planned and as soon as one is confirmed, and tell us about any medicine or supplement a relative, a pharmacy or a video has recommended to you.

Honestly

Started early, treatment holds on to what is there more than it brings back what has gone, and that is said before anything is prescribed. It is a long treatment: stopping usually means the shedding returns, an increase in shedding at the start is expected and is not a reason to stop, and oral minoxidil requires blood pressure and pulse to be checked and is not used in pregnancy, in breastfeeding or in unstable heart disease.

Common questions

See also

Alopecia areata, Scalp injections (PRP), Scalp conditions, Trichoscopy