Expert Consensus Offers Guidance for Treating Androgenetic Alopecia

The current consensus reflects the available data and expert opinions of professionals in the alopecia field when considering management and routine clinical practice.| Image Credit: Nadzeya- stock.adobe.com

A consensus document from the Spanish Hair Disorders Society of the Spanish Academy of Dermatology and Venerology, published in Actas Dermo-Sifiliográficas, utilized expert data to guide professionals into the routine of management of androgenetic alopecia (AGA).¹

The most common cause of hair loss among men and women is AGA, which affects nearly 50% of Caucasian men aged 50 years old and 50% of Caucasian women around 60 years old. Individuals of Asian or Black ethnicity have a lower prevalence of AGA.

Currently, topical minoxidil and both oral and topical finasteride are the only 2 approved treatments for patients with AGA. Various techniques have been developed, such as mesotherapy with platelet-rich plasma (PRP) or low-level laser therapy. Mesotherapy nourishes the hair follicles and improves blood circulation in the scalp by directly attacking the targeted area.² This method can improve skin texture, firmness, and elasticity by injecting active substances into the mesoderm. Platelet-rich plasma is also an injection for patients with hair loss and has similar effects to mesotherapy, including wrinkle reduction, fine lines, uneven skin tone, and collagen-stimulation.

Research has shown positive outcomes in patients with alopecia treated with low-level light therapy, also known as photobiomodulation.³ This method uses a cascade of cellular responses to the absorption of nonablative red and near-infrared light energy.⁴

The purpose of the consensus is to offer recommendations on how to utilize the available treatment options for AGA management in a routine clinical practice setting.¹

Survey Methods and Results

Members of the Spanish Hair Disorders Group in the Spanish Academy of Dermatology and Venereology developed and designed the consensus document. The qualitative literature review consisted of 4 thematic blocks: generalities, medical treatment of AGA, procedures and hair transplantation, and special cases.

The review began in October 2022 and limited the included articles to English or Spanish publications from during or after 2012. Following the literature review, a questionnaire including 160 statements was created and sent to panelists, who answered online. A total of 34 Spanish dermatologists participated and voted in 2 rounds.

A total of 130 items were agreed upon in the first round, with 8 recommendations re-edited. Following the second round, 12 additional recommendations were agreed upon. Once the 2 rounds of the Delphi method ended, 138 of the 160 items were agreed upon (86%).

Panelists acknowledged the treatment and management of AGA can be complicated due to the limited number of approved treatment methods, the lack of clinical trials reflecting safety and efficacy profiles of therapies used in the routine clinical practice.

One of the most important factors for therapeutic success in AGA is to improve adherence to treatment by individualizing therapeutic strategies. Experts agreed the efficacy of a treatment method should be maintained for at least 6 months to 12 months. Physicians were advised to rule out the association of AGA with other types of alopecia and scalp diseases that may require targeted treatment methods along with underlying causes that could exacerbate alopecia for female AGA.

Medical Treatment of AGA

Medical recommendations for both male and female patients with AGA were created. First-line therapy for male AGA included 5-α-reductase inhibitors with a preference for 0.5 mg of oral dutasteride over 1 mg of oral finasteride. Experts agreed that low-dose oral minoxidil was more effective than the topical formulation in female AGA, and oral minoxidil was deemed the optimal first-line therapy for both men and women with AGA. More specifically, premenopausal women benefitted from the combination of topical or oral minoxidil plus a 5-α-reductase inhibitor or spironolactone. For postmenopausal women, the combination of topical or oral minoxidil with 5-α-reductase inhibitors was considered the most effective option.

Men with AGA were recommended topical finasteride or dutasteride and dutasteride in mesotherapy for second-line pharmacological therapies. Topical formulas of 5-α-reductase inhibitors, oral contraceptives, oral bicalutamide, dutasteride in mesotherapy, and PRP were suggested for women with AGA. An alternative treatment for women with AGA is oral cyproterone acetate, which should only be used after exhausting all other forms of treatment.

The panelists advised against pregnancy during treatment with 5-α-reductase inhibitors, bicalutamide, and other anti-androgens because of their potential teratogenicity.

Procedures in AGA Management

For the management of AGA, adjunctive therapies should be individualized based on each case. Concentrations of dutasteride 0.01% or 0.05% have been shown most effective in treatment studies, while there was no demonstration of efficacy when mesotherapy with biotin vitamins was used. Additionally, microneedling has been suggested with topical therapies like minoxidil to allow percutaneous penetration and efficacy. Overall, the botulinum toxin should be individualized dependent on the case, as well.

Hair Transplant as AGA Treatment

Patients with female AGA and male AGA may be offered hair transplantation in cases where the alopecia is stable and patients have enough hair follicles in the donor area. Oftentimes, hair transplants are considered the sole treatment for elderly patients with established alopecia.

The procedure involves harvested hair from a donor site then transplanted to the affected hair loss area.⁵ However, hair transplantation issues can arise when patients with tightly coiled hair, typically non-White individuals, experience curved follicle extraction and higher levels of hair follicle transection.

Professionals stray away from recommending hair transplants for younger patients or those that have not received treatment for their alopecia with clinical progression. Physicians should always identify the patient’s expectations and medical history, rule out any presence of body dysmorphic disorder, and mitigate unrealistic expectations.¹

Special Cases

In some instances, pediatric and adolescent patients should be assessed by a pediatric endocrinologist, even if there are no signs of early puberty. While there is little evidence on the safety and efficacy of adjuvant treatment like PRP therapy or low-level laser therapy, pediatric patients can be considered for this type of treatment.

Elderly patients and those with comorbidities should coordinate with a patient’s primary care physician or specialist. Prior medical history and usual treatment methods should be reviewed when prescribing systemic treatment for AGA. The safest therapeutic options for this patient population are 5-α-reductase inhibitors and topical therapies, including adjuvant procedures.

Patients who are pregnant are not advised pharmacological treatment, topical therapy, or mesotherapy with drugs because potential systemic absorption may occur. In some cases, low-level laser therapy may be considered if necessary. Only specific nutricosmetics that have been proved to be safe during pregnancy should be administered.

While most treatment options for AGA are safe and adverse events are rare, there are drugs that should be monitored during prescription through lab tests, the participants noted.

Treating AGA varies based on the individual patients and their characteristics is important, and further studies are necessary to fill a gap in scientific research validating the safety and efficacy profile of certain methods. The current consensus on routine management of AGA in clinic reflects the available data and expert opinions of professionals in the alopecia field.

References

1. S Vañó Galván, P Fernandez Crehuet, G Garnacho, et al. Recomendaciones sobre el manejo clínico de la alopecia androgénica: un documento de consenso del Grupo Español de Tricología de la Academia Española de Dermatología y Venereología. Actas Dermosifiliogr. 2024;115(4)1-9. doi:10.1016/j.ad.2023.10.043

2. Mesotherapy vs PRP (platelet rich plasma) for hair loss. Hortman Clinics. September 24, 2023. Accessed July 11, 2024. https://www.hortmanclinics.com/?p=4897#:~:text=Mesotherapy%20is%20an%20aesthetic%20treatment

3. Santoro C. Lasers offer new options for hair loss treatment in alopecia management. The American Journal of Managed Care®. June 29, 2024. Accessed July 11, 2024. https://www.ajmc.com/view/lasers-offer-new-options-for-hair-loss-treatment-in-alopecia-management

4. Santoro C. Light therapy clothing shows potential for mild psoriasis, PMLE, AA treatment. AJMC®. March 29, 2024. Accessed July 11, 2024. https://www.ajmc.com/view/light-therapy-clothing-shows-potential-for-mild-psoriasis-pmle-aa-treatment

5. Santoro C. Evaluating hair camouflage as a tool for Black women with alopecia: A critical review. AJMC®. January 18, 2024. Accessed July 11, 2024. https://www.ajmc.com/view/evaluating-hair-camouflage-as-a-tool-for-black-women-with-alopecia-a-critical-review