Treatment of androgenetic alopecia in men

Treatment options in male androgenetic alopecia include:

• wait and see method - some patients prefer not to do anything and accept the cosmetic outcome (1)
• pharmacotherapy - topical or systemic drugs
  
  
  • topical solution - minoxidil 2% or 5% solution
  • mechanism of action is unknown
    • is thought to increase the duration of anagen phase
    • noticeable hair growth is seen 4 months after initiation of therapy
    • 5% solution is shown to be more effective than the 2% solution
    • discontinuation of treatment for a few months results shedding of hair slowly
    • transient and self-limiting telogen effluvium may be seen 3 to 5 weeks after initiation of therapy and patients should be advised to continue therapy despite the effect (1)
      
      
  • finasteride
    • selectively inhibits type 2 5 alpha - reductase isoenzyme (responsible for the conversion of testosterone (T) to dihydrotestosterone (DHT))
    • FDA-approved daily oral dose of 1 mg for the treatment of male pattern baldness has been demonstrated to reduce concentrations of DHT in scalp significantly, where type II 5alpha-reductase is also the predominantly (but not exclusively) expressed isozyme
      • in many, but not all, men, hair loss is halted by finasteride treatment and in some men, there is noticeable hair regrowth within two years of treatment uptake
      • 1 mg daily oral treatment is well tolerated by patients, with rare side effects that may include some loss of libido and erectile function
      • as for minoxidil, cessation of treatment recommences the balding process, indicating that the effects of finasteride are not curative
    • improves the terminal-to-vellus hair ratio in a scalp by inhibiting or reversing miniaturization of hair follicle
    • after discontinuation of therapy the hair loss progresses, therefore should be taken long term on daily basis (1)
    • rare reversible adverse reactions include - erectile dysfunction, loss of libido, a small volume of ejaculate or gynecomastia (2)
  • dutasteride
    • a dual 5alpha-reductase, has been used for the treatment of male androgenetic alopecia
      • evidence shows that dutasteride seems to provide a better efficacy compared with finasteride in treating androgenetic alopecia. The two drugs appear to show similar rates of adverse reactions, especially in sexual dysfunction (3)
        
        
  • hair transplant
    
    
  • cosmetic aids
    • wigs and hairpieces

Note:

• neither minoxidil nor finasteride restores all the lost hair or reverse total baldness (1)
• analysis of 23 trials indicate 5mg/d oral dutasteride has highest probability of being most efficacious treatment, followed by (in decreasing order of efficacy): 5mg/d oral finasteride (OF), 5mg/d oral minoxidil (OM), 1mg/d OF, 5% topical minoxidil (TM), 2% TM, & 0.25mg/d OM (4)

Reference:

1. Stough D et al. Psychological effect, pathophysiology, and management of androgenetic alopecia in men. Mayo Clin Proc. 2005;80(10):1316-22
2. Lee S, Lee YB, Choe SJ, et al. Adverse Sexual Effects of Treatment with Finasteride or Dutasteride for Male Androgenetic Alopecia: A Systematic Review and Meta-analysis. Acta Derm Venereol. 2019 Jan 1;99(1):12-17.
3. Zhou Z, Song S, Gao Z, Wu J, Ma J, Cui Y. The efficacy and safety of dutasteride compared with finasteride in treating men with androgenetic alopecia: a systematic review and meta-analysis. Clin Interv Aging. 2019;14:399-406. Published 2019 Feb 20. doi:10.2147/CIA.S192435
4. Gupta AK, Venkataraman M, Talukder M, Bamimore MA. Relative Efficacy of Minoxidil and the 5-alpha Reductase Inhibitors in Androgenetic Alopecia Treatment of Male Patients: A Network Meta-analysis. JAMA Dermatol. Published online February 02, 2022. doi:10.1001/jamadermatol.2021.5743