Evidence-based guideline for the treatment of Androgenetic Alopecia in women and in men

Dr. Daniel Fernandes Melo

Dermatologist, Professor of Trichology at Federal University of Rio de Janeiro (UERJ), Brazil

Commentary

This is a valuable study regarding male and female androgenetic alopecia. The present paper brings strong information about treatment options for this prevalent disease that causes significant impairment in quality of life. This guideline provides dermatology an evidence-based tool regarding efficacy and safety therapy for patients presenting with androgenetic alopecia.

Methodology

The methodology involved a systematic search of literature of the most important databases from 2008 to 2015. After careful evaluation, the authors selected 47 articles to include as reference in the final guideline version. All the studies were classified by the grade of evidence in A1 - Meta-analysis which includes at least one randomized clinical trial of grade A2 evidence with consistent results of the different studies; A2 - Randomized, double-blind, comparative clinical studies of high-quality; B - Randomized, clinical studies of lesser quality or other comparable studies; C - Non-comparable studies and D – Expert opinion. Also, particular therapeutic regimen was summarized in a level of evidence. And finally, the consented therapeutic recommendations were graded by the strength of recommendation, using a 6-point specific scale. (recommended, suggested, can be considered, not suggested, not recommended, it is not possible to make a recommendation for or against treatment at the present time).

Discussion

• Minoxidil

  Regarding topical minoxidil in men, the article recommends topical solution 2 to 5% 1mL or half a cap of 5% foam twice daily for adults. The authors suggest that 5% topical minoxidil can provide greater efficacy but they cannot make a recommendation for the 5% minoxidil foam instead of the 5% solution at the present time. The response to treatment should be assessed at 6 months and a maintenance is recommended, alone or in combination with 1mg oral finasteride.

  In adult women presenting with female pattern hair loss, the article recommends topical minoxidil 2% solution 1 mL twice daily or half a cap of 5%, minoxidil topical foam once daily. To date, they cannot recommend 5% foam instead of 2% topical solution. As well as it occurs in men, the therapy must be continued, and first clinical results can be observed after 6-month therapy.

• Finasteride

  When the topic is oral finasteride, the present guideline recommends 1 mg/day in men to improve or to prevent progression of AGA in patients above 18 years. Oral finasteride 1 mg daily is not suggested in the treatment of postmenopausal women with female pattern hair loss. Currently, for female patients, they cannot make a recommendation for or against treatment with oral finasteride 5 mg/day. The authors are able to see clinical results after 6 months an suggest maintenance of therapy for better results

  Topical finasteride, serenoa repens, and curcuma aeruginosa have controversial results in the selected studies. Therefore, it is not possible to make any recommendation for or against this kind of treatments at the present time.

• Dutasteride

  Oral dutasteride 0.5mg/day can be an option in non-responsive cases of oral 1mg finasteride for male AGA. They consider it ineffective when there is no response after one year of using oral finasteride.

• Hormonal therapy

  Oral estrogens or androgen receptor-antagonists to improve or prevent progression of AGA are not recommended in male patients, including topical fluridil and topical fulvestrant. The last one should also not be used in female patients with AGA.

  Although widely used to improve or stop progression of AGA in women, chlormadinone acetate, cyproterone acetate, drospirenone, and spironolactone cannot be officially recommended. These drugs may be considered in women with clinical or biochemical evidence of hyperandrogenism.

  The present study cannot make a recommendation for the use of topical alfatradiol, fluridil, topical natural, estrogens or progesterones to improve or prevent progression of AGA in female patients at the present time.

• Surgery

  For both male and female patients, follicular unit transplantation (FUT) can be considered in male patients with sufficient donor hair. For men, the combination with oral finasteride 1 mg daily may provide a better clinical outcome.

• Platelet rich plasma

  The article reinforces that there is no standardized technique for performing PRP to permit objective evaluation of its effects on AGA. Therefore, it is not possible to make a recommendation for or against treatment of AGA with platelet-rich plasma at the present time in both genders.

• Low level laser therapy (LLLT)

  The authors suggest using LLLT as ancillary therapy for AGA with devices that use energy levels shown to be effective in randomized controlled clinical trials. They reaffirm they cannot make a recommendation for or against treatment for more than 6 months with LLLT for AGA at the present time, as there is no evidence evaluating long-term safety regarding this therapy.

Conclusion

This is a summary of a relevant paper that brings valuable information regarding the most important evidences in the treatment of male and female androgenetic alopecia. The authors have extensively revised the literature and organized the evidence levels of the main types of therapies for this prevalent disease.