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January 20th, 2009:

How is Androgenetic Areata (AGA) treated?

Only 2 proven, food and drug administration (FDA) approved medications are currently available for treatment of androgenetic alopecia: minoxidil and finasteride.

  • Minoxidil (5%): Rogaine: Topical minoxidil solution promotes hair growth in several conditions in which the hair follicle is small and not growing to its full potential. Minoxidil is FDA-approved for treating male and female pattern hair loss. It may also be useful in promoting hair growth in alopecia areata. The solution, applied twice daily, has been shown to promote hair growth in both adults and children, and may be used on the scalp, brow, and beard areas. With regular and proper use of the solution, new hair growth appears in about 12 weeks.

    Although the method of action is essentially unknown, minoxidil appears to lengthen the duration of the anagen phase, and it may increase the blood supply to the follicle. Regrowth is more pronounced at the vertex than in the frontal areas and is not noted for at least 4 months. Continuing topical treatment with the drug is necessary indefinitely because discontinuation of treatment produces a rapid reversion to the pretreatment balding pattern.

    Patients who respond best to this drug are those who have a recent onset of androgenetic alopecia and small areas of hair loss. The drug is marketed as a 2% or a 5% solution, with the 5% solution being somewhat more effective. A recent 48-week study compared the 2 strengths in men. Findings indicated that 45% more regrowth occurred with the 5% compared with the 2% solution. In general, women respond better to topical minoxidil than men. The increase in effectiveness of the 5% solution was not evident for women in the FDA-controlled studies. Subsequent studies have shown at best a modest advantage to the higher concentration in women. In addition, the occurrence of facial hair growth appears to be increased with the use of the higher-concentration formulation.

  • Finasteride: Propecia: Finasteride is given orally and is a 5 alpha-reductase type 2 inhibitor. It is not an antiandrogen. The drug can be used only in men because it can produce ambiguous genitalia in a developing male fetus. Finasteride has been shown to diminish the progression of androgenetic alopecia in males who are treated, and, in many patients, it has stimulated new regrowth.

    Although it affects vertex balding more than frontal hair loss, the medication has been shown to increase regrowth in the frontal area as well. Finasteride must be continued indefinitely because discontinuation results in gradual progression of the disorder. A study in postmenopausal women indicated no beneficial effect of the medication in treating female androgenetic alopecia.

  • Exogenous Estrogen: In the past, exogenous estrogen was used to treat androgenetic alopecia. This treatment is used less often now, because minoxidil is more effective. In fertile women with androgenetic alopecia who request oral contraception, it is important to select a pill containing the least androgenic progestin, such as norgestimate (in Ortho-Cyclen, Ortho Tri-Cyclen), norethindrone (in Ovcon 35), desogestrel (in Mircette), or ethynodiol diacetate (in Demulen, Zovia).
  • Hair Transplantation: Hair transplants involve removing healthy hair follicles from one area of the scalp and transplanting them to the bald areas. Surgical treatment of androgenetic alopecia has been successfully performed for the past 4 decades. Although the cosmetic results are often satisfactory, the main problem is covering the bald area with donor plugs (or follicles) sufficient in number to be effective. Micrografting produces a more natural appearance than the old technique of transplanting plugs. Patients with less than 40 follicular units/cm2 in their donor areas are poor candidates for the procedure. Scalp reduction has been attempted to decrease the size of the scalp to be covered by transplanted hair. However, the scars produced by the reduction technique often spread and become more noticeable with time.

    Hair weaving techniques are available, and, together with hairpieces, they offer the patient a prosthetic method of coverage.

  • Spironolactone: Aldactone: This drug is a weak competitive inhibitor of androgen binding to androgen receptors. It also decreases the synthesis of testosterone. For these reasons, orally administered spironolactone has been tried in the treatment of androgenetic alopecia, although questions remain about its usefulness. Spironolactone can be beneficial in women who also have hirsuitism. However, the FDA has not labeled this drug for the treatment of androgenetic alopecia.

Who is most likely to get AGA?

Men and women should look at both sides of their family tree for relatives with hereditary hair loss. The condition can be inherited from their mother, their father, or from both parents.

In the United States, 30 million women—or one in four—experience hereditary hair loss. Less frequent causes for hair loss in women include stress, illness, medication, diet, and pregnancy. But 70 percent of women with thinning hair can attribute it to hereditary hair loss.

Race neither increases nor decreases a person’s likelihood of experiencing hereditary hair loss. Hereditary hair loss affects all ethnicities.