REVIEWS

The effectiveness of treatments for

androgenetic alopecia: A systematic
review and meta-analysis
Areej Adil, BSc, and Marshall Godwin, MSc, MD
St. John’s, Newfoundland

Background: Androgenetic alopecia, or male pattern hair loss, is a hair loss disorder mediated by
dihydrotestosterone, the potent form of testosterone. Currently, minoxidil and finasteride are Food and
Drug Administration (FDA)eapproved, and HairMax LaserComb, which is FDA-cleared, are the only
treatments recognized by the FDA as treatments of androgenetic alopecia.

Objective: This systematic review and meta-analysis assesses the efficacy of nonsurgical treatments of
androgenetic alopecia in comparison to placebo for improving hair density, thickness, growth (defined by
an increased anagen:telogen ratio), or subjective global assessments done by patients and investigators.

Methods: A systematic review of randomized controlled trials was conducted. PubMed, Embase, and
Cochrane were searched up to December 2016, with no lower limit on the year. We included only
randomized controlled trials of good or fair quality based on the US Preventive Services Task Force quality
assessment process.

Results: A meta-analysis was conducted separately for 5 groups of studies that tested the following hair
loss treatments: low-level laser light therapy in men, 5% minoxidil in men, 2% minoxidil in men, 1 mg
finasteride in men, and 2% minoxidil in women. All treatments were superior to placebo (P \.00001) in the
5 meta-analyses. Other treatments were not included because the appropriate data were lacking.

Limitations: High heterogeneity in most studies.

Conclusions: This meta-analysis strongly suggests that minoxidil, finasteride, and low-level laser light
therapy are effective for promoting hair growth in men with androgenetic alopecia and that minoxidil is
effective in women with androgenetic alopecia. ( J Am Acad Dermatol 2017;77:136-41.)

Key words: alopecia; androgenetic alopecia; finasteride; laser light therapy; male pattern hair loss; meta-
analysis; minoxidil; systematic review.

A ndrogenetic alopecia, or male-pattern hair

loss, is a hair loss disorder mediated by
dihydrotestosterone, the potent form of
testosterone. Dihydrotestosterone induces miniatur-
Abbreviations used:
FDA:
LLLLT:
RCT:
Food and Drug Administration
low-level laser light therapy
randomized controlled trails
ization of hair follicles, causing transformation of
terminal hair into vellus hair.1 Without treatment,
patients undergo progressive hair loss.2 trends with some variation across different popula-
Androgenetic alopecia is common, and its incidence tions. Approximately 73% of men and 57% of women
increases with age. The prevalence shows similar over the age of 80 are affected by androgenetic

From the Memorial University of Newfoundland. Correspondence to: Marshall Godwin, MSc, MD, Room 424,
Funding sources: None. Janeway Hostel, Health Sciences Centre, 300 Prince Phillip Dr,
Conflicts of interest: None declared. St. John’s, Newfoundland A1B 3V6. E-mail: godwinm@[Link].
Accepted for publication February 23, 2017. Published online April 7, 2017.
Reprints not available from the authors. 0190-9622/$36.00
Ó 2017 by the American Academy of Dermatology, Inc.
[Link]

136
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VOLUME 77, NUMBER 1

alopecia, and 58% of men over the age of 50 are found in Cochrane, and 1 in Embase. We also
affected.3-5 Androgenetic alopecia can lead to nega- searched through the references of reviews written
tive psychological effects in both men and women. on androgenetic alopecia treatments and identified 1
These include self-conscious preoccupation, worries additional RCT through this method.
about aging, helplessness, and feelings of dimin-
ished attractiveness; these effects are more pro- Search strategy
nounced in women.6-8 The final search string was ‘‘alopecia’’
Currently, minoxidil and finasteride are the [Mesh:noexp] OR ‘‘androgenetic alopecia’’ OR
only Food and Drug ‘‘male pattern baldness’’
Administration (FDA)eap- AND randomized controlled
CAPSULE SUMMARY
proved drugs and low-level trial [ptyp]. No additional
laser light therapy (LLLLT) the Minoxidil, finasteride, and low-level laser
d
filters were used. This search
only FDA-cleared device for light therapy are Food and Drug resulted in 213 articles
the treatment of androgenetic Administrationeapproved/cleared (Fig 1). An additional article
alopecia. Studies have treatments for androgenetic alopecia. was found by searching
been conducted on these through article references
treatments, but, to our know- Before this meta-analysis, available
d

resulting in the final total of

ledge, a meta-analysis sum- studies showed conflicting results. By 214 articles. Using the titles
marizing the efficacy of these pooling the results of these studies in a and abstracts of these
treatments for androgenetic meta-analysis, we were able to increase 214 articles, we eliminated
alopecia has not been the power to show the real effect and studies unrelated to andro-
conducted. This systematic the confidence in the validity of that genetic alopecia, basic sci-
review and meta-analysis effect. ence research articles, pilot
aims to determine the efficacy Minoxidil, finasteride, and low-level laser
d
studies, commentaries, re-
of nonsurgical treatments of light therapy have been shown to be views, and studies that
androgenetic alopecia in effective treatments for male-pattern did not include a placebo
comparison with placebo for hair loss in a meta-analysis of treatment group. This strat-
improving hair density, thick- randomized controlled trials. egy narrowed down the list
ness, growth (defined by to 45 articles. The full text
increased anagen:telogen ra- of these articles was
tio), or subjective global as- reviewed to assess their eli-
sessments done by patients and investigators. gibility for inclusion.

METHODS Study selection and quality assessment

Eligibility criteria The 45 articles were reviewed by 2 authors. The
Only randomized controlled trials (RCTs) study- review assessed whether the eligibility criteria were
ing the effects of a nonsurgical treatment on patients met and whether the article met the quality criteria
with androgenetic alopecia were included in this used in the US Preventive Services Task Force for
study. Studies had to compare treatment with a labeling RCTs good or fair; articles labeled poor by this
placebo and be conducted in a double-blind fashion. method were excluded. This process excluded 22 of
Pilot studies were excluded. The primary outcome of the 45 articles leaving 23 articles available for inclusion
each study had to be change in hair density and had (Fig 1). One of these articles had 2 intervention arms
to provide an effect size such as mean and a mesure (minoxidil 5% and minoxidil 2%).
of variance (standard deviation, standard error, or
95% confidence interval). Also, studies had to be of RESULTS
fair or good quality according to the US preventive A cut off of at least 3 articles was set for conducting
services task force quality rating criteria. All studies a meta-analysis. A meta-analysis was conducted
included were published in English. separately for 5 groups of studies that tested the
following hair loss treatments: laser treatment in
Information sources men, 5% minoxidil in men, 2% minoxidil in
We searched the PubMed, Embase, and Cochrane men, 1 mg finasteride in men, and 2% minoxidil in
databases. The databases were searched from their women. Only a qualitative analysis (Supplementary
earliest dates until December 2016. We searched Table I; available at [Link] was
PubMed first and identified the majority of RCTs done for 4 studies testing 0.5 mg dutasteride in men
included in this study. Eight additional RCTs were because only 2 articles presented data with some
138 Adil and Godwin J AM ACAD DERMATOL
JULY 2017

Fig 1. Article identification, assessment, and selection.

measure of variance that could be used in a meta- populations did vary somewhat from study to
analysis. study, and there was variability in how the
Overall, all treatments were superior to placebo outcomes were assessed. We opted to use the
(P \ .00001) in the 5 meta-analyses (Fig 2, A-E ). random effects model, which is more conserva-
Most studies were conducted with male subjects. tive than the fixed effect model, because of this
We found sufficient data to assess 2% minoxidil clinical heterogeneity.
solution twice daily for women. Meta-analysis Because there were only a few studies for each
of these studies showed a mean difference of intervention, we used all of the studies to create a
112.41 hairs/cm2 in the 2% minoxidil group funnel plot looking for publication bias. Fig 3
compared with placebo treatment. The treatments suggests the possibility of a publication bias, which
that showed a mean difference in hair count listed might mean some negative studies have not been
from highest to lowest for men are finasteride 1 mg published.
daily (18.37 hairs/cm2), LLLLT (17.66 hairs/cm2), 5% No serious side effects were reported in any of the
minoxidil twice daily (14.94 hairs/cm2), and 2% studies. A small number of study participants re-
minoxidil twice daily (8.11 hairs/cm2). ported decreased libido with finasteride and dutas-
Heterogeneity was negligible (I2 = 0%) in all teride. Most studies were industry supported, which
groups except for finasteride versus placebo should be considered when interpreting the results.
(I2 = 91%; P \ .001). Although statistical hetero-
geneity was, for the most part, not an issue with DISCUSSION
these studies and the interventions were deliv- This meta-analysis strongly suggests that minox-
ered in a very consistent way across studies, the idil, finasteride, and LLLLT are effective for
J AM ACAD DERMATOL Adil and Godwin 139
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Fig 2. Forest plots assessing treatments for androgenetic alopecia in men and women. A, Plot
for 5% minoxidil vs placebo in men. B, Plot for 2% minoxidil vs placebo in men. C, Plot for
finasteride 1 mg vs placebo in men. D, Plot for low-level laser light therapy (LLLLT) vs placebo
in men. E, Plot for 2% minoxidil vs placebo in women.

promoting hair growth in men with androgenetic potential for publication bias. Studies that show
alopecia, and that minoxidil is effective in women significant results are more likely to be published.
with androgenetic alopecia. We used change in hair-density per cm2 from
The high level of homogeneity among most of baseline to follow-up as the outcome for this
the comparisons and the funnel plot suggest the meta-analysis. Many studies also used secondary
140 Adil and Godwin J AM ACAD DERMATOL
JULY 2017

11. Kim H, Choi JW, Kim JY, Shin JW, Lee SJ, Huh CH. Low-level
light therapy for androgenetic alopecia: a 24-week, random-
ized, double-blind, sham device-controlled multicenter trial.
Dermatol Surg. 2013;39(8):1177-1183.
12. Olsen EA, Whiting D, Bergfeld W, et al. A multicenter,
randomized, placebo-controlled, double-blind clinical trial of
a novel formulation of 5% minoxidil topical foam versus
placebo in the treatment of androgenetic alopecia in men. J
Am Acad Dermatol. 2007;57(5):767-774.
13. Berger RS, Fu JL, Smiles KA, et al. The effects of minoxidil, 1%
pyrithione zinc and a combination of both on hair density: a
randomized controlled trial. Br J Dermatol. 2003;149(2):354-362.
14. Olsen EA, Dunlap FE, Funicella T, et al. A randomized clinical
trial of 5% topical minoxidil versus 2% topical minoxidil and
placebo in the treatment of androgenetic alopecia in men. J
Am Acad Dermatol. 2002;47(3):377-385.
Fig 3. Funnel plot for all the included studies in this meta-
15. Lucky AW, Piacquadio DJ, Ditre CM, et al. A randomized,
analysis assessing treatments for androgenetic alopecia. placebo-controlled trial of 5% and 2% topical minoxidil
solutions in the treatment of female pattern hair loss. J Am
measures, such as patient satisfaction or investigator Acad Dermatol. 2004;50(4):541-553.
rating using photos at various time points. While 16. DeVillez RL, Jacobs JP, Szpunar CA, Warner ML. Androgenetic
alopecia in the female. Treatment with 2% topical minoxidil
these could be considered softer outcomes they
solution. Arch Dermatol. 1994;130(3):303-307.
might, in fact, be a truer reflection of the clinical 17. Jacobs JP, Szpunar CA, Warner ML. Use of topical minoxidil
significance of these results. Hair loss is a disorder therapy for androgenetic alopecia in women. Int J Dermatol.
that often affects the self-esteem of an individual; 1993;32(10):758-762.
visibly significant results are required to help patients 18. Whiting DA, Jacobson C. Treatment of female androgenetic
alopecia with minoxidil 2%. Int J Dermatol. 1992;31(11):
in that regard.
800-804.
19. Olsen EA. Topical minoxidil in the treatment of androgenetic
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568-575. Measuring reversal of hair miniaturization in androgenetic
8. Ludwig E. Classification of the types of androgenetic alopecia alopecia by follicular counts in horizontal sections of serial
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hair loss: results of a randomized placebo-controlled study of Annual Meeting March 3-7, 2006. J Am Acad Dermatol. 2006;
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Supplementary Table I. Details of studies included in the review

141.e1 Adil and Godwin

Results, mean difference
hair density/cm2 (SD)*
Follow-up, between baseline and
Article Sex Study population details Intervention group Control weeks follow-up
Leavitt et al 20099 Men Mean age: 47.9 years LLLLT (Hairmax Laser Sham device 26 Hairmax: 17.3 (12.1)
Exclusion: use of medications 6 months Comb) N = 39 Placebo: 2.1 (18.1)
before study that could affect hair 655 nm
growth, hair transplantation, scalp N = 71
reduction, current hair weave, or
tattooing of the alopecic area
Race: 90% white
AGA type: NH type IIa-V
Lanzafame et al 201310 Men Mean age: 18-48 years LLLLT Placebo 16 LLLLT: 17.7 (25.7)
Exclusion: N/S 655 nm N = 19 Placebo: 0.06 (23.3)
Race: N/S N = 22
AGA type: NH type IIa-V
Kim et al 201311 Men Mean age: 44.2 years LLLLT Placebo 24 LLLLT: 16.6 (9.3)
Exclusion: use of medications affecting hair 630 nm, 650 nm, and N=6 Placebo: 2.1 (7.4)
growth within the past 6 months, hair 660 nm
disorders other than AGA, and systemic N=9
diseases that might affect results
Country: Korean
AGA type: NH type III-VII
Olsen et al 200712 Men Mean age: 39.2 years Minoxidil 5% topical Placebo 16 Minoxidil 5%: 20.9 (22.5)
Exclusion: use of medications that may foam applied twice N = 172 Placebo: 4.7 (19.7)
affect hair growth within past 6 months, daily
chemotherapy within the past year, N = 180
uncontrolled hypertension, scalp
conditions other than AGA, hair
transplants, scalp reduction, or hair
weaves
Race: 86.6% white
AGA type: NH type III-V
Berger et al 200313 Men Mean age: 40 years Minoxidil 5% topical Placebo 26 Minoxidil 5%: 12.32

J AM ACAD DERMATOL
Exclusion: other skin diseases of the scalp, solution (1 mL) shampoo (SEM = 2.05)
hair loss disorders other than AGA, used applied twice daily N = 50 Placebo: 0.58 (SEM = 2.05)
products known to influence hair growth plus placebo
in the past 6 months shampoo
Race: 97% white N = 50

JULY 2017
AGA type: NH type III or IV
Continued
Supplementary Table I. Cont’d

VOLUME 77, NUMBER 1

J AM ACAD DERMATOL
Results, mean difference
hair density/cm2 (SD)*
Follow-up, between baseline and
Article Sex Study population details Intervention group Control weeks follow-up
Olsen et al 2002a14 Men Mean age: 36.5 years Minoxidil 5% applied Placebo 48 Minoxidil 5%: 18.6 (25.4)
Exclusion: systemic illness, hypersensitive to twice daily N = 71 Placebo: 3.9 (21.7)
minoxidil, concomitantly use of hair N = 139
restorers or systemic drugs
Race: 79% white, 17% Hispanic
AGA type: 3-6 on Savin Scale
Lucky et al 200415 Women Mean age: 37 years Minoxidil 2% topical Placebo 48 Minoxidil 2%: 20.7 (17.6)
Inclusion: Female-pattern hair loss, hair (1 mL) applied twice N = 51 Placebo: 9.4 (14.6)
density rating of 4-7 on the Savin Female daily
Density Scale N = 108
Exclusion: systemic illnesses, pregnant or
breast feeding, hypersensitive to
minoxidil, use of hair restorers or systemic
drugs
Race: 74% white
AGA type: 97% had Ludwig grade I or II hair
loss.
DeVillez et al 199416 Women Mean age: 34 years Minoxidil 2% topical Placebo 32 Minoxidil 2%: 22.7 (69)
Exclusion: previously use of topical (1 mL) applied twice N = 128 Placebo: 10.1 (55)
minoxidil, pregnant or breast feeding, use daily
of hair restorers or systemic drugs within N = 128
the past 3 months
Race: 91% white
AGA type: Ludwig grade I or II
Jacobs et al 199317 Women Mean age: 33.7 years Minoxidil 2% applied Placebo 32 Minoxidil 2%: 33.1 (58)
Exclusion: N/S twice daily N = 139 Placebo: 19.1 (65)
Race: 86% white N = 155

Adil and Godwin 141.e2

AGA type: Ludwig grade I or II
Whiting and Jacobson Women Mean age: 34 years Minoxidil 2% topical Placebo 32 Minoxidil 2%: 28 (29)
199218 Exclusion: cardiac, scalp, systemic disease; (1 mL) applied twice N = 13 Placebo: 20 (18)
previous use of topical minoxidil; daily
pregnancy or breastfeeding; use of hair N = 15
restorers or systemic drugs within the
past 3 months
Race: 85% white
AGA type: Ludwig grade I or II
Continued
Supplementary Table I. Cont’d

141.e3 Adil and Godwin

Results, mean difference
hair density/cm2 (SD)*
Follow-up, between baseline and
Article Sex Study population details Intervention group Control weeks follow-up
Olsen 199119 Women Mean age: 37 years Minoxidil 2% topical Placebo 32 Minoxidil 2%: 50.14 (29.76)
Exclusion: receiving hormonal therapy, use (1 mL) applied twice N = 14 Placebo: 20.64 (21.3)
of medication that could affect hair daily
growth within the preceding 3 months, N = 14
anemia, iron deficiency, thyroid disease
Race: N/S
AGA type: Ludwig grade I or II
Olsen et al 2002b14 Men Mean age: 36.5 years Minoxidil 2% twice Placebo 48 Minoxidil 2%: 12.7 (20.7)
Exclusion: systemic illness, hypersensitive to daily N = 71 Placebo: 3.9 (21.7)
minoxidil, concomitant use of hair N = 139
restorers or systemic drugs
Race: 79% white, 17% Hispanic, 1.5% black,
1.3% Asian, 1.2% other
AGA type: pattern 3-6 on Savin Scale
Shupack et al 198720 Men Mean age: 33 years Minoxidil 2% topical Placebo 24 Minoxidil 2%: 10.68 (6.26)
Exclusion: chronic disease, concomitant (1 mL) applied twice N = 11 Placebo: 2.96 (4.01)
dermatologic disorders of the scalp daily
Race: N/S N = 11
AGA type: NH type III-IV
Roberts 198721 Men Mean age: 35 years Minoxidil 2% topical Placebo 16 Minoxidil 2%: 19.57 (P # .05)
Inclusion: N/S (1 mL) applied twice N = 18 Placebo: 13.04 (P # .05)
Race: N/S daily
AGA type: N/S N = 17
Petzoldt et al 198822 Men Mean age: 32.9 years Minoxidil 2% topical Placebo 24 Minoxidil 2%: 79 (202.1)
Exclusion: cardiovascular disease; (1 mL) applied twice N = 83 Placebo: 30 (163.6)
dermatologic problems of scalp; liver, daily
kidney, or endocrine disease; previous N = 80
topical minoxidil use; antihypertensives or
hair restorers
Country: Germany

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AGA type: NH type III-IV
Olsen et al 198523 Men Mean age: 36.2 years Minoxidil 2% topical Placebo 16 Minoxidil 2%: 29.8 (19.35)
Exclusion: heart disease (1 mL) applied twice N = 44 Placebo: 22.5 (20.34)
Race: 88% white daily
AGA type: NH type IIIv-VI N = 41

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Continued
Supplementary Table I. Cont’d

VOLUME 77, NUMBER 1

J AM ACAD DERMATOL
Results, mean difference
hair density/cm2 (SD)*
Follow-up, between baseline and
Article Sex Study population details Intervention group Control weeks follow-up
Stough et al 200224 Men Mean age: 38.6 years Finasteride 1 mg/day Placebo 48 Finasteride: 16 (4)
Exclusion: illness that might confound N=9 N=9 Placebo: 4 (5)
results, surgical therapy for scalp hair loss,
therapy of scalp hair loss, nonidentical
twin pairs
Race: 100% white
AGA type: NH type II-V
Neste et al 200025 Men Mean age: 29.8 years Finasteride 1 mg/day Placebo 48 Finasteride: 7.2 (17.22)
Exclusion: surgical correction of hair loss, use N = 93 N = 91 Placebo: 10.1 (16.79)
of minoxidil within past year, (anti)
androgenic drugs
use of systemic drugs
Race: N/S
AGA type: NH IIv-V
Leyden et al 199926 Men Mean age: 32.5 years Finasteride 1 mg/day Placebo 48 Finasteride: 9.6 (19.3)
Exclusion: N/S N = 166 N = 160 Placebo: 20.6 (18.97)
Race: N/S
AGA type: NH II-III
Whiting et al 199927 Men Mean age: N/S Finasteride 1 mg/day Placebo 48 Finasteride: 2.3 (13.09)
Exclusion: N/S N = 14 N = 12 Placebo: 0.1 (12.8)
Race: N/S
AGA type: N/S
Eun et al 201028 Men Mean age: 37.8 years Dutasteride Placebo 24 Dutasteride: 12.2 (23.6)
Exclusion: significant lab value abnormality, 0.5 mg/day N = 73 N = 75 Placebo: 4.7 (16.8)
(anti)androgenic use within 6 months,
finasteride use within past 12 months, use
of dutasteride.

Adil and Godwin 141.e4

AGA type: NH type IIIv-V
Olsen et al 200629 Men Mean age: 36.4 years Dutasteride 0.5 mg/day Placebo 24 Dutasteride: 94.6
Exclusion: use of 5a-reductase inhibitor or N = 61 N = 50 (SD not provided)
any medication for alopecia in past Placebo: 32.3 (6 59.2)
6 months, clinically significant health
problems, use of any androgenic or
antiandrogenics in past 6 months
Country: US
AGA type: NH IIIv-V
Continued
Supplementary Table I. Cont’d

141.e5 Adil and Godwin

Results, mean difference
hair density/cm2 (SD)*
Follow-up, between baseline and
Article Sex Study population details Intervention group Control weeks follow-up
Stough et al 200630 Men Mean age: 18-50 years Dutasteride 0.5 mg/day Placebo 48 Dutasteride: 16.5
Exclusion: illness that might confound the N = 17 (twin study) N = 17 Placebo: 3.8
results of the study, surgical correction of
hair loss, correction of hair loss
Country: US
AGA type: NH II-V
Harcha et al 201431 Men Mean age: 38.5 years Dutasteride 0.5 mg/day Placebo 24 Dutasteride: 89.6
Exclusion: serum testosterone \250 ng/dL, N = 183 N = 183 Placebo: 4.9
unstable liver disease, malignancy within
previous 5 years, prostate cancer before
50 years in a first-degree relative or serum
prostate-specific antigen level [2.0 ng/
mL, breast cancer, global hair thinning,
hair loss not caused by androgenetic
alopecia, scarring of the scalp
Race: 55% Asian, 40% Hispanic, 5% white
AGA type: NH types IIIv-V (except IVa, Va)

AGA, Androgenetic alopecia; LLLLT, low-level laser light therapy; NH, Norwood Hamilton scale; N/S, not specified; SD, standard deviation; SEM, standard error of the mean.
*Standard deviation was used except where indicated. SEM and P values were used in some studies.

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JULY 2017