Open Access Review

Article DOI: 10.7759/cureus.42768

Comparing Current Therapeutic Modalities of

Androgenic Alopecia: A Literature Review of
Review began 07/27/2023
Clinical Trials
Review ended 07/29/2023
Published 07/31/2023 Parth S. Bajoria 1 , Prathma Anandbhai Dave 2 , Ralph Kingsford Rohit 3 , Charu Tibrewal 4 , Naisargi Shrikant
Modi 4 , Siddharth Kamal Gandhi 5 , Priyansh Patel 2
© Copyright 2023
Bajoria et al. This is an open access article
distributed under the terms of the Creative 1. Department of Internal Medicine, Gujarat Medical Education and Research Society Gandhinagar, Gandhinagar, IND
Commons Attribution License CC-BY 4.0., 2. Department of Internal Medicine, Medical College Baroda, Vadodara, IND 3. Department of Internal Medicine,
which permits unrestricted use, distribution, Dayanand Medical College & Hospital, Ludhiana, IND 4. Department of Internal Medicine, Civil Hospital Ahmedabad,
and reproduction in any medium, provided
Ahmedabad, IND 5. Department of Internal Medicine, M.P. Shah Government Medical College, Jamnagar, IND
the original author and source are credited.

Corresponding author: Priyansh Patel, princepatel_1998@[Link]

Abstract
Androgenic alopecia (AGA), commonly known as male pattern baldness (MPB), is a hereditary condition
characterized by hair follicles that are sensitive to androgens. This article focuses on examining the recent
advancements in the comprehension and management of AGA. The genetic factors and pathophysiology of
AGA, including the role of dihydrotestosterone (DHT) and the androgen receptor gene, are discussed. The
consequences of hair loss on self-esteem and identity, as well as on mental health, are examined. Diagnostic
methods, such as the hair-pull test and trichoscopy, are discussed. The article also presents the Hamilton-
Norwood classification, which is the most commonly employed system for classifying MPB. The article then
delves into the various treatment options available, including topical minoxidil, oral finasteride, platelet-
rich plasma therapy, low-level light therapy, hair transplant, and other alternative treatments. The efficacy
and combination therapies for these treatments are examined. Additionally, emerging treatments such as
caffeine-based solutions and prostaglandin inhibitors are discussed. By examining the recent advancements
in AGA treatment, this article provides a comprehensive overview for healthcare professionals to make
informed decisions when selecting the best treatment options for their patients.

Categories: Dermatology, Internal Medicine, Therapeutics

Keywords: androgenic alopecia, treatment choices, drug therapy, minoxidil, finasteride, dutasteride, hair transplant

Introduction And Background

Androgenetic alopecia (AGA), also known as male pattern baldness (MPB), although it is seen in females too,
is a hereditary condition characterized by hair follicles that are prone to shrinking in response to androgens.
This primarily occurs at the crown of the scalp [1]. Numerous studies have suggested that elevated levels of
dihydrotestosterone (DHT) and excessive expression of the androgen receptor gene are linked to the
pathophysiology of AGA. Moreover, an enzyme called 5α-reductase (5-AR), found in the dermal papilla,
plays a critical role in converting testosterone, both from the bloodstream and within the hair follicle, into
DHT. DHT then binds to the androgen receptor within the hair follicle, leading to the activation of signaling
pathways associated with ongoing miniaturization and eventual hair loss [2]. The pattern of hair loss varies
in both sexes. In males, it is called male pattern hair loss (MPHL), and it involves a gradual thinning of hair
on the vertex and frontal regions of the scalp, accompanied by a receding hairline. In females, it is called
female pattern hair loss (FPHL), which presents with gradual thinning and hair loss in the frontal and vertex
of the scalp without the frontal hairline receding [3]. The hair on the scalp holds significant symbolic value
in defining a person's appearance and plays a crucial sociocultural role. Hairstyles and hair lengths are
distinctive elements of an individual's identity, and the experience of hair loss can result in dissatisfaction
with one's appearance, particularly among women, and can significantly impact self-esteem. In men, hair
loss is also associated with psychological and social challenges [4]. Topical minoxidil and oral finasteride are
widely considered the primary treatments for MPHL. For FPHL, the initial recommended treatment is
typically topical minoxidil. However, apart from these approved treatments, there are several other
pharmacologic and nonpharmacologic options available, although they may be considered off-label. These
alternative treatments are used in certain cases and can include various medications or therapies aimed at
promoting hair growth or preventing further hair loss [5]. Multiple studies have been carried out to decipher
the best treatment for AGA. However, it is a big challenge for doctors to select the best treatment for their
patients due to the lack of knowledge of the adverse effects and the potency of different modalities. In this
article, we aim to review the most promising treatments that have made a breakthrough in the treatment of
AGA in the last 10 years.

Methodology
Working in collaboration with other authors of this paper, we searched articles on PubMed Central,
MEDLINE, and Google Scholar indexed journals in May 2023. The keywords from our research topic

How to cite this article

Bajoria P S, Dave P, Rohit R, et al. (July 31, 2023) Comparing Current Therapeutic Modalities of Androgenic Alopecia: A Literature Review of
Clinical Trials. Cureus 15(7): e42768. DOI 10.7759/cureus.42768
 “androgenic alopecia” AND “therapy” were searched on PubMed, which yielded 14,253 results. Following
this, we explored the medical subject headings (MeSH) glossary and created a search strategy "Alopecia/drug
therapy"[Majr] OR "Alopecia/therapy"[Majr] and were left with 3,998 articles. The inclusion criteria consisted
of free full texts published between the 10-year period from 2013 to 2023 in the English language. Only
studies done on humans were taken into consideration, which left us with 44 results in the end. Out of
those, after quality appraisal, we were left with 35 studies that were included in this review.

Review
Genetics and AGA
AGA is a complicated condition that is impacted by a combination of environmental and genetic factors.
Genes related to the androgen receptor and 5-AR have been identified as significant players in AGA. Recent
genome-wide studies have found strong associations between AGA and the androgen receptor gene, as well
as the ectodysplasin A2 receptor on the X chromosome [6]. Existing research has identified several genes,
such as PGD2, neurotrophin-3 protein, PGDS, BMP2, BDNF, ephrinA3, neural growth factor-β, GSN, and
ASS1, to show varying levels of expression in both, scalp biopsies and cell cultures from the dermal papilla,
of individuals suffering with AGA; nonetheless, more research is necessary to authenticate these
findings [7]. AGA, despite its connection to the activity of androgenic hormones and genetic predisposition,
also involves familial clustering. However, it can manifest in multiple family members without following a
single-gene inheritance pattern, making it a complex trait [6].

Pathophysiology
The hair follicle experiences three primary stages in its lifecycle. During the anagen (growth) stage, the hair
follicle undergoes an active phase where it assumes a structure resembling an onion and functions to
generate the hair strand. It is followed by the catagen phase, which lasts for a few weeks, where the hair shaft
loses 1/6th of its diameter by apoptosis-driven regression. This is followed by the telogen or dormant phase,
where there is no hair growth [8]. AGA occurs due to the gradual reduction in the length of consecutive
growth phases of hair (anagen phases) and the gradual shrinking of hair follicles that are genetically
susceptible, triggered by androgens. Additionally, the process involves the substitution of thick, dark hairs
(terminal hairs) with thin, lightly colored hairs (vellus hair) [9]. The conversion of testosterone to DHT is
primarily carried out by the enzyme 5-AR, and DHT plays a crucial role in the development of AGA in males.
5-AR exists in three different forms: types I, II, and III. The skin, encompassing the sebaceous glands and
hair follicles, primarily has the type 1 enzyme [10]. In about two-thirds of biopsy cases, there is an observed
presence of a relatively moderate perifollicular lymphohistiocytic inflammatory infiltrate surrounding the
infundibulum. However, this finding lacks specificity since it is also observed in approximately one-third of
normal control cases [11]. A recent development in our understanding of hair follicle regeneration and hair
shaft growth involves the recognition of the vital role played by the Wnt/β-catenin signaling pathway in
maintaining the properties of dermal papilla cells (DPC) that are necessary for these processes. Additionally,
it has been found that androgens and ligand-activated androgen receptors can have a negative impact on the
Wnt/β-catenin signaling pathway, as shown in Figure 1. More precisely, increased expression of glycogen
synthase kinase 3 beta by androgens is what obstructs this pathway [12]. One distinguishing feature of AGA
is the perceived enlargement of sebaceous glands in relation to the size of miniaturized hair follicles.
However, it is important to note that this observation is not indicative of true sebaceous hyperplasia, as the
sebaceous glands maintain their normal size and structure and their enlargement is only apparent [13].
Another hypothesis regarding AGA suggests that the disappearance of the arrector pili muscle is a
contributing factor. The smooth muscle plays a role in regulating body temperature and sebum production
while also serving as a link between the hair follicle and the upper layers of the skin. Researchers have put
forward the idea that the loss of the arrector pili muscle could be linked to the permanent development of
AGA [14].

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 FIGURE 1: Pathophysiology of AGA
AGA: androgenic alopecia, DHT: dihydrotestosterone

Created using [Link]

Image credits: Parth S. Bajoria, Priyansh Patel, and Prathma Anandbhai Dave

Consequences of AGA
It is clear that the development of AGA is dependent on factors such as age, lifestyle, and hormonal
disorders. AGA tends to affect more individuals with advanced age and stressful lifestyles. Hair is a crucial
part of an individual’s appearance, and losing hair can create a feeling of looking older and losing
confidence. There are plenty of other psychological effects that follow, which are shown in Figure 2 [15].

FIGURE 2: AGA and its consequences

AGA: androgenic alopecia, UV: ultraviolet

Image credits: Parth S. Bajoria, Priyansh Patel, and Prathma Anandbhai Dave

Diagnosis
The diagnosis of AGA involves assessing the patient's medical history, clinical findings, duration and
location of hair loss, shedding or thinning of hair, and reviewing family history, current medications, and
conducting basic laboratory tests to exclude other possible causes of hair loss [3]. Evaluation of AGA is
usually done by pull test or trichoscopy. To identify ongoing hair loss, the hair-pull test is conducted by
gently pulling 50-60 hairs near the scalp using the middle finger, index finger, and thumb. If six or more
hairs are detached during this process, it suggests that there is ongoing hair loss [5]. Trichoscopy is a non-
invasive technique used to examine the hair and scalp, which provides valuable information about various
characteristics. The most commonly observed trichoscopic features in AGA include variations in hair

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 diameter (anisotrichosis), peripilar signs (brown or white halo surrounding a hair follicle), the presence of
yellow or white dots (a marker of severe AGA), a honeycomb pattern of pigmentation (seen in individuals
with darker skin tones), bald patches, and arborizing red lines [16].

Classification
Devised by Dr. James Hamilton and later revised by Dr. O'Tar Norwood, the Hamilton-Norwood classification
is a commonly employed system for classifying MPB. It consists of seven stages (types I-VII) that depict the
progression of hair loss in men, from minimal to extensive [17]. Figure 3 shows a brief description of each
stage.

FIGURE 3: Hamilton-Norwood classification for male-pattern baldness

The image was made based on information obtained from Gupta et al. [17], an open-access article distributed
under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new
creations are licensed under the identical terms.

Image credits: Parth S Bajoria, Priyansh Patel, and Prathma Ananbhai Dave

Treatment
Treating AGA is challenging due to its chronic nature and the interplay of genetic and environmental
factors. While the Food and Drug Administration (FDA) has approved only topical minoxidil and oral
finasteride, several non-FDA-approved treatments have shown effectiveness. Further research is needed to
explore these newer treatments, which are mentioned below [3].

Non-medical Treatment

The most straightforward and convenient approach for addressing mild male AGA is through camouflage.
This involves adopting hair styling techniques to conceal the balding scalp, utilizing electrostatically-held
small fibers, and dyeing the scalp to match the hair color. These affordable measures can yield cosmetically
pleasing outcomes. Additionally, modern wigs offer the ability to style and wash and provide a natural
appearance [18].

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 Medical Treatment

Minoxidil: Topical minoxidil (2% or 5%) was the first FDA-approved drug for the treatment of AGA. It is
available as a topical solution as well as foam preparation; however, the foam preparation is associated with
lesser local reactions such as erythema or pruritus as per Hasanzadeh et al. [19]. Multiple studies have
reported that combination therapy is more efficacious than 5% topical minoxidil alone. Faghihi et al.
conducted a study on 50 participants for about 12 months and suggested that adding low-level light therapy
to topical minoxidil therapy was more effective than minoxidil therapy alone [20], whereas Pakhomova et al.
conducted a study on 69 men divided into three groups of topical minoxidil therapy alone, platelet-rich
plasma (PRP) alone and PRP+minoxidil therapy. Her study concluded that combination therapy was highly
efficacious as compared to either monotherapy and that PRP monotherapy was more efficacious than topical
minoxidil in most aspects [21]. Mirmirani et al. conducted a prospective pilot study that was placebo-
controlled and double-blinded. The study evaluated the efficacy of minoxidil topical foam 5% compared to a
placebo in 16 men diagnosed with type IV or V AGA and concluded that minoxidil was equally effective in
the treatment of both, the frontal and the vertex of the scalp, which are the most commonly affected areas in
men with AGA, although there is a variation in regional gene expression profile of these areas [22]. Sakr et
al. concluded after a 32-week pilot study that the use of a multimodal minoxidil formulation containing
diclofenac and tea tree oil, demonstrated greater efficacy, stability, and safety for treating AGA by promoting
earlier responses, potentially due to diclofenac's anti-inflammatory effects on scalp and hair follicles and tea
tree oil's ability to eliminate microbial or fungal presence in follicles [23].

5-AR inhibitors: Oral finasteride was the other drug approved by FDA to be used for AGA. To minimize the
systemic effects associated with its use, the use of topical finasteride has been suggested in recent years as it
selectively targets 5-AR inhibition in the scalp. Piraccini et al. supported this finding with their study on 458
patients although the increase in hair count between oral and topical formulation groups was similar [1]. As
with minoxidil, combination therapy generates superior outcomes in patients taking oral finasteride. Van
Neste et al. supported this in their study of 22 patients and concluded that the use of oral finasteride along
with topical 5% minoxidil (applied at a volume of 1 mL once a day) led to an improvement in the growth of
underactive hair follicles although it did not result in an increase in the speed of hair growth [24].
Dutasteride is a second-generation drug of the same class. It shares a similar side-effect profile as finasteride
although it is more efficacious as per Shanshanwal et al. [10].

PRP therapy: PRP is derived from whole blood by centrifugation. Gressenberger et al. conducted a pilot study
on 30 male patients and said that PRP did not significantly improve hair growth as a monotherapy [25].
Singh et al. studied 80 patients using double-blinded randomized controlled trials (RCTs) and concluded that
PRP, along with topical minoxidil 5%, was more efficacious than either PRP or topical minoxidil alone and
also PRP demonstrated quicker results compared to topical minoxidil [26] as did Pakhomova et al.
suggest [22].

Platelet lysate (PL): PRP and PL are produced in a similar manner, but PL undergoes an additional step that
increases the concentration of growth factors in the serum. It is faster acting as compared to PRP. Guan et al.
studied 107 AGA patients and said that PL was as efficacious as PRP in terms of increasing hair count,
diameter, and absolute anagen counts, making it ideal to replace PRP [27].

Low-level light therapy (LLLT): LLLT or photobiomodulation delivered via caps or helmets has been claimed
to prevent MPHL, as well as FPHL. In a 26-week-long study of four RCTs, Jimenez et al. concluded that the
increase in terminal hair count by LLLT was similar to the results observed in short-term trials of a 5%
minoxidil topical solution and a daily dose of one mg of finasteride, but less effective compared to longer-
term trials lasting at least one year [28]. Blum et al. in their study on 119 subjects with the cold X5 hair laser
said that chronic therapy leads to hair growth [29].

Miscellaneous Treatments

Treatment for AGA usually continues for an individual’s entire life and therefore taking into account the
risk/benefit profile of a drug takes prime importance. Specifically, 0.2% topical caffeine-based solutions are
typically safe with very minimal adverse effects for long-term treatment of AGA, and they are not inferior to
topical 5% minoxidil therapy as per Dhurat et al. [9]. Prostaglandins (PGs) play a crucial role in the hair
follicle cycle, with PGE2-promoting hair growth and PGD2 inhibiting it. Hossein Mostafa et al. compared
topical cetirizine 1% (a PGD2 inhibitor) with minoxidil 5% and found that cetirizine had fewer side effects.
Both groups showed increased hair density after 16 weeks, but the minoxidil group had greater improvement
[30]. Adipose tissue-derived stem cells (ADSCs) release growth hormones that promote cell development,
and Tak et al. suggested that applying ADSC-cetirizine solution directly to the scalp, along with finasteride
or minoxidil, could be a viable alternative treatment for AGA [31]. Botulinum toxin (BT) derived from
Clostridium botulinum blocks acetylcholine release, relaxing muscles, improving blood flow, increasing
oxygen, reducing DHT activation, and promoting hair regrowth. Zhou et al. studied the safety and
effectiveness of BT type A and concluded that BT type A given along with finasteride has higher efficacy as
compared to BT type A injections alone [2]. Pekmezci et al. studied herbal shampoo and solutions containing
anti-androgenic, anti-inflammatory, anti-oxidative, and angiogenic properties, on 120 subjects and

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 concluded that they reduced hair loss in patients with AGA. Moreover, the shampoo and solution used
together had higher efficacy than either used alone [32]. Procyanidin B2, abundantly present in apples, is a
safe and highly effective compound for promoting hair growth and improving skin quality, as supported by
Tenore et al.'s clinical trial using AppleMets and laboratory studies showcasing increased keratin content.
This natural extract-based nutraceutical supplement enhances hair density, weight, and keratin content
simultaneously [33].

Surgical Treatment

Hair transplantation, commonly used for medical treatment failure/resistant AGA, is a surgical procedure
that implants new hairs into areas with significant hair loss, providing a natural look and permanent results
with over 90% graft survival. It can be classified as follicular unit transplantation (FUT) or follicular unit
extraction (FUE) and robotic techniques are also available, albeit with higher costs and maintenance
demands [34]. The major treatments are discussed and compared in Table 1.

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 Drug Mechanism of Action Dosage and Route Adverse Effects Comments

Contact/Irritant
The Influx of calcium ions up- dermatitis,
1 mL applied twice a day.
regulates ATP-synthase, pruritus, skin First-line FDA-approved therapy. Easy
Available in 2% and 5%
Minoxidil which enhances the process irritation and to use. Loss of results on
topical as well as foam
of stem cell differentiation and erythema, facial discontinuation [18]. Cost-efficient.
preparation [3].
promotes hair growth [18]. hypertrichosis
[34].

Erectile
FDA-approved. Good compliance due
dysfunction,
to a once-daily oral regimen. Cessation
Oral Highly selective and binds reduced libido,
1 mg once daily [3]. of therapy leads to the loss of observed
Finasteride irreversibly to type-II 5-AR [3]. orthostatic
results [19] and the reversal of any side
hypotension, and
effects that may have occurred [3].
dizziness [34].

Contact
dermatitis, skin Lesser systemic side effects than oral
Topical Highly selective and binds
0.25% spray or 1% gel [3]. irritation, sexual counterparts [18]. Variable response to
Finasteride irreversibly to type-II 5-AR [3].
side effects therapy.
(rarely) [3,18].

Erectile
Acts as an inhibitor of both the dysfunction,
2.5 or 5 mg once daily Higher efficacy than finasteride [18].
Dutasteride iso-enzymes of 5-AR (types I reduced libido,
[34]. Used off-label.
and II) [3]. gynecomastia
[18].

Injections of 4-8 mL via

Enhances blood flow to the intra-dermal or
Minor bleeding, Works better when used as a
hair follicles, preventing cell subcutaneous route. 3-4
PRP therapy pain, and combination therapy with topical
death, thereby extending the sessions monthly,
headache [3]. agents [26].
growth phase [18]. followed by a session
every three months [34].

Wavelengths ranging from

Expedites the process of Paresthesia, mild Capillus laser cap and Hairmax laser
650 to 900 nm and a
mitosis, stimulates stem cells urticaria, and comb are the only 2 FDA-approved
LLLT power of 5 mW can be an
within the hair follicles, and scalp tenderness devices for AGA as of now [34].
effective treatment choice
reduces inflammation [28]. [3]. Excellent safety profile.
[28].

Extraction of hair follicles from

the back of the scalp, where The graft survival rate is more than 90%
Pain, bleeding,
Hair hair is immune to balding, and Done with either the FUT in AGA patients [34]. Generates a
pruritus,
transplantation relocating them to the areas or FUE method [18]. natural appearing look. One of the
scarring [3].
affected by the loss of costliest treatments for AGA.
hair [18].

TABLE 1: Comparing therapeutic modalities for AGA

AGA: androgenic alopecia, ATP: adenosine triphosphate, FDA: Food and drug association, mL: milliliter, mg: milligram, nm: nanometer, mW: milliwatt,
FUT: follicular unit transplantation, FUE: follicular unit extraction, LLLT: Low-level light therapy, PRP: platelet-rich plasma, 5-AR: 5-alpha reductase

Limitation
Most of the clinical trials were of short duration, and a few were conducted on small sample sizes. Hence,
larger and longer studies are further required. We omitted articles in languages other than English and also
omitted animal studies. Only articles published in the last decade were considered so there might be other
relevant studies that are published before this decade. Only literature found on PubMed was reviewed, and
other databases were not explored. Only clinical trials were included to make results in the study. Results
from other types of studies were excluded. Moreover, the lack of research evidence regarding the use of
nutritional supplements and dietary options in the treatment of AGA and the management of environmental
risk factors associated with AGA also needs to be addressed.

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 Conclusions
This narrative review examined the current therapeutics available for AGA, putting light on the
advancements and challenges in treating this common hair loss condition. Throughout the analysis, it
became evident that various treatment options exist, including pharmacological and non-pharmacological
approaches. Pharmacological interventions, such as minoxidil and finasteride, have demonstrated efficacy
in promoting hair growth and slowing down hair loss in many individuals. However, their effectiveness can
vary among different patients, and they may be associated with certain side effects. Moreover, the long-term
outcomes and maintenance of hair growth with these medications need further investigation. Non-
pharmacological approaches, including LLLT and PRP therapy, have shown promise in stimulating hair
growth and improving the overall condition of the scalp. Nevertheless, more rigorous clinical trials are
required to determine the potency of these treatments and refine the most-effective treatment protocols.
Our article compares the various treatments and also portrays the side-effect profile. We also talked about
various combination therapies available and their efficacy demonstrated in different studies. We have also
talked about some newer treatments, which have been proven safe but need more extensive research. There
is very little research available for the surgical treatment of AGA; hence, extensive research is required for it.
Although there are many treatments available, a definitive treatment regimen for AGA remains elusive. Gene
therapies, stem cell-based treatments, and novel pharmaceutical agents currently under investigation hold
great potential for revolutionizing the management of this condition. Nevertheless, these emerging
therapies necessitate rigorous evaluation to ensure safety, efficacy, and long-term outcomes.

Additional Information
Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.

Acknowledgements
1st Author - BPS, 2nd Author - DPA, 3rd Author - RRK, 4th Author - TC, 5th Author - MN, 6th Author - GSK,
7th Author - PP. BPS and PP contributed equally to the work and should be considered co-first authors. BPS
and PP were involved in drafting the concept of the Abstract and the Discussion; wrote the Discussion;
performed the literature search and quality appraisal of the finalized studies; and conceived the overall
structure, framework, and concept of the study. They also drafted and edited images and formatted, edited,
and helped draft the final manuscript. DPA was involved in writing the Abstract, extracted and analyzed the
data from the finalized studies, and helped draft the images and draft the final manuscript. RRK was
involved in drafting the design of the Introduction and quality assessment of studies; conceived the overall
structure, framework, and concept of the study; and helped draft the final manuscript. TC was involved in
writing the Introduction and drafting the structure of the Discussion, extracted and analyzed data from the
finalized studies, and helped draft the final manuscript. MN extracted and analyzed data from the finalized
studies, helped draft the concept and design for the Conclusion, wrote the Conclusion, and helped draft the
final manuscript. GSK and PP were involved in the literature search; drafted the concept and design for the
Conclusion; conceived the overall structure, framework, and concept of the study; and helped draft the final
manuscript. All authors have read and approved the final manuscript. All authors agree to be accountable for
all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work
are appropriately investigated and resolved.

References
1. Piraccini BM, Blume-Peytavi U, Scarci F, et al.: Efficacy and safety of topical finasteride spray solution for
male androgenetic alopecia: a phase III, randomized, controlled clinical trial. J Eur Acad Dermatol Venereol.
2022, 36:286-94. 10.1111/jdv.17738
2. Zhou Y, Yu S, Zhao J, Feng X, Zhang M, Zhao Z: Effectiveness and safety of botulinum toxin type A in the
treatment of androgenetic alopecia. Biomed Res Int. 2020, 2020:1501893. 10.1155/2020/1501893
3. Devjani S, Ezemma O, Kelley KJ, Stratton E, Senna M: Androgenetic alopecia: therapy update . Drugs. 2023,
83:701-15. 10.1007/s40265-023-01880-x
4. Krefft-Trzciniecka K, Piętowska Z, Nowicka D, Szepietowski JC: Human stem cell use in androgenetic
alopecia: a systematic review. Cells. 2023, 12:951. 10.3390/cells12060951
5. Tamashunas NL, Bergfeld WF: Male and female pattern hair loss: treatable and worth treating . Cleve Clin J
Med. 2021, 88:173-82. 10.3949/ccjm.88a.20014
6. Martinez-Jacobo L, Villarreal-Villarreal CD, Ortiz-López R, Ocampo-Candiani J, Rojas-Martínez A: Genetic
and molecular aspects of androgenetic alopecia. Indian J Dermatol Venereol Leprol. 2018, 84:263-8.
10.4103/ijdvl.IJDVL_262_17
7. Midorikawa T, Chikazawa T, Yoshino T, Takada K, Arase S: Different gene expression profile observed in
dermal papilla cells related to androgenic alopecia by DNA macroarray analysis. J Dermatol Sci. 2004, 36:25-
32. 10.1016/[Link].2004.05.001
8. Hoover E, Alhajj M, Flores JL: Physiology, hair. StatPearls. StatPearls Publishing, Treasure Island (FL); 2023.

2023 Bajoria et al. Cureus 15(7): e42768. DOI 10.7759/cureus.42768 8 of 9

 9. Dhurat R, Chitallia J, May TW, et al.: An open-label randomized multicenter study assessing the
noninferiority of a caffeine-based topical liquid 0.2% versus minoxidil 5% solution in male androgenetic
alopecia. Skin Pharmacol Physiol. 2018, 30:298-305. 10.1159/000481141
10. Shanshanwal SJ, Dhurat RS: Superiority of dutasteride over finasteride in hair regrowth and reversal of
miniaturization in men with androgenetic alopecia: a randomized controlled open-label, evaluator-blinded
study. Indian J Dermatol Venereol Leprol. 2017, 83:47-54. 10.4103/0378-6323.188652
11. Sinclair R: Male pattern androgenetic alopecia. BMJ. 1998, 317:865. 10.1136/bmj.317.7162.865
12. Kaliyadan F, Nambiar A, Vijayaraghavan S: Androgenetic alopecia: an update. Indian J Dermatol Venereol
Leprol. 2013, 79:613-25. 10.4103/0378-6323.116730
13. Bernárdez C, Molina-Ruiz AM, Requena L: Histologic features of alopecias-part I: nonscarring alopecias .
Actas Dermosifiliogr. 2015, 106:158-67. 10.1016/[Link].2014.07.006
14. Girijala RL, Riahi RR, Cohen PR: Platelet-rich plasma for androgenic alopecia treatment: a comprehensive
review. Dermatol Online J. 2018, 24:13030-8. 10.5070/D3247040910
15. Stough D, Stenn K, Haber R, Parsley WM, Vogel JE, Whiting DA, Washenik K: Psychological effect,
pathophysiology, and management of androgenetic alopecia in men. Mayo Clin Proc. 2005, 80:1316-22.
10.4065/80.10.1316
16. Fernández-Domper L, Ballesteros-Redondo M, Vañó-Galván S: [Translated article] Trichoscopy: an update.
Actas Dermosifiliogr. 2023, 114:T327-33. 10.1016/[Link].2023.02.006
17. Gupta M, Mysore V: Classifications of patterned hair loss: a review . J Cutan Aesthet Surg. 2016, 9:3-12.
10.4103/0974-2077.178536
18. Asfour L, Cranwell W, Sinclair R: Endotext. Male androgenetic alopecia. Feingold KR, Anawalt B, Blackman
MR, et al. (ed): [Link], Inc., South Dartmouth (MA); 2000.
19. Hasanzadeh H, Nasrollahi SA, Halavati N, Saberi M, Firooz A: Efficacy and safety of 5% minoxidil topical
foam in male pattern hair loss treatment and patient satisfaction. Acta Dermatovenerol Alp Pannonica
Adriat. 2016, 25:41-4. 10.15570/actaapa.2016.12
20. Faghihi G, Mozafarpoor S, Asilian A, et al.: The effectiveness of adding low-level light therapy to minoxidil
5% solution in the treatment of patients with androgenetic alopecia. Indian J Dermatol Venereol Leprol.
2018, 84:547-53. 10.4103/ijdvl.IJDVL_1156_16
21. Pakhomova EE, Smirnova IO: Comparative evaluation of the clinical efficacy of PRP-therapy, minoxidil, and
their combination with immunohistochemical study of the dynamics of cell proliferation in the treatment
of men with androgenetic alopecia. Int J Mol Sci. 2020, 21:6516. 10.3390/ijms21186516
22. Mirmirani P, Consolo M, Oyetakin-White P, Baron E, Leahy P, Karnik P: Similar response patterns to topical
minoxidil foam 5% in frontal and vertex scalp of men with androgenetic alopecia: a microarray analysis. Br J
Dermatol. 2015, 172:1555-61. 10.1111/bjd.13399
23. Sakr FM, Gado AM, Mohammed HR, Adam AN: Preparation and evaluation of a multimodal minoxidil
microemulsion versus minoxidil alone in the treatment of androgenic alopecia of mixed etiology: a pilot
study. Drug Des Devel Ther. 2013, 7:413-23. 10.2147/DDDT.S43481
24. Van Neste D: Placebo-controlled dose-effect studies with topical minoxidil 2% or 5% in male-patterned hair
loss treated with oral finasteride employing an analytical and exhaustive study protocol. Skin Res Technol.
2020, 26:542-57. 10.1111/srt.12827
25. Gressenberger P, Pregartner G, Gary T, Wolf P, Kopera D: Platelet-rich plasma for androgenetic alopecia
treatment: a randomized placebo-controlled pilot study. Acta Derm Venereol. 2020, 100:1-7.
10.2340/00015555-3609
26. Singh SK, Kumar V, Rai T: Comparison of efficacy of platelet-rich plasma therapy with or without topical 5%
minoxidil in male-type baldness: a randomized, double-blind placebo control trial. Indian J Dermatol
Venereol Leprol. 2020, 86:150-7. 10.4103/ijdvl.IJDVL_589_18
27. Guan Q, Guo ZH, Dai DM, et al.: Platelet lysate promotes hair growth: in vitro and in vivo mechanism and
randomized, controlled trial. Biomed Pharmacother. 2023, 161:114517. 10.1016/[Link].2023.114517
28. Jimenez JJ, Wikramanayake TC, Bergfeld W, Hordinsky M, Hickman JG, Hamblin MR, Schachner LA: Efficacy
and safety of a low-level laser device in the treatment of male and female pattern hair loss: a multicenter,
randomized, sham device-controlled, double-blind study. Am J Clin Dermatol. 2014, 15:115-27.
10.1007/s40257-013-0060-6
29. Blum K, Han D, Madigan MA, Lohmann R, Braverman ER: "Cold" X5 Hairlaser™ used to treat male
androgenic alopecia and hair growth: an uncontrolled pilot study. BMC Res Notes. 2014, 7:103.
10.1186/1756-0500-7-103
30. Hossein Mostafa D, Samadi A, Niknam S, Nasrollahi SA, Guishard A, Firooz A: Efficacy of cetirizine 1%
versus minoxidil 5% topical solution in the treatment of male alopecia: a randomized, single-blind
controlled study. J Pharm Pharm Sci. 2021, 24:137-266. 10.18433/jpps31456
31. Tak YJ, Lee SY, Cho AR, Kim YS: A randomized, double-blind, vehicle-controlled clinical study of hair
regeneration using adipose-derived stem cell constituent extract in androgenetic alopecia. Stem Cells
Transl Med. 2020, 9:839-49. 10.1002/sctm.19-0410
32. Pekmezci E, Dündar C, Türkoğlu M: A proprietary herbal extract against hair loss in androgenetic alopecia
and telogen effluvium: a placebo-controlled, single-blind, clinical-instrumental study. Acta Dermatovenerol
Alp Pannonica Adriat. 2018, 27:51-7.
33. Tenore GC, Caruso D, Buonomo G, et al.: Annurca apple nutraceutical formulation enhances keratin
expression in a human model of skin and promotes hair growth and tropism in a randomized clinical trial. J
Med Food. 2018, 21:90-103. 10.1089/jmf.2017.0016
34. Nestor MS, Ablon G, Gade A, Han H, Fischer DL: Treatment options for androgenetic alopecia: efficacy, side
effects, compliance, financial considerations, and ethics. J Cosmet Dermatol. 2021, 20:3759-81.
10.1111/jocd.14537

2023 Bajoria et al. Cureus 15(7): e42768. DOI 10.7759/cureus.42768 9 of 9