Shedding light on treatments for female pattern hair loss
Dermatologist hair experts discuss the efficacy and safety considerations of off-label treatments for female pattern hair loss.
Feature
By Allison Evans, Assistant Managing Editor, April 1, 2025
A female patient presents with thinning hair and a reduction in hair density at the top of the scalp. Is it telogen effluvium? Is there a thyroid or iron issue? Is it female pattern alopecia? Pattern hair loss in women is not as easily recognizable as it is in men, and the diagnosis may be difficult to make.
While topical minoxidil is the only FDA-approved treatment for female pattern hair loss, there is mounting evidence supporting the use of off-label treatments — including FDA-cleared devices — as monotherapy or in combination, including low-dose oral minoxidil, spironolactone, finasteride, and low-level light therapy, among other treatments.
Much less is known about female pattern hair loss than male pattern hair loss, partly because of less recognizable patterns of hair loss in women, but also because of the common presence of other confounding factors. “Women with thinning hair are complicated because there are so many reasons why women may experience hair thinning,” said Maria K. Hordinsky, MD, FAAD, the R. W. Goltz Professor and former chair of the department of dermatology at the University of Minnesota.
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Key takeaways from this article:
While topical minoxidil is the only FDA-approved treatment for female pattern hair loss, there is mounting evidence suggesting benefits of off-label treatment when used as monotherapy or in combination with other treatments.
Oral minoxidil has revolutionized the treatment landscape for alopecia due to its vasodilatory properties, which are thought to increase microcirculation surrounding the hair follicle, stimulating hair growth.
Over the past few years, it has become increasingly common to use LDOM instead of, or in addition to, topical minoxidil, although hypertrichosis is not an uncommon side effect.
Spironolactone has been around for a long time and can be helpful in treating female pattern hair loss, although it may be superseded by LDOM now. If a patient has hormonal issues or elevated testosterone related to polycystic ovary syndrome and they have thinning hair on the top of the head, it can be a good option.
Although the use of topical 0.5% finasteride combined with 2% minoxidil solution was found to be effective in female pattern hair loss, the use of topical finasteride alone has not been found to be very effective and is not used as often for female pattern hair loss.
There is data demonstrating efficacy for low-level laser light therapy, PRP, and microneedling; however, it is most effective when used in conjunction with medical therapy.
Before treating patients, make sure female hair loss patients do not have telogen effluvium or inflammatory alopecia such as CCCA.
Low-dose oral minoxidil (LDOM)
Oral minoxidil has revolutionized the treatment landscape for alopecia due to its vasodilatory properties, which are thought to increase microcirculation surrounding the hair follicle, stimulating hair growth. Over the past few years, it has become increasingly common to use LDOM instead of, or in addition to, topical minoxidil.
A JAAD study found that 1 mg of oral minoxidil and 5% topical minoxidil produced similar hair improvements (doi: 10.1016/j.jaad.2019.08.060). Despite the results from this randomized controlled trial, Kristen Lo Sicco, MD, FAAD, associate professor at the Ronald O. Perelman department of dermatology at NYU Grossman School of Medicine, believes there is emerging evidence supporting the efficacy, cost-effectiveness, and sustainability of use for LDOM over topical minoxidil at higher doses — between 1.25 mg and 5 mg.
Dr. Lo Sicco, Dr. Shapiro, and colleagues showed that low-dose oral minoxidil can have an effect on hair diameter (doi: 10.1111/jdv.17731). “Hair density and hair diameter are the two objective measures that are very important when treating women with female pattern hair loss,” said Dr. Lo Sicco.
While LDOM has been a relatively successful treatment option, it does come with the potential for side effects that may cause discontinuation of the treatment. A 2021 JAAD study demonstrated that LDOM has a good safety profile as a treatment for hair loss, with hypertrichosis as the most common side effect. Systemic adverse effects were infrequent and only 1.7% of patients chose to discontinue treatment.
“About 15% of women might experience growth of excess facial hair and want nothing to do with it,” Dr. Hordinsky said. Women who experience this side effect but have a positive response may choose to simply remove unwanted hair.
“When treating patients, it’s important to keep family planning in mind. I keep patients off oral minoxidil when they’re pregnant,” said Maryanne Senna, MD, FAAD, assistant professor of dermatology at Harvard Medical School, and director of the Lahey Hair Loss Center of Excellence and Research Unit. “I don’t require that women be on birth control in order for me to prescribe these treatments, but I counsel them each time I see them and document it in the note. I let patients know that once they become pregnant, they have to discontinue oral minoxidil,” Dr. Senna said. Since there is less data about whether the medication crosses the milk barrier, Dr. Senna advises her patients to wait until they’re done breastfeeding before resuming oral minoxidil.
A true contraindication for this therapy is patients with congestive heart failure or those at high risk for it, Dr. Lo Sicco said. “We have done studies, however, that show using low-dose oral minoxidil in otherwise healthy alopecia patients does not show significant risk of fluid retention in the chest (pericardial or pleural effusion).”
Spironolactone
Spironolactone has been around for a long time and can be helpful in treating female pattern hair loss. “I think it’s now being superseded by LDOM. However, if a patient has hormonal issues or elevated testosterone related to polycystic ovarian disease and they have thinning hair on the top of the head, it can be a very good option,” Dr. Hordinsky said.
Its antiandrogen properties make spironolactone a great treatment for FPHL, although it is contraindicated in male androgenic alopecia. The standard dose for females is 12.5 mg to 200 mg daily.
“If a woman has PCOS or hirsutism, you’re probably going to reach for something like spironolactone because it not only grows hair on the head, but it can reduce hair elsewhere on the body,” Dr. Senna added. “In those cases, I try to avoid higher doses of minoxidil since it can increase non-scalp hair growth.”
Dr. Senna and her colleagues published an article on spironolactone use in women ages 20 to 80. They published a follow-up publication looking at the drug’s use only in older women, who are more susceptible to side effects like mild renal injury or hyperkalemia. “What we showed is that you don’t need super high doses of spironolactone to see benefit, especially in older patients. I think that they metabolize the drug differently, which makes them more prone to these side effects, so it’s important to realize that they don’t need as high of doses to get a similar effect as doses in younger women.”
“The truth of the matter is that in many cases we’re treating with both spironolactone and minoxidil because it’s been shown that you can have better results,” she added. A combination of 0.25 mg oral minoxidil and 25 mg spironolactone has been shown to decrease hair shedding and improve hair density in patients with female pattern hair loss (doi: 10.1111/ijd.13838).
Spironolactone is another treatment in which family planning needs to be delayed, noted Dr. Senna. “You must not get pregnant while taking this drug. We have to have a very important conversation with patients and counsel them on the risks.”
Considerations for patients with skin of color
Diagnosing female pattern hair loss can be difficult regardless of skin type; however, it is important to distinguish between central centrifugal cicatricial alopecia (CCCA) and female pattern hair loss in women with skin of color. CCCA can start to present itself as pattern hair loss, and that’s where it gets tricky, Dr. Hordinsky noted, because many women can have more than one hair problem.
“The most common off-label treatment that we have studied for female androgenetic alopecia is low-dose oral minoxidil,” said Dr. Lo Sicco. LDOM is helpful for many types of alopecia, including scarring alopecia. “Minoxidil works by pushing more hairs into the anagen or growth phase, so that has the biggest impact on the number of hairs or hair density. That’s why it’s important for both scarring and non-scarring alopecia, because it can keep more hair on the scalp at any given time and help as a camouflaging technique.”
“If you’re not 100% sure of the diagnosis, or if the patient is not responding, it may be time to do a biopsy,” said Ronda S. Farah, MD, FAAD, associate professor in the department of dermatology at the University of Minnesota.
Low-level laser therapy has been cleared for use in androgenetic alopecia, but not for darker skin tones, said Dr. Farah. “We did a study to investigate whether these lasers for androgenetic alopecia, like combs and helmets, are safe for darker skin types. In our small group, a portion of them improved,” Dr. Farah said.
Focusing on scalp and hair shaft health is another important facet of treating hair loss patients, especially straight and curly hair types, Dr. Farah noted. “Note hair types, what shampoo and conditioning regimen might look like, whether they’re using hair processing agents, general scalp health. That’s where you might see a more tailored effect based on hair type. You’re trying to make everything optimal to get the hair follicle to grow.”
Dr. Senna encourages all dermatologists to get out their dermatoscope and look at the scalp to rule out scarring alopecias, which can be subtle. “If you’re not treating the inflammation, patients can experience permanent hair loss.”
“In my experience, it’s important to pause for diagnostic accuracy and consider a biopsy when any patient has hair thinning on the crown, no matter what their skin type. Always make sure you haven’t missed a case of lingering CCCA or lichen planopilaris,” Dr. Farah said.
5-alpha reductase inhibitors
5-alpha reductase inhibitors block the enzyme 5-alpha-reductase, thus blocking the conversion of testosterone to its active form dihydrotestosterone (DHT). Finasteride is a type II 5-alpha-reductase inhibitor and dutasteride blocks both type I and type II.
Although the use of topical 0.5% finasteride combined with 2% minoxidil solution was found to be effective in female pattern hair loss, the use of topical finasteride alone has not been found to be very effective and is not used as often for female pattern hair loss.
Oral finasteride is contraindicated in premenopausal women and is categorized as pregnancy category X due to the feminization of male fetuses in several animal studies. For postmenopausal women, it is used at doses of 2.5 to 5 mg once daily.
Dr. Senna prefers not to use 5-alpha reductase inhibitors for female patients because she wasn’t seeing results. There is conflicting data. “I think there is more to female pattern hair loss than DHT. DHT very clearly plays a role in male androgenetic alopecia. But I don’t think that we fully understand what actually causes female pattern hair loss — it’s multifactorial.”
According to a JAAD study, the authors looked at 1 mg of finasteride versus placebo for one year for 137 post-menopausal females and found that there was no benefit, Dr. Senna noted. There were no controlled studies of higher doses of finasteride.
“The most telling study looked at 36 women who had high androgens, whether from PCOS or something else, and they treated them with 5 mg of finasteride for one year. The results were the same for those who were treated and those who weren’t treated at all,” Dr. Senna said, which also mirrored her clinical experience.
Dr. Lo Sicco, however, published a study that found that when they combined minoxidil with 5-alpha reductase inhibitors, subjects had a statistically significant increase in hair counts, although it didn’t have a significant increase in the diameter. “This is one of the first studies to show that combination therapy can be superior to monotherapy.”
“Another important thing to note is that many dermatologists do not feel comfortable prescribing the 5-alpha reductase inhibitors because of the potential for teratogenicity,” Dr. Lo Sicco said. “I never use dutasteride in a woman of childbearing potential because it has a half-life that’s more than a month. But a lot of experts use finasteride even in women of childbearing potential, on reliable forms of birth control as the half-life is very short compared to dutasteride.”
Light therapy
Low-level light therapy, or photobiomodulation, doesn’t have a rapid response, but there are data to support that it can work and that there is very little concern for negative side effects, Dr. Hordinsky explained. “There are low-level light devices that have been cleared by the FDA for growing hair, although it’s important to note that this is very different from being FDA approved. It’s also a great tool to have if someone is pregnant and can’t use systemic medications.”
Low-level laser light devices aren’t new, but they have received renewed popularity from TikTokers and other social media platforms, Dr. Senna said. Patients often like the idea of being able to use caps and combs at home, she said; however, not all devices are created equal. “The data suggest that LED lights tend to not work as well as the infrared laser lights. Secondly, from my clinical experience, within a year most patients don’t stay compliant with putting the red light on their head two or three times a week.”
A new laser — the Folix laser, which is an FDA-cleared fractional laser — has entered the scene for hair loss treatment. Patients must go into the clinic and receive treatment every one to two months for at least three treatments and then move on to maintenance. “We’re still getting experience with it, but this device looks promising,” Dr. Hordinsky said.
“These devices can be expensive, and I think you can get better efficacy from minoxidil or spironolactone,” Dr. Senna said. “I tell my patients that using these devices isn’t going to hurt, but I make sure they’re okay spending their money on a light-based device that might not change their life.”
Are hair supplements effective?
While the data are conflicting, Dr. Senna believes vitamin D and ferritin play a role in female pattern hair loss and in the hair follicle cycle. “For those who are vitamin D deficient, there are a lot of good reasons to optimize that.”
“A ferritin level below 40 is the best marker we have of iron deficiency, even if someone’s not anemic,” she said. “I have found that if people’s ferritin, even if they’re not anemic, is not above 40, they tend to not respond as well to hair loss treatments.”
Dr. Lo Sicco echoed this. “We have the most evidence in terms of nutrition that if you are deficient in vitamin D, iron, or zinc, that repleting those can have a benefit on your hair counts.”
Dr. Hordinsky cautioned about the doubling up of vitamin D and other nutraceuticals, which often also contain vitamin D. “Sometimes we check vitamin D levels and they’re really high. There are risks and benefits to taking nutraceuticals.”
In a JAAD International research letter, Drs. Shapiro and Lo Sicco assessed patients (80% female) who received supplementation with either iron, zinc, vitamin D, or thyroid hormone at the initial visit and those who were deficient nonsupplemented patients. The results failed to demonstrate a statistically significant association between supplementation and hair growth. However, there was an upward trend in hair growth for those who were deficient and supplemented.
Other “in” ingredients right now include pumpkin seed oil, rosemary oil, and saw palmetto. “If you have a bit of androgen excess, the saw palmetto could be helpful for hair thinning, but none of these have been tested in clinical trials,” Dr. Hordinsky said. “There is still a lot of conflicting data and studies that do not include hair counts,” Dr. Senna added.
Rosemary oil may work as long as patients aren’t allergic to it, and the hydrating effect from the oil can be beneficial, Dr. Hordinsky said. “There are papers that support that, particularly rosemary oil, could be equivalent to 2% topical minoxidil in terms of hair growth. But there are not a lot of good studies on this topic. The general philosophy is that if you don’t cause harm, there’s no harm in trying it.”
Another paper discussed the effect of using a caffeine and adenosine shampoo (0.4% caffeine and 0.2% adenosine) shampoo. The results revealed that the overall and local hair density increased significantly in the experimental group, although the hair diameter did not change significantly.
While there was some hair growth, the shampoo was still not as effective as topical minoxidil, Dr. Senna said.
“It’s important to note that these supplements are not equivalent to prescription therapies,” Dr. Lo Sicco added.
“With many of these studies showing efficacy, we still don’t know what the best dose would be or exactly what these formulations are. It’s a matter of being honest and transparent with patients and allowing them to make an educated decision,” Dr. Senna said.
Microneedling, PRP
“Microneedling can work quite well,” said Dr. Senna. “We published a pilot trial in women where a device did actually stimulate regrowth. The patients were treated over 12 weeks.” Again, she emphasized, all devices are not created equal.
“For microneedling to actually help stimulate hair growth, it’s really uncomfortable. I find that patients who try to microneedle themselves, it’s very hard to do in an effective way that is needed to stimulate hair regrowth. There’s certainly some data to suggest that it’s beneficial, but I think it’s not likely with at-home devices,” she added.
“Whether it’s PRP or microneedling or light therapy, we see the best results when used in conjunction with medical therapy,” Dr. Senna said.
Setting expectations
With what are considered aesthetic treatments like low-level light therapy and PRP, patients will be spending more money than purchasing topical minoxidil, Dr. Hordinsky said. “Patients need to go into these treatments knowing that you don’t know what the outcome is going to be. For people looking for a full head of hair, they may not be excited about the results.”
“Many female patients with pattern hair loss will do anything to get their hair back. Often, they will combine treatments, such as laser, PRP, and LDOM. But no matter what, it takes time for hair to grow. The patient has to commit to these treatments for at least four to six months to see results,” Dr. Hordinsky said.
Dr. Senna also emphasized how important it is to make sure female hair loss patients do not have telogen effluvium. Dermatologists can quickly screen for life changes, like high stress, recent weight loss, thyroid dose adjustments, and the like. “Often when you ask patients when they started noticing their hair loss, they’ll say ‘March 2024,’ whereas with pattern hair loss patients will usually talk about a more gradual hair loss over a few years.”
“It takes a good eye to make sure that one is countering scalp inflammation, figuring out what the hair problem is, setting expectations with whatever treatment is discussed, and making sure another diagnosis isn’t missed,” Dr. Hordinsky said.
