Androgenetic Alopecia: Causes, Symptoms and Treatments

What is androgenetic alopecia and why does it occur

Androgenetic alopecia is the most common form of hair loss, both in men and women. They call it common baldness, but it is anything but trivial. It affects about 50% of men by age 50 and nearly 30% of women by age 60. It is not a disease, it is a genetic condition related to how your body reacts to male hormones, particularly dihydrotestosterone (DHT).

The mechanism is simple on paper, but frustrating in reality. DHT binds to receptors in hair follicles in sensitive areas - generally on the top of the scalp, not on the nape or sides. This binding progressively shortens the growth phase of the hair (the anagen phase) and lengthens the resting phase. Result: existing hairs become thinner, shorter, lighter. With each cycle, the follicle miniaturizes a little more. By the fourth or fifth cycle, the hair is an invisible thread, almost like vellus hair.

The genetic component is decisive. If your father or grandfather lost their hair early, the odds go up. But it is not just about heredity: the sensitivity of the follicle to DHT also matters, which varies from person to person. That is why two brothers with the same genetic makeup can have completely different progressions.

In women, androgenetic alopecia presents more diffusely on the top of the head, typically preserving the frontal hairline. In men, the classic pattern starts with the temples and extends to the vertex. Triggering factors such as hormonal changes, menopause, chronic stress, or certain medications can accelerate the process, but the underlying cause remains the genetic program.

Understanding why it occurs is the first step: it does not stop the hair loss, but it avoids chasing useless solutions. DHT is not an enemy - it is needed for male development - but for some it becomes a localized problem. And this can be acted upon.

How to recognize androgenetic alopecia: symptoms and diagnosis

The first sign is the hairline receding at the temples, a sort of "M" that widens year after year. Then comes thinning on the crown (vertex). In about 70% of men with AGA, the first symptom is precisely this bitemporal recession, already evident between the ages of 20 and 30. In women, the pattern is different: the central part widens, without true total baldness, but with a spread that accelerates after menopause.

How is AGA distinguished from telogen effluvium?

Telogen effluvium is a diffuse and temporary hair loss, often triggered by stress, high fever, or childbirth. In one month, up to 300-400 hairs fall per day (compared to the normal 50-100). AGA instead is progressive and follows a precise pattern. A simple test is the pull test: the dermatologist grabs a lock of 50-60 hairs and pulls gently. If more than 5-6 hairs come out, there is an active telogen phase. But that is not enough: trichoscopy is needed to see the diameter of the hairs. Table: key signs for differential diagnosis | Clinical sign | Androgenetic alopecia | Telogen effluvium | | :| :| :| | Distribution of hair loss | Temples and vertex (men), central part (women) | Diffuse over the entire scalp | | Duration | Progressive, years | Acute, 3-6 months (if chronic can last longer) | | Miniaturization | Present (thin hairs, varying diameter) | Absent | | Pull test | Often negative | Positive (5+ hairs) | | Response to treatment | Minoxidil or finasteride after 4-6 months | Spontaneous resolution in 6 months |

When the diagnosis arrives: the typical picture

The script that leads to diagnosis is almost always the same. People notice the problem in a photograph, not in the mirror. Trichoscopy reveals a substantial share of miniaturized follicles in the frontal area, with reduced-diameter shafts sitting next to still-normal hairs. The Norwood stage is already II or III and the crown is beginning to show through. In most cases the onset has been silent for years: looking back at old photographs, the bitemporal "M" was visible long before the patient noticed it. This is the typical dynamic of AGA, and it explains why so many arrive late: people wait until the thinning is obvious before acting, and meanwhile the therapeutic window narrows.

Physical examination and tools

Diagnosis is based on clinical findings: history (when hair loss started, family history), pattern inspection, and trichoscopy (dermatoscopy at 20-70x magnification). With trichoscopy, you see yellow dots (empty follicles or with sebum) and hair shaft diameter diversity (hairs with variable diameter, a sign of miniaturization). In doubtful cases, a scalp biopsy is performed (3-4 mm in diameter). In Bologna, a specialist visit with trichoscopy costs between €120 and €200. The investment is worth it: a correct diagnosis rules out useless treatments.

Male and female androgenetic alopecia: the differences

In men, androgenetic alopecia follows a fairly predictable script. Thinning begins at the temples and vertex, leaving the nape intact. About 80% of men aged 70 show some degree of loss, but signs can start as early as age 20. Testosterone is converted into dihydrotestosterone (DHT) by the enzyme 5-alpha

Medical treatments: drugs and therapies to stop hair loss

The first step to stop hair loss is to understand that androgenetic alopecia is not "cured" in the classic sense. It is kept under control. With the right medications and a little patience, you can slow down the process, often stop it for years, and in many cases recover some of that lost volume.

The cornerstone of medical treatment remains finasteride, a 5-alpha-reductase inhibitor. Taking 1 mg daily reduces the conversion of testosterone to dihydrotestosterone (DHT) by about 70%. Clinical studies are clear: after two years, 66% of men with androgenetic alopecia maintained their hair, and nearly half saw moderate or good regrowth. I say "after two years" because results do not come in three weeks. It takes at least 3-6 months to notice stabilization of hair loss, and 12-18 months to evaluate the full response.

It is worth repeating: no one should expect a miracle in four days. Those who stop after two months because "it doesn't work" have wasted time and money. Side effects? They can happen, but they are less common than what you read on forums: erectile dysfunction in 2-4% of men, decreased libido. And they almost always disappear upon discontinuation.

Topical minoxidil is the other weapon, often used in combination. 5% for men, 2% for women (caution: 5% can cause hypertrichosis on the forehead and cheeks). Applied twice daily to the scalp. Mechanism? It dilates blood vessels, prolongs the anagen phase, and stimulates follicles to produce thicker hair. After about a year of consistent application, a good share of users report visible regrowth. The problem is consistency: if you stop, the gained hair falls out within 3-4 months.

Combination therapy and alternatives

The combination of finasteride + minoxidil is much more effective than single drugs. Large-scale data: at 12 months, 74% of patients on combination therapy show improvement versus 52% on finasteride alone. For those who cannot tolerate finasteride, there is dutasteride (0.5 mg/day, off-label in Italy, requires prescription). It blocks both isoforms of 5-alpha-reductase and reduces DHT by 90%. More potent, but also riskier: the incidence of sexual side effects is slightly higher.

Among physical therapies, low-level laser therapy (LLLT) has some evidence: LED helmets or combs at 650 nm, 20-30 minutes daily. Some clinical research reports a modest increase in density after several months of regular use. It's not groundbreaking, but if the patient has contraindications to medications, it can be an option.

PRP (platelet-rich plasma) is becoming common: intradermal injections every 4-6 weeks for 3 cycles, then maintenance every 4-6 months. Results are variable.

Hair transplant and definitive solutions

Androgenetic alopecia has no cure, but for many men, hair transplantation represents the closest solution to a definitive resolution. Provided you know how to choose the right time and the right technician.

The principle is simple: hair from the lateral and posterior areas of the scalp is genetically resistant to DHT. By moving it to thinning areas, it grows back for life. No other technique—medications, laser, PRP—can promise as much. But there is a catch.

The transplant does not stop the progression of androgenetic alopecia. If a man stops medical therapy (finasteride, minoxidil) after the transplant, native hair will continue to fall out, creating a patchy effect or a road between two islands of transplanted hair. This is called the "shock-loss effect" or, worse, "unnatural design." For this reason, serious surgeons require at least six months of stable medical therapy before operating.

Who is the ideal candidate?

Age matters. Operating on a 20-year-old with Norwood 2 is risky: alopecia can progress and leave bare areas behind the transplant. Better to wait until age 28-30, when the balding pattern has stabilized. The best candidates have stable alopecia for at least two years, a dense donor area (at least 60 follicles per cm² in the occipital zone), and realistic expectations.

Techniques compared

In 2026, the two dominant techniques are FUE and DHI. FUE involves extracting individual follicular units with micro-punches of 0.7-0.9 mm. DHI (or Choi Implanter) directly inserts the follicle into the recipient area without creating channels first: less trauma, faster recovery. Both leave minimal scarring, but DHI is better for long hair and areas with diffuse thinning.

A typical transplant requires 2000-3000 grafts, takes 6-8 hours under local anesthesia, and has a graft survival rate of 90-95% if performed by experienced hands. Initial results are seen at 4 months, final density at 12-18 months.

Phase Time Transplanted hair shedding 2-4 weeks Initial regrowth 3-4 months Intermediate result 8-10 months Final result 12-18 months

Costs? In Italy, prices start at €3,000-4,000 for 2000 grafts and go up to €8,000-10,000 for extensive sessions. Low-cost clinics abroad are frightening for a reason: if the surgeon fails to recognize poor donor quality or an active phase of androgenetic alopecia, you risk a result worse than the starting point.

A well-performed transplant leaves the large majority of patients satisfied; the disappointments almost always come from those who skipped the pharmacological stabilization phase. The lesson is clear: the transplant is definitive as an aesthetic solution, but it does not replace the medical management of alopecia.

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