Androgenetic alopecia

Androgenetic alopecia (AGA) is more frequent than any other type of hair loss: up to 80% of men and up to half of women meet it during their lives. In people with an inherited predisposition, the hair follicles on the top and crown of the head gradually shrink under the influence of androgens, and thick pigmented hair is replaced by ever thinner, shorter hairs.

It is not sudden baldness but a slow process that usually speeds up with age. The earlier the diagnosis, the more of your own hair can be kept. Heredity cannot be switched off, but the process can be slowed and, in many patients, stabilised.

At the clinical trichology department of the Trichology Institute in Kharkiv, AGA in men and women is treated by trichologists who are qualified dermatovenereologists. Our doctors research the mechanisms of this condition and describe them in their own publications, including the review Androgenetic alopecia by Professor Yuliya Ovcharenko and Yulia Kachuk.

When to see a trichologist

Do not wait until the thinning is visible to others. Book a consultation if you notice:

a receding hairline at the temples or thinning on the crown;
a parting that gets wider year by year, or a thinner ponytail;
hair on the top of the head that is clearly finer and shorter than at the back;
increased shedding that lasts longer than a few weeks or keeps coming back;
baldness in close relatives and the first similar changes in yourself;
in women, thinning together with an irregular cycle, acne or excess hair on the face and body.

It is also worth coming in if your hair started to thin after childbirth, after stopping contraceptives, during menopause or while taking hormonal medicines. Such events sometimes unmask androgenetic alopecia that had been developing unnoticed.

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What causes androgenetic alopecia

AGA results from a combination of heredity and the action of androgens. It is polygenic: several genes have been linked to it, including the androgen receptor gene and the genes of the enzyme 5-alpha reductase. A family history of baldness raises the risk considerably, although how male and female patterns are inherited is not fully understood.

The key player is dihydrotestosterone (DHT), which is made from testosterone by 5-alpha reductase right inside the hair follicle. Areas prone to baldness show higher DHT levels and more androgen receptors. With each cycle the growth phase gets shorter, the follicle miniaturises, and the pause between a hair falling out and a new one appearing grows longer.

Follicle sensitivity to androgens depends on the area: it is high on the top and crown, while follicles at the back of the head do not respond to androgens. That is why the back of the head keeps its density and serves as the donor area for transplantation.

Androgens are not the whole story. Around shrinking follicles there is often slow, painless micro-inflammation and, later, perifollicular fibrosis. Possible co-factors include microbes at the follicle opening, oxidative stress, internal and external stress and ultraviolet light. In women, AGA can be a sign of androgen excess caused by ovarian or adrenal disorders, but it also develops with normal hormone levels. How different hormones affect hair is explained in the publication Hormones and hair.

What androgenetic alopecia looks like

In men

The typical picture is receding temples and thinning on the crown. Another variant is diffuse thinning on the crown with the front hairline preserved, as in the female pattern. The degree of hair loss in men is graded on the Hamilton–Norwood scale, which has seven stages.

In women

In most women the front hairline is preserved, and thinning follows one of three patterns:

diffuse thinning on the top of the head;
the "Christmas tree" pattern: diffuse thinning in the central part of the scalp along the parting;
thinning with receding temples, similar to the male pattern.

Female thinning is graded on the Ludwig scale. In women AGA can start as early as the teenage years or late, around menopause.

Shared signs

Hair thins gradually, and episodes of heavier shedding alternate with quieter periods. Hairs in the affected area become finer, lighter and shorter. The scalp is often red because of accompanying seborrhoeic dermatitis and may itch or burn. After 50, age-related (involutional) thinning often joins AGA, and the two can be hard to tell apart.

Diagnosis at the Trichology Institute

AGA should not be diagnosed by eye: telogen effluvium, diffuse alopecia areata, thyroid disease, excess prolactin and deficiencies can look much the same. So the examination has several steps.

Trichologist consultation with digital trichoscopy on FotoFinder equipment. The doctor asks how the changes began and progressed, about your family history, medicines and hormonal events, and examines your hair and scalp.
Trichoscopy. Signs of AGA: hairs of different diameters (over 20% of them in androgen-dependent areas), more vellus hairs, follicular units holding just one hair, yellow dots and peripilar signs. The findings are compared with the back of the head, where follicles do not respond to androgens.
TrichoScale phototrichogram and TrichoLab quantitative trichoscopy. They measure density, hair diameter and the share of hairs in each growth phase. These figures become the baseline for judging treatment.
Blood tests. The list depends on your situation; women with signs of androgen excess are referred for hormone tests. Samples can be taken at the clinic, see Laboratory diagnostics.
Biopsy is rarely needed: only with an atypical picture or a suspicion of scarring alopecia. The procedure is described on the Skin biopsy page.

The trichoscopic criteria that separate AGA from other non-scarring alopecias are set out by our doctors in Trichoscopic differential diagnostic algorithms for non-scarring alopecias. Patients of the department are seen by Professor Yuliya Ovcharenko and Professor Inessa Serbina; difficult cases can be reviewed under Professor Ovcharenko's supervision.

Treating androgenetic alopecia

The aim of treatment is to stop progression, increase hair diameter and density, and keep the result. The doctor builds the plan around you: sex, age, stage, hormonal background, other conditions and pregnancy plans. AGA treatment is long term, and its effect is judged over months, not weeks.

Medical treatment

Treatments with proven effect in AGA are 5-alpha reductase inhibitors, which reduce DHT production, and topical hair growth stimulants. Women with signs of androgen excess may benefit from anti-androgens. These medicines have contraindications, including pregnancy planning, so only a doctor chooses the medicine, its form and the length of treatment after an examination. As support, the doctor may add metabolic supplements with amino acids and B vitamins.

Injection and device-based methods

We see AGA not only as a hormonal problem but also as one of micro-inflammation and oxidative stress around the follicle. So, where indicated, basic therapy is combined with:

scalp plasma therapy (PRP): in our experience, the best candidates are men with AGA up to Norwood stage 4 and women with Ludwig stage 1–2;
scalp mesotherapy; our doctors have studied injections of hyaluronic acid with sodium succinate combined with basic therapy in women with AGA at the clinic;
low-level laser therapy with the Theradome PRO LH80 laser helmet and Trichogenesis hair growth multistimulation.

These methods add to medical treatment rather than replace it. For an overview see Injection options in the therapy of hair pathology; procedures are listed in the clinical trichology price list.

When therapy is not enough

When thinning has been stabilised and the bald areas no longer change, hair transplantation can be discussed. Follicles from the back of the head are insensitive to androgens and keep this property in their new place. Operations at the Institute are performed by transplant surgeon Akaki Tsilosani. In women, transplantation makes sense when thinning is localised and the back of the head is dense; with diffuse thinning over the whole scalp it does not work. Transplantation does not stop AGA, so therapy to protect your own hair continues after surgery.

Trichopigmentation adds visual density, on its own or together with transplantation. When the bald area is large and transplantation is not possible, hair replacement systems are an option.

Create a treatment plan

Outlook and follow-up

AGA is a chronic condition, so treatment does not end with the first results. Shedding is usually the first thing to ease; density catches up later. If topical stimulant therapy is stopped without medical advice, shedding returns in about 8–12 weeks, and the hair regrown during treatment is gradually lost.

At follow-up visits we compare phototrichogram and trichoscopy data from the same area and adjust the plan accordingly. This shows changes that are hard to see in the mirror.

The doctor also keeps an eye on related conditions: seborrhoeic dermatitis, age-related thinning, which often combines with AGA after 50 (see Involutional hair loss), and the skin of bald areas, which stays exposed to ultraviolet light. The effect of the sun on a balding scalp is discussed in Scalp ageing and associated conditions.

We see patients by appointment at 17 Danylevskoho St, Kharkiv. Consultation fees are in the price list.

Doctors

Prices

Consultation of a trichologist using digital trichoscopy	2000/1500 UAH
Consultation of the trichologist, follow up (up to 2 months after the first one)	800 UAH
Online consultation with trichologist	2000 UAH
Quantitative trichoscopy using TrichoLab	1500 UAH

Frequently Asked Questions

What happens if I stop treating androgenetic alopecia?

Treatment holds AGA back but does not remove the inherited sensitivity of the follicles. After therapy stops, miniaturisation gradually resumes. This is well described for topical growth stimulants: about 8–12 weeks after stopping, shedding increases, and the hair regrown during treatment is gradually lost.

If your current plan is inconvenient or does not suit you, do not drop it on your own; discuss it with your doctor. The plan can be changed or moved to a maintenance mode without losing what you have gained.

My father went bald early. Does that mean the same will happen to me?

A family history substantially raises the risk of AGA, but it does not decide in advance when it starts or how far it goes. The condition is polygenic: several genes are involved, including the androgen receptor gene on the X chromosome, which a man inherits from his mother. So baldness on both your father's and your mother's side matters.

If baldness runs in the family, have trichoscopy at the first changes: at an early stage much more of your own hair can be kept.

Can young women and teenage girls have androgenetic alopecia?

Yes. In women AGA can start as early as the teenage years or appear late, around menopause. In young women it is often put down to diets, stress or "just heavier shedding" and goes unnoticed for a long time.

If a girl's hair is thinning on the top of the head and she also has an irregular cycle, acne or excess facial hair, the doctor will check for androgen excess. Treatment for teenagers is chosen with particular care, taking age and hormonal development into account.

My hormones are normal. Why was I diagnosed with androgenetic alopecia?

AGA does not require excess androgens in the blood. What matters is the higher sensitivity of follicles on the top of the head to normal hormone levels and the conversion of testosterone to DHT right in the scalp. That is why AGA often develops with normal test results.

At the same time, in women thinning can be a sign of androgen excess due to polycystic ovaries, adrenal disorders and other conditions. Tests are needed so that such causes are not missed. More in the publication Hormones and hair.

Does plasma therapy help with androgenetic alopecia?

Plasma therapy (PRP) means injections of the patient's own platelet-rich plasma, which contains growth factors. Studies are still few and there is no single standard protocol, but in early stages of AGA the method shows a positive effect and combines well with approved treatments.

In our experience, the best candidates are men with AGA up to stage 4 on the Hamilton–Norwood scale and women with Ludwig stage 1–2. The method is discussed in detail in Injection options in the therapy of hair pathology.

Who is a laser helmet for hair growth suitable for?

Low-level laser therapy is recommended as part of combined AGA treatment: it is thought to extend the growth phase, improve blood flow and reduce local inflammation. The Institute uses the Theradome PRO LH80 laser helmet, which lights the whole scalp evenly. The laser is used together with other methods, not instead of them.

There are limits: caution is needed with dark skin phototypes and with medicines that increase light sensitivity, and the method is contraindicated with malignant tumours of the scalp. More on the Laser therapy page.

When can I have a hair transplant for androgenetic alopecia?

A transplant is planned once the process is stable and there is enough dense hair at the back of the head. Restoring the front hairline usually gives a better result than restoring the crown, where hair loss tends to progress even after surgery.

Transplanted hair from the back of the head is insensitive to androgens, but your own hair around it keeps miniaturising, so therapy continues after surgery. Whether a transplant makes sense and which method to use is decided by a trichologist together with the surgeon in the hair transplantation department.

Can vitamins cure androgenetic alopecia?

No. The hair follicle is highly active metabolically and needs amino acids, vitamins and trace elements, so metabolic supplements, for example based on L-cystine with B vitamins, can be part of combined treatment. But the cause of AGA is the inherited sensitivity of follicles to androgens, and vitamins do not affect it.

Relying on supplements alone can cost you the time when the process is still easy to stabilise. Whether you need a supplement and which one is for the doctor to decide, ideally with your test results.

How can androgenetic alopecia be told apart from age-related thinning?

Age-related, or involutional, thinning starts after 50: hair thins very slowly and diffusely. This process does not depend on androgens and works differently from AGA. But on trichoscopy the two look alike, and in older age they often develop together.

So the doctor assesses several areas of the scalp, the age of onset and how the changes progressed. The diagnosis determines which methods make sense. Read about age-related hair changes in Involutional hair loss.

Why is my scalp red and itchy with androgenetic alopecia?

Many patients with AGA have a scalp that is red to some degree. The most common cause is accompanying seborrhoeic dermatitis. There is also persistent redness with burning and tenderness that gets worse in the sun. Slow micro-inflammation is also found around follicles in AGA.

Such scalp conditions are treated together with the hair, because inflammation may hinder the response to therapy. We wrote about persistent scalp redness in Red scalp syndrome, or rosacea of the scalp.

Is the sun harmful with androgenetic alopecia?

Hair does not fully protect the scalp from ultraviolet light, and in thinning areas the skin is almost bare. Examinations of men with AGA found signs of solar elastosis in the skin of the balding area, and these changes can precede hair loss. With age, patches of actinic keratosis may also appear on bald areas.

So protect your scalp from the sun with a hat and show any new spots or crusts to a doctor. More in Scalp ageing and associated conditions.

I am planning a pregnancy. Can androgenetic alopecia be treated?

Yes, but the plan is chosen with this in mind. 5-alpha reductase inhibitors and anti-androgens are not prescribed to women who are planning a pregnancy or are pregnant, because they can disrupt the development of the genitals of a male foetus. So tell your doctor about pregnancy plans at the very first visit.

For this period the doctor will suggest methods compatible with planning a pregnancy. After childbirth hair often sheds more heavily, and it is worth discussing this in advance so that temporary shedding can be told apart from AGA progression.