A 35-year-old male with androgenetic alopecia. He had been transplanted twice, 6 and 7 years earlier, respectively. He was not advised to follow with a pharmacological treatment and progressed with hair loss over the next 6 years. He was successfully treated with 1 mg oral finasteride: (a) before, (b) after 3 months, and (c) after 12 months of treatment

Autologous hair transplantation remains the only treatment option for advanced patterned baldness. With the advent of micrografting, hair restoration surgery has in general become satisfying. Modern techniques use the visual qualities of hair and varying design patterns to create the optical illusion of more hair than is actually present. However, caution should be exercised in patients under the age of 35 years whose alopecia is still evolving. On all accounts, these patients need to be advised to treat pharmacologically, in the 18 to 40 years age group, usually with oral finasteride for a sustained result of the surgery.

A 30-year-old female, with a positive family history for alopecia and a personal history of 10-year hair loss progression, despite previous treatment with topical alfatradiol, iron supplementations, and an oral contraceptive based on 20 μg ethinylestradiol and 3 mg drospirenone. She was successfully treated with 5 % topical minoxidil solution b.i.d.: (a) before, (b) after 9 months, and (c) after 15 months of treatment

This is an exemplary example for the superiority of topical minoxidil for treatment of female androgenetic alopecia. Traditionally, hair loss in women has been treated with iron supplementation and antiandrogens. The fact is that both have been overestimated in the treatment of female androgenetic alopecia, since they have no proven efficacy in women with normal serum androgen and ferritin levels. Minoxidil causes hair follicles at rest to grow, promotes hair growth through increasing anagen duration, and enlarges suboptimal follicles. Its effect may start as early as 8 weeks and is typically recognizable at 6 months. This case is noteworthy, in that minoxidil treatment increased hair growth even between months 9 and 15, underlining the importance of long-term patient adherence to treatment for best results.

A 10-year-old otherwise healthy girl of Indian origin with a positive family history and 2-year personal history of progressive thinning of hair in the crown area. A diagnosis of premature (androgenetic) alopecia was made. The condition was successfully treated with 2 % topical minoxidil once daily: (a) before, (b) after 3 months, and (c) after 6 months of treatment

A 15-year-old otherwise healthy boy with a positive family history of alopecia noticed progressive thinning of hair since age 12. A diagnosis of premature (androgenetic) alopecia was made. The condition was successfully treated with 2 % topical minoxidil b.i.d.: (a) before, (b) after 3 months, and (c) after 6 months of treatment

The first case series of premature alopecia in children was reported by Tosti et al. There usually is a strong family history of androgenetic alopecia, the children are otherwise healthy, and the hair loss shows a characteristic female pattern distribution (also in males). Efficacy and safety data for topical minoxidil solution are not available before the age of 18 years. Moreover, systemic side effects of topical minoxidil (hypertrichosis and cardiovascular) are observed more frequently in children. Nevertheless, treatment with topical 2 % minoxidil solution, before the age of 12 once daily, thereafter twice daily, is usually safe and very effective.

A 37-year-old male with androgenetic alopecia was successfully treated with 1 mg oral finasteride for 2 years, before switching to split finasteride tablets with deterioration of result: (a) before, (b) after 6 months, (c) after 12 months, and (d) after 24 months of successful treatment with 1 mg oral finasteride (Propecia®) and (e) deterioration within 9 months after switching to a quarter tablet daily of a 5 mg oral finasteride generic

In an effort to save money, some users buy 5 mg finasteride tablets instead of the original 1 mg pill and split them into several parts to approximate the 1 mg dosage. Navarro Guerrero et al. performed a galenic-pharmaceutical study of pieces of Proscar® (5 mg finasteride) tablets and Propecia® in the treatment of male androgenetic alopecia and demonstrated a high variability in the dosage of pieces of tablets ranging from 0.49 to 1.81 mg of finasteride, only 10 % being within the dosage range. Finally, the 1 mg finasteride pills are coated to prevent contact with the active ingredient during handling, and dust or crumbs from broken 5 mg finasteride tablets should be kept away from pregnant women or women who may become pregnant due to teratogenicity. Splitting 5 mg finasteride tablets to treat androgenetic alopecia is therefore an inappropriate practice from the point of view of dosage variability and safety.

A 28-year-old male with androgenetic alopecia successfully treated with 1 mg oral finasteride over 12 months was successfully switched to 0.5 mg oral dutasteride for further improvement: (a) before, (b) after 6 months, and (c) after 12 months of 1 mg oral finasteride treatment and (d) further improvement within 3 months after switching to 0.5 mg oral dutasteride

Gubelin Harcha et al. recently demonstrated efficacy and safety of 0.5 mg dutasteride in increasing hair growth and restoration in male androgenetic alopecia while being well tolerated. In another study performed by Jung et al., 0.5 mg dutasteride/day also proved to be effective in men with androgenetic alopecia recalcitrant to finasteride. As opposed to finasteride, which is a selective 5-alpha reductase isotype I-inhibitor, dutasteride is a dual inhibitor of 5-alpha reductase isotypes I and II, therefore further lowering circulating plasma levels of dihydrotestosterone. A point to be made is that the plasma half-life time of dutasteride (3–5 weeks) is significantly longer than that of finasteride (age-dependent, from 5 to 8 h).

A 60-year-old female with androgenetic alopecia allergic to minoxidil successfully treated with 5 mg oral finasteride: (a) before, (b) after 6 months, and (c) after 12 months of treatment

Thai and Sinclair originally reported successful oral finasteride treatment of female androgenetic alopecia in a postmenopausal woman. Trüeb et al. later reported successful treatment with 2.5 or 5 mg/d oral finasteride in 5 normoandrogenic, postmenopausal women. In the so far largest series of 37 premenopausal women treated for 1 year with finasteride in doses of 2.5–5 mg daily, Iorizzo et al. showed improvement in 62 % as assessed by global photography.

A 34-year-old female with androgenetic alopecia and inadequate response to 5 % topical minoxidil b.i.d. was successfully treated with low-level laser therapy (LLLT): (a) before, (b) after 1 year of 5 % topical minoxidil b.i.d, and (c) after 6 months adding on LLLT

Currently, topical minoxidil solution and 1 mg oral finasteride are the treatments with the highest levels of medical evidence for treatment of female and male androgenetic alopecia, respectively, but patients who exhibit intolerance or poor response to these treatments are in need of additional treatment modalities. Although low-level energy laser treatments (LLLT) have been therapeutically used in medicine for photobiostimulation in a variety of indications more than 30 years, it has only recently found the attention of the scientific community for the treatment of androgenetic alopecia. In a study of 32 patients with androgenetic alopecia treated with LLT, Munck et al. demonstrated clinical efficacy of the device both as monotherapy and as concomitant therapy, in terms of clinically relevant improvement of appearance of hair. Of the patients, 25 % showed significant improvement, and 62.5 % showed moderate improvement in global photographic assessments. The effect was observed as early as 3 months of treatment and was sustained up to a maximum observation time of 24 months. The technology appears to work better for some than for others, and it seems that patients with intermediate alopecia respond best, since effective photobiostimulation depends on a minimum of hair for effective photobiostimulation and on a maximum of hair for the laser beam to reach the scalp without absorption or interference from existing hairs.

A 37-year-old male with androgenetic alopecia was successfully treated with 1 mg oral finasteride for 15 months and wished to switch to 5 % topical minoxidil b.i.d.: (a) before, (b) after 15 months of 1 mg oral finasteride treatment, and (c) 4 months after successful switch to 5 % topical minoxidil b.i.d

1 mg oral finasteride daily is the first-line agent for improvement or prevention of progression of male androgenetic alopecia in male patients aged 1–40 years. Finasteride daily has also proven to be effective in aging male, though with a lesser degree of efficacy and a higher frequency of sexual adverse effects. Therefore, in men aged 35 years or more, a successful switch from oral finasteride to topical minoxidil may be considered in anticipation of age-related more frequent sexual function-related problems

A 70-year-old otherwise healthy male complaining of age-related thinning of hair was successfully treated with 5 % topical minoxidil b.i.d.: (a) before, (b) after 3 months, and (c) 6 months of treatment

Senescent alopecia has been defined as non-androgen-dependent hair thinning found in those over 60 years of age. Much like androgenetic alopecia, it involves a progressive decrease in the number of anagen follicles and hair diameter. It frequently occurs together with androgenetic alopecia, further complicating its delineation from the latter. Nevertheless, recent data comparing androgenetic and senescent alopecia using microarray analysis have demonstrated significant differences in the gene expression patterns suggesting they represent different entities. Moreover, topical minoxidil has not been studied in the specific perspective of aging and senescent alopecia. Nevertheless, clear treatment benefits of topical minoxidil solution are noted in the older age group that has retained some hair.

A 83-year-old otherwise healthy female with age-related thinning of hair was successfully treated with 2 % topical minoxidil b.i.d.: (a) before, (b) after 3 months, and (c) 6 months of treatment

Hair length, color, and cosmetic properties play an important role in people’s physical appearance and self-perception. Our preoccupation with the condition of our hair is heightened as today’s increasing life expectancy fuels the desire to preserve youthfulness. For the time being, the current available treatment for age-related hair loss is topical minoxidil, though with some limitations: Specifically, older patients often suffer from a variety of conditions that may also affect the condition of the hair—nutritional deficiency, endocrine disorders, psychological problems, and drug-related adverse effects. Therefore, one must remain suspicious of the possibility of a more general problem underlying the patient’s complaint in taking care of the elderly with hair problems. Finally, nocebo reactions are observed more frequently in women of the older age group. Symptoms have a high level of psychosomatic background and include nausea, headaches, and drowsiness. Frequently observed objective findings are increased pulse frequency and blood pressure. The influence of the prescribing physician should be kept in mind, since inspiring confidence versus skepticism and fear clearly impacts the outcome of treatment.

A 74-year-old otherwise healthy female suffering of hair loss was prescribed 5 % topical minoxidil once daily without success after 6 months of treatment. It was found that she was not supplied with an appropriate pipette and therefore underdosed her medication. After a switch to the appropriate 1 mL pipette, her hair growth increased within 3 months: (a) before treatment, (b) after 6 months of inadequate treatment, and (c) 3 months after switching to the appropriate 1 mL pipette. (d) At the left is the wrong pipette, and at the right the correct 1 mL pipette for application of 5 % minoxidil solution

Even with a correct diagnosis of a hair condition and appropriate treatment for that specific condition, a proportion of patients do not get better. When it comes to topical treatments, poor adherence is the most likely reason for nonresponse. In this case, the patient was provided with a wrong pipette and therefore unknowingly underdosed her topical minoxidil. In the treatment of hair loss, one must always remain open-minded for the possibility of a multitude of cause-relationships underlying hair loss and treatment failures.

A 16-year-old female with alopecia areata >30 % of scalp surface and >6 months’ duration and evidence of female pattern hair loss as a comorbid condition. She was successfully treated with a combination treatment of repeated intralesional triamcinolone acetonide 10 mg/ml and a compound of topical 5 % minoxidil and 0.2 % triamcinolone acetonide: (a, b) before, (c, d) after 3 months, and (e, f) after 6 months of treatment

A recent meta-analysis of published trials on treatment of alopecia areata states that only few treatments have been well evaluated in randomized trials. The authors found no randomized controlled trials on the use of diphenylcyclopropenone (DCP), or intralesional corticosteroids, and although topical steroids and minoxidil are widely prescribed, the authors found no convincing evidence that they are beneficial. Therefore, they concluded that considering the possibility of spontaneous remission, especially for those in early stages of the disease, the options of not being treated therapeutically or, depending on individual preference, of wearing a wig may be alternative ways of dealing with this condition. Nevertheless, depending on patient age, surface area, and disease duration, a treatment algorithm for successful treatment of alopecia areata can be designed.

A 25-year-old female with diffuse alopecia areata of <3 months’ duration. Successful i.v. methylprednisolone pulse therapy (500 mg on 3 consecutive days, repeated after 1 and 2 months): (a) before, (b) after 4 months, and (c) after 8 months of treatment

A 55-year-old female with diffuse alopecia areata of <3 months’ duration. Successful i.v. methylprednisolone pulse therapy (500 mg on 3 consecutive days, repeated after 1 and 2 months) followed by a compound of topical 5 % minoxidil and 0.02 % triamcinolone acetonide b.i.d: (a) before, (b) after 6 months, (c) after 9 months, (d) after 12 months, and (e) after 15 months of successful treatment, including repigmentation of initial regrowth of white hair

The art of using corticosteroids for treatment of alopecia is maximizing efficacy and minimizing toxicity. Friedli et al. originally reported effectiveness of intravenous methylprednisolone pulse therapy for alopecia areata with rapid and extensive hair loss much in the same way as for treatment of other autoimmune diseases. Subsequently, Nakajima confirmed efficacy of intravenous methylprednisolone pulse therapy and found remission rates 88 % for multilocular disease with surface area <50 %, 59.4 % with surface area >50 %, and 21.4 % in alopecia totalis/universalis. After 6 months of disease onset, the remission rate was 15.8 %. Finally, Im et al. identified disease duration before treatment in relation to the type of alopecia areata to be of prognostic relevance, with good response obtained for all types of alopecia areata with a duration of <3 months before treatment and for the multifocal type of alopecia areata with a duration of <6 months.

A 50-year-old otherwise healthy male with sudden graying of hair (a) before, (b) after 6 months, and (c) after 9 months of successful treatment with a compound of topical 3 % minoxidil and 0.2 % triamcinolone acetonide b.i.d

The condition of sudden graying or whitening of scalp hair has most recently been designated Thomas More syndrome, alluding to the English martyr Thomas More, whose hair allegedly turned white overnight in the Tower of London before his execution. Although the actual incidence is rare, this stigmatizing phenomenon has captured storytellers’ imagination like few other afflictions as a sign of grave sorrow. History also records that the hair of the ill-fated French Queen Marie Antoinette turned white the night before her walk to the guillotine during the French Revolution, hence the original term Marie Antoinette syndrome for the same condition. Although Marie Antoinette has originally been chosen as eponym for the syndrome, presumably out of dermatological gallantry, Thomas More, whose hair turned white in 1535, ought to have the right of seniority over Marie Antoinette who succumbed to the same fate in 1793. Since there seems to be no other particular reason for favoring Marie Antoinette over Thomas More, out of fairness, it seems appropriate to use the term ‘Marie Antoinette syndrome’ for the condition afflicting women and ‘Thomas More syndrome’ in men. Today, the syndrome is interpreted as an acute episode of diffuse alopecia areata in which the ‘overnight’ whitening of hair is caused by the preferential loss of pigmented hairs in a supposedly immune-mediated disorder. Ultimately, these observations have led authorities to speculate that the autoimmune target in alopecia areata may be related to the hair follicle melanin pigment system. Treatment is the same as of alopecia areata with the potential of repigmentation.

A 40-year-old male with a 20-year history of recurring alopecia areata and total alopecia for 1 year. A trial with homeopathic treatment did not have any effect. Successful treatment with clobetasol propionate 0.05 % ointment under occlusion with Saran wrap on 6 consecutive nights per week: (a) before, (b) after 4 months, and (c) after 6 months of treatment. Small residual patches were thereafter injected with 10 mg/ml triamcinolone acetonide