Changes

May 2026 — reviewed. A literature search was conducted in April to May 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made.

Update

Goals

To support primary healthcare professionals to:

• Make a diagnosis of male pattern hair loss.
• Offer appropriate management in primary care.
• Refer when appropriate to other healthcare professionals (for example, dermatologist, endocrinologist, or mental health services).

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

What is male pattern hair loss?

• Male pattern hair loss (or male androgenetic alopecia) is a patterned, non-scarring, progressive hair loss from the scalp. Hair loss usually involves the front and sides of the scalp initially, then progresses towards the back of the head.
  • Androgenetic alopecia affects men and women, with characteristic patterns for each gender, although the gender-typical patterns may less commonly occur in either. This topic relates only to the condition in men. See the separate topic Female pattern hair loss (female androgenetic alopecia) for information on this type of hair loss in women.

[Blume-Peytavi et al, 2010; Alessandrini, 2020; WHO, 2026]

What causes male pattern hair loss?

• In androgenetic alopecia, there is a change in the hair follicle cycle (progressive shortening of the anogen growth phase and extension of the telogen resting phase), resulting in miniaturization of the hair follicle and a change in long terminal hair to short, fine, vellus hair.
• Although not fully understood, the changes in hair growth are caused by androgens in genetically predisposed people.
  • Dihydrotestosterone (DHT) is the androgen primarily affecting androgen-sensitive hair follicles, which are mainly those in the frontal and temporal areas and the crown.
  • DHT is converted from testosterone by the enzyme 5-alpha-reductase (hence the use of 5-alpha reductase inhibitors in management of the condition). DHT then binds to an androgen receptor on the follicle, activating the changes.
  • Other factors which have been implicated in pathogenesis include androgen receptors (increased expression or activity) and prostaglandins.
  • Sensitivity to androgen is determined genetically, but male androgenetic alopecia has a complex polygenic basis, the details of which have only been partly identified in studies.

[EDF, 2017; Alessandrini, 2020; Dakkak, 2024]

What are the risk factors?

• Age.
  • The prevalence of male androgenetic alopecia (AGA) rises with age.
• Ethnicity.
  • The risk of developing male AGA is higher in Caucasian men, but lower in some other populations such as those of Asian, native American or African origin.
• Family history.
  • Inheritance is polygenic, with input from either or both parents. The risk is lower in men with a non-balding father and higher in those with a balding father.
• Other possible risk factors which have been associated with the presence and/or progression of AGA include:
  • Smoking.
  • Insufficient quality sleep.
  • Comorbidities including overweight/obesity, hypertension, insulin resistance, and insufficient/deficient Vitamin D levels.

[Blume-Peytavi et al, 2010; EDF, 2017; Manabe, 2018; Chen, 2024; Li, 2026]

How common is male pattern hair loss?

• Male pattern hair loss is the most common cause of non-scarring alopecia.
  • It affects up to 80% of men in the course of their life, with a frequency that increases with age after puberty. 
  • Almost all Caucasian men develop some recession of the front of the hair line and at the temples during their teens.
  • It affects 30% of Caucasian men by 30 years of age, 50–60% by the age of 50 years of age, and about 80% by 70 years of age and above.
  • Global incidence varies among ethnic groups, with lower rates reported in some populations, such as those of Asian, Native American or African origin.

[Blume-Peytavi et al, 2010; EDF, 2017; Alessandrini, 2020]

What are the complications?

• Male pattern hair loss can lead to adverse psychosocial effects.
  
  • Physical appearance and hair, in particular, are important determinants of individuality and image in a social and cultural context. Hair loss can therefore lead to:
    • Impaired self-esteem due to negative effects on their individual feelings of attractiveness.
    • Feelings of isolation.
    • Embarrassment in seeking help.
    • Frustration at limited treatment options.
    • Negative perceptions from other people.
    • Impaired quality of life.
  • Psychosocial effects may be more severe in men with more extensive hair loss and earlier onset of symptoms. However, the psychosocial impact on men is often not proportionate to the objective appearance of hair loss.
• Other complications of male pattern hair loss include damage to the scalp as a result of loss of protection against ultraviolet light, cold, and mechanical injury.

[Blume-Peytavi et al, 2010; EDF, 2017; Aukerman, 2023; Frith, 2024]

What is the prognosis?

• Hair loss progresses over time in untreated men, but the rate of progression is unpredictable and extremely variable [Tosti, 2005; Piraccini, 2014]:  
  • Some men eventually lose almost all of the scalp hairs, whilst others retain a considerable amount, particularly in the occipital and parietal areas above the ears.
  • Most of the men who eventually have complete hair loss take 15–25 years to do so, but some may have complete hair loss in less than 5 years.
  • Periods of accelerated hair loss may last up to 6 months, followed by quiescent periods lasting 6–18 months. Shedding activity and thinning may be more noticeable in the autumn and winter months.
  • Men who present with thinning hair in their late teens or 20s are more likely to lose all their hair than those who have gradual thinning that is not obvious until their 30s or 40s.
• Psychological consequences and impact on quality of life are variable, and there is conflicting evidence about the extent and frequency of this, with one systematic review and meta-analysis pointing to heterogeneity in studies and the possibility of conflicts of interest and biased samples [Aukerman, 2023; Frith, 2024].
• Drug treatments can successfully slow down hair loss and, to a lesser extent, produce regrowth of lost hair; however, complete reversal of hair loss is never achieved. 
  
  • With topical treatment  [EMC, 2025a; EMC, 2025b]: 
    • Continuous use for 2 months or more is required before evidence of hair growth can be expected.
    • Trends in the data suggest that men who are younger, have been balding for a shorter period of time, or have a smaller area of baldness on the vertex are more likely to respond to topical treatment; however, individual responses cannot be predicted.
    • Peak hair growth is achieved after 4 months, but treatment must be continued to maintain results.
    • If treatment is stopped, the regrown hair may be lost after 3 to 4 months, and the balding process will continue.
  • With oral treatment [EMC, 2026]:
    • Continuous use for 3–6 months is required before evidence of stabilization of hair loss can be expected.
    • Treatment must be continued to maintain results. If treatment is stopped, the beneficial effects begin to reverse by 6 months and return to baseline by 9–12 months.
• Hair transplantation may be successful, but is expensive for patients and outcomes are variable and depend on the skill of the surgeon and patient selection [PCDS, 2025].

How should I assess a man with hair loss in primary care?

• Take a detailed history to assess the severity and impact of hair loss and to identify possible causes and risk factors. Ask about:
  
  • The timing and pattern of the hair loss, including age of onset, course of hair loss (chronic or intermittent), speed of progression, scalp areas affected, and the history of hair loss (hair shedding or hair thinning). Men with androgenetic alopecia typically describe long-standing, slowly progressing hair loss.
  • Any associated symptoms. Initial signs of androgenetic alopecia may include itching and a burning or stinging sensation in the scalp. However, usually there are no associated symptoms.
  • Past and newly diagnosed medical problems, including systemic disease (such as a recent severe infection), endocrine disorders (such as hypothyroidism), iron deficiency, or an autoimmune or inflammatory disorder.
  • Family history of hair loss.
  • Use of medication that can cause or worsen hair loss (such as chemotherapy, anti-thyroid drugs, anti-epileptics, androgens or anabolic steroids) and any past treatment and response.
  • Dietary habits (such as excessive dieting or fasting, significant rapid weight loss, chronic deficient diet).
  • The normal hair care routine, including hairstyles which result in traction, changes in hairstyle to compensate for alopecia and the use of hair care procedures or products.
  • Smoking history.
  • The psychological impact of hair loss and its impact on quality of life.
• Examine the man.
  • Inspect the scalp. Look for papules or pustules, scaling, scarring, or areas of inflammation. Ask about tenderness or pruritus. The skin of the scalp usually appears normal in androgenetic alopecia.
  • Assess the pattern and distribution of hair thinning.
    • Typically, male pattern hair loss presents with bitemporal recession of the hairline and thinning of the hair of the crown (vertex) and frontal parietal areas. The degree of hair loss can be assessed using the Hamilton-Norwood Scale.
    • About 10% of men with male pattern hair loss present with a female pattern of hair loss, which includes thinning in the density of hair at the crown and frontal scalp, and widening of the central parting, with retention of the frontal hairline. See the section on the Ludwig Scale in the CKS topic on Female pattern hair loss for more information. 
  • Examine the facial and body hairs and nails to help exclude an underlying cause or alternative diagnosis for hair loss.  Absent or reduced eyebrows/eyelashes and/or body hair or may suggest alopecia areata. See the CKS topic Alopecia areata for more information. Nails are usually normal in androgenetic alopecia but may be abnormal in alopecia areata, nutritional deficiencies and other conditions.
• Consider the use of the pull test (depending on clinical judgement and expertise) to determine the ongoing activity and severity of hair loss. 
  • This involves using the thumb and index finger to pull a tuft of 50–60 hairs at around 2 cm from the scalp with gentle traction in different areas of the scalp.
  • The test is positive (confirming active shedding) if more than 3–6 hairs or more than 10% of the grasped hairs are pulled away from the scalp. If positive in the androgen dependent areas, a diagnosis of androgenetic alopecia is more likely (whereas if positive all over the scalp, telogen effluvium is indicated).
  • The test is more likely to be of diagnostic value to a specialist who performs it on a regular basis.
  • Note that the test shows high inter-operator variation, is affected by time since last shampoo and traction force, and that the definition of a positive test varies in the literature.
• Use trichoscopy (dermoscopy of the hair) if there is diagnostic doubt and if the equipment and expertise is available.
  • This magnifies the scalp skin and hair for assessment. In androgenetic alopecia, there are an increased number of vellus hairs or miniaturized hairs (smaller, finer, paler), and more than 20% of hairs in the affected region are of differing diameter. In more severe cases, there may be yellow dots in androgen-dependent regions signifying empty follicles or those containing very miniaturized hairs.
• Suspect an underlying cause or alternative diagnosis if there is:
  • Profound shedding or rapid onset of hair loss — may indicate telogen effluvium.
  • Temporal hair thinning — may indicate traction alopecia, frontal fibrosing alopecia, or hypothyroidism.
  • Absent or reduced eyebrows or eyelashes — may suggest a frontal fibrosing alopecia or alopecia areata.
  • Inflammation, papules or pustules, scaling, or scarring of the scalp — may suggest scarring alopecia.  
  • Systemic disease, such as a recent severe infection, iron deficiency, or hypothyroidism.
  • Exposure to (or a change of) medication.
  • Change in dietary habits or rapid weight loss.
• Consider whether any investigations are required.

What investigations should I consider?

• Laboratory testing for the diagnosis of male pattern hair loss is generally unnecessary as the diagnosis is usually made on history and clinical findings alone.
• Consider checking thyroid function, full blood count, and ferritin and vitamin D levels, particularly if:
  • An underlying cause or alternative diagnosis (such as telogen effluvium) is suspected.
  • The presentation is atypical.
  • There are features of hypothyroidism, anaemia, or vitamin D deficiency. See the CKS topics on Hypothyroidism, Anaemia - iron deficiency, Anaemia - B12 and folate deficiency, and Vitamin D deficiency in adults for more information.

What else might it be?

• Other causes of non-scarring alopecia include:
  
  • Telogen effluvium — a common condition characterized by excessive diffuse shedding of hair due to a stressor causing hair follicles to be prematurely advanced into the telogen (resting) phase. It occurs 2–4 months after a triggering event and is usually self-limiting, lasting for about 6–9 months.
    • Triggers include childbirth, severe infection, excessive diets, major surgery, haemorrhage and drug treatment (for example, lithium, valproate, anti-depressants, warfarin, metoprolol, propranolol, retinoids, isoniazid and oral contraceptives). It may also be an idiopathic condition.
    • Usually, scalp coverage is good because more than half the hair must be lost before it is objectively apparent.
    • In the active phase, the hair pull test may be positive. Later, regrowth with tapered short hairs may be seen.
  • Anagen effluvium — most often chemotherapy-induced anagen (growth stage) hair loss, which usually occurs within two weeks of administration of the chemotherapeutic medication. Usually, growth resumes when the treatment is finished.
  • Alopecia areata — characterized by diffuse, patchy hair shedding in sharply defined areas. There may be associated nail changes such as pitting. It is an auto-immune process and may be associated with other auto-immune conditions. See the CKS topic on Alopecia areata for more information.
  • Syphilis — characterized by patchy hair loss of the scalp and lateral eyebrows, described as having a 'moth-eaten' appearance. These features usually persist for a few weeks and heal spontaneously with or without treatment. See the CKS topic on Syphilis for more information.
  • Traction alopecia — a type of hair loss caused by constant pulling, such as from hair being persistently pulled back in styles such as tight braiding or ponytail.
  • Trichotillomania — a mental health condition in which people pull their hair out. It may be associated with obsessive-compulsive disorder and is more common in children and adolescents and in females. Hair loss is asymmetrical and has an unusual shape. Single or multiple areas can be affected, including eyebrows and eyelashes.
  • Hair fragility from chemical application (such as bleaching or perms).
• Causes of scarring alopecia include:
  
  • Tinea capitis — typical features include an itchy, scaly scalp with patchy, irregular hair loss. Lymphadenopathy (post-auricular and cervical) is often a sign of inflammatory tinea capitis, and in more severe cases, erythema, pustules, permanent alopecia, and scarring of hair follicles may occur. (Tinea capitis may cause scarring or non-scarring alopecia.) For more information, see the CKS topic on Fungal skin infection - scalp.
  • Seborrhoeic dermatitis — an inflammatory condition, causing scaly patches or diffuse scaling in the scalp, which may be associated with or may aggravate hair loss. See the CKS topic on Seborrhoeic dermatitis for more information.
  • Cicatricial alopecia — a diverse group of rare conditions where hair follicles are replaced with fibrotic tissue, leading to permanent hair loss.
  • Discoid lupus erythematosus — characterized by persistent scaly, disc-like plaques on the scalp, face, and ears that may cause violaceous or pink erythema, scarring, and hair loss.
  • Dermatomyositis — a rare acquired inflammatory myopathy that is accompanied by an itchy skin rash. Although a scaly scalp with hair thinning may occur, it is usually characterized by reddish or bluish-purple patches, mostly on sun-exposed areas of the body. 
• Other underlying causes of hair loss include:
  • Endocrine disorders, such as hypothyroidism. See the CKS topic on Hypothyroidism for more information.
  • Iron or vitamin D deficiency. See the CKS topics on Anaemia - iron deficiency, Anaemia - B12 and folate deficiency, and Vitamin D deficiency in adults for more information.
  • Medication — in addition to those listed above, others, including those:
    
    • With an androgenic effect (such as anabolic steroids).
    • With an antithyroid action (such as carbimazole).
  • Other systemic diseases, such as a recent severe infection, systemic lupus erythematosus, or cancer.

Scenario: Management

From age 18 years onwards (Male).

Topical minoxidil

Finasteride

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of alopecia, androgenetic - male.

Search dates

June 2021 - May 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp Alopecia/
• male pattern baldness or hair loss.kw,ti,ab. Telogen effluvium.tw, Androgenic alopecia.tw, generalized alopecia.tw.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
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• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
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Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

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Competing interests declared for this topic:

None.