The treatment of androgenetic alopecia (AGA) is continuously evolving. In 2017 and 2019–2020, we conducted cross-sectional studies aimed at describing prescribing habits for AGA among dermatologists practicing in Spain.1,2 In 2020, the most widely prescribed treatments for male androgenetic alopecia (MAGA) and postmenopausal female androgenetic alopecia (FAGA) were topical minoxidil and oral finasteride. In contrast, for premenopausal FAGA, the most frequently prescribed treatments were topical minoxidil, oral contraceptives, and nutricosmetics. Four years later, we repeated the survey to describe the current situation and compare it with previous data.

We created a digital questionnaire using Google Forms was distributed via social media to dermatologists practicing in Spain from March to June 2024. The survey collected information about the respondents’ workplace, specialty, and whether they were residents or attending physicians. Participants were asked about the most common types of alopecia they manage and the treatments they prescribe for male and female androgenetic alopecia, including premenopausal and postmenopausal cases. Additionally, the survey addressed whether dermatologists recommend hair care treatments, their preferences regarding nutricosmetic products, and whether they perform hair transplantation procedures.

Responses from a total of 202 dermatologists were included. Of these, 164 (81.2%) were attending physicians and 38 (18.8%) were dermatology residents. In addition, 158 (78.2%) were dermatologists with a general dermatology consultation, whereas 44 (21.8%) had a specialized hair disorders consultation.

Regarding workplace setting, 58 dermatologists (28.7%) worked exclusively in private practice, 59 (29.2%) worked in the public healthcare system, and 85 (42.1%) worked in both settings.

The geographical distribution of completed questionnaires was as follows: Madrid (37%), Andalusia (11%), Catalonia (10%), Basque Country (7%), Galicia (7.5%), and other regions (<5%), including the Valencian Community, Navarra, Asturias, Aragon, Cantabria, Castile – La Mancha, Castile and León, Balearic Islands, Canary Islands, and the Region of Murcia.

The most frequent reason for consultation was AGA (51%), followed by telogen effluvium (20%), lichen planopilaris (13%), frontal fibrosing alopecia (FFA, 9%), alopecia areata (7.5%), and other conditions (5%).

The most prescribed individual treatments for male AGA are shown in Fig. 1. When analyzing combinations of treatments, the strongest statistically significant positive correlations were observed between (P<.05; r≥0.25): oral dutasteride and oral minoxidil, oral finasteride and topical minoxidil, topical finasteride and topical minoxidil, and mesotherapy with dutasteride and platelet-rich plasma. All correlations are presented in the Supplementary data (Fig. 1).

Fig. 1.

Frequency of each treatment used in patients with male androgenetic alopecia. PRP, platelet-rich plasma; LLLT, low-level laser therapy.

Treatments prescribed for premenopausal women with AGA are presented in Fig. 2. The strongest statistically significant positive correlations were observed between (P<.05; r≥0.25): oral bicalutamide and spironolactone; oral bicalutamide and mesotherapy with bicalutamide; oral bicalutamide and mesotherapy with dutasteride; oral bicalutamide and platelet-rich plasma; oral dutasteride and oral finasteride; spironolactone and mesotherapy with dutasteride; topical finasteride and mesotherapy with bicalutamide; oral finasteride and topical finasteride; mesotherapy with bicalutamide and mesotherapy with dutasteride; mesotherapy with bicalutamide and platelet-rich plasma; and mesotherapy with dutasteride and platelet-rich plasma. All correlations are available in the Supplementary data (Fig. 2).

Fig. 2.

Frequency of each treatment used in patients with premenopausal female androgenetic alopecia. PRP, platelet-rich plasma; LLLT, low-level laser therapy.

Treatments prescribed for postmenopausal women with AGA are shown in Fig. 3. The strongest statistically significant positive correlations were found between (P<.05; r≥0.25): topical finasteride and topical minoxidil; topical finasteride and nutricosmetics; mesotherapy with dutasteride and platelet-rich plasma; and topical minoxidil and nutricosmetics. All correlations are presented in the Supplementary data (Fig. 3).

Fig. 3.

Frequency of each treatment used in patients with postmenopausal female androgenetic alopecia. PRP, platelet-rich plasma; LLLT, low-level laser therapy.

Regarding hair transplantation, only 18.3% of dermatologists who responded to the survey reported performing surgical transplantation.

As a novel aspect, participants were asked about factors influencing their selection of nutricosmetic products for patient recommendations. The most important factor was ingredient composition (155 respondents, 76.7%), followed by clinical studies related to the product (94 respondents, 46.5%), administration format (40 respondents, 19.8%), advertising impact (14 respondents, 6.9%), and patient recommendations (8 respondents, 4%). Statistically significant correlations were observed between clinical studies and administration format, clinical studies and ingredient composition, and administration format and ingredient composition.

Dermatologists were also asked about the adoption of scalp and hair care approaches (skinification) in their clinical practice. Most respondents (88%) indicated that these approaches had not been adopted. Among those who reported using these techniques, hydrafacial treatments were the most common (8%), followed by LED therapies (4.5%), Indiba treatments (2%), scalp exfoliation (2%), and scalp massages, masks, or revitalizing treatments (1.5%).

Compared with the results obtained in 2019, AGA remains the most frequent reason for consultation, followed by telogen effluvium.

When comparing current data with those from 2019–2020, we observed an increase in the prescription of oral minoxidil and a decline in the use of topical minoxidil. In 2019–2020, oral minoxidil was prescribed for male AGA by 50.6% of dermatologists, for premenopausal AGA by 67.9%, and for postmenopausal AGA by 63%. In the present survey, the proportions increased to 89.1%, 92.1%, and 93.1%, respectively.1 Oral minoxidil may be preferred over topical formulations because of cosmetic advantages and a favorable safety profile. This is supported by a multicenter safety study involving 1404 patients, as well as additional studies including patients with hypertension and healthy individuals in whom blood pressure and heart rate were monitored.3–6 Another relevant finding is the increased prescription of oral dutasteride, which has surpassed oral finasteride as the most frequently prescribed antiandrogen for male AGA. Despite its off-label use, there is substantial evidence supporting the efficacy of dutasteride for male AGA.7,8 Regarding premenopausal AGA, spironolactone has become the most widely prescribed antiandrogen, surpassing oral contraceptives and finasteride compared with the 2019–2020 survey.2 This may be related to its effectiveness, favorable safety profile, and suitability for patients planning pregnancy.9 In postmenopausal androgenetic alopecia, dutasteride has emerged as the most widely prescribed antiandrogen, replacing finasteride. A recent therapeutic guideline from the Spanish Group of Hair Disorders recommends oral minoxidil combined with either a 5α-reductase inhibitor or spironolactone as first-line treatment for female AGA.10 The survey results are consistent with these recommendations. Another development in the treatment of androgenetic alopecia in both males and premenopausal females is the increasing use of mesotherapy with bicalutamide.11 Many of the significant correlations observed suggest that dermatologists frequently combine multiple therapies to address alopecia through different mechanisms, including hormonal modulation, stimulation of hair growth, and improvement of scalp health. This approach may be particularly relevant in female alopecia, where treatment responses can be more variable.

Regarding hair transplantation, 18.5% of participants reported performing this procedure compared with 4.9% in the previous 2019–2020 survey.2 The increase may reflect growing awareness and demand for hair restoration procedures, although survey bias cannot be excluded.

Among nutricosmetic products, formulation composition appears to be the most important factor influencing dermatologist recommendations, followed by scientific evidence. Other factors such as administration format and advertising visibility appear to have a smaller influence.

A novel aspect of this study was the assessment of whether dermatologists recommend skinification treatments in addition to traditional medical therapies. Surprisingly, most respondents reported not incorporating these approaches into their practice despite growing patient interest. Dermatologists may play an important role in guiding the integration of scalp and hair care strategies into comprehensive patient management.

This study has several limitations, including the inability to reach all dermatologists practicing in Spain through the digital survey, which may affect the representativeness of the results. In addition, the survey may not fully capture individualized treatment strategies or differences in maintenance regimens.

AGA remains the leading reason for dermatologic consultation, followed by telogen effluvium. There has been a notable increase in the use of oral minoxidil, and oral dutasteride has emerged as the most frequently prescribed antiandrogen for male AGA, surpassing finasteride and reflecting its increasing acceptance despite off-label use.

For premenopausal AGA, spironolactone has become the most frequently prescribed antiandrogen, surpassing oral contraceptives and finasteride. In postmenopausal AGA, dutasteride has become the most widely used antiandrogen, replacing finasteride.

During the preparation of this work, the authors used ChatGPT to improve the formal aspects of the writing. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

The authors declare that they have no conflict of interest.