WASHINGTON — Hair is integral to gender identity for many transgender patients, and just as unwanted hair can affect gender dysphoria, so can patterned hair loss resulting from gender-affirming hormone therapy.

“Very often hair loss is considered cosmetic, and it absolutely is not. And in this environment where patients are just trying to feel like themselves, hair loss associated with that process can really impede someone from getting to where they need to be,” said Adam Friedman, MD, professor and chair of dermatology at The George Washington University (GWU) School of Medicine and Health Sciences in Washington, DC.

And while high-quality research on hair-loss treatments outside of cisgender populations is sparse, dermatologists can extrapolate data and play an important role in this element of gender-affirming care, according to Friedman, who spoke at a conference held at GWU titled “From Evidence to Equity: Dermatologic Care for Sexual and Gender Minorities.”

In transmasculine patients receiving testosterone therapy, increased dihydrotestosterone production leads to increased facial and body hair growth but also increases the risk for patterned hair loss, typically 2-5 years after testosterone initiation. A 2021 retrospective cohort study of 988 patients who underwent masculinizing hormone therapy showed an increase in the incidence of androgenetic alopecia (AGA) from 0.4% prior to testosterone initiation to 3.1% over a median of 3.4 years.

The 2- to 5-year lag to development of AGA is not yet well appreciated, Friedman said. “Often, the patient doesn’t know they’re connected, so it’s important for us to educate other specialists” involved in gender-affirming care, he said. And for patients, “we have to normalize that [pattern hair loss] is something that can happen with transitioning and that there are things we can do about it.”

In transfeminine patients, estrogen and antiandrogen therapy can reduce body hair growth rate and density but typically do not eliminate facial hair, making hair-removal therapies such as electrolysis and laser treatment important tools. In these patients, however, “we also need to consider the risk for patterned hair loss,” Friedman said. “They may already be moving in that direction when they’re transitioning.”

When assessing hair loss in transgender or gender diverse (TGD) patients, “the male- or female-pattern hair-loss nomenclature has to be thrown in the dumpster,” he said, as does use of sex-based classification systems or scales, such as the Norwood-Hamilton and Ludwig scales.

Instead, he recommended using the Basic and Specific classification and/or the Bouhanna scale, which are applicable across all gender identities.

Selecting Treatments for Patterned Hair Loss

In Friedman’s toolbox, low-dose oral minoxidil (LDOM) ranks high as a first-line option for transmasculine individuals and, especially in combination with spironolactone (used off-label for female-pattern hair loss), for transfeminine patients.

Topical minoxidil is an appropriate first-line therapy as well — and was proposed as such in a 2023 review of AGA in TGD patients. But “in real-world practice, topical therapy frequently falls short because patients struggle with twice-daily applications, scalp irritation, [or] cosmetic issues or simply don’t achieve the response they’re hoping for,” Friedman told Medscape Medical News after the meeting.

“While we don’t yet have robust transgender-specific trials, the efficacy data [for LDOM] from [AGA] studies are compelling,” he said, noting that initial hair density increases as early as 3 months after treatment initiation. Large retrospective safety studies, moreover, have shown LDOM to be generally well tolerated.

When LDOM is chosen, Friedman typically starts transfeminine patients on 0.625 mg of LDOM daily and transmasculine patients on 1.5-2 mg daily, often increasing to 1.25 mg/d and 2.5-5 mg/d, respectively.

For transfeminine patients, LDOM in combination with spironolactone is a valuable option because of the medications’ complementary mechanisms, he said. While minoxidil directly stimulates follicular growth, spironolactone reduces androgen signaling. (Spironolactone generally should be avoided in transmasculine patients due to its testosterone-lowering effects.)

Spironolactone often serves a dual purpose for transfeminine patients “because it’s already commonly incorporated into gender-affirming hormone therapy and may also improve hirsutism, making it particularly appealing,” Friedman said.

Spironolactone also may help mitigate LDOM-induced hypertrichosis and edema (facial and leg), he explained at the meeting, noting two recent publications: a 2025 report on reduction of LDOM-induced edema with spironolactone and a 2026 letter on reduction of LDOM-induced facial hypertrichosis with spironolactone.

Hypertrichosis is the most common adverse effect of LDOM. In a 2021 retrospective study of patients treated with LDOM for at least 3 months (a study not focused on the TGD population), hypertrichosis affected 15%. Lightheadedness, fluid retention, and tachycardia were among the less common systemic adverse events, affecting 1.7%, 1.3%, and 0.9%, respectively. Periorbital edema was even more uncommon (0.3%).

Hypertrichosis may be welcomed by some transmasculine patients but unwelcomed by some transfeminine patients. “That’s why you want to start low and go slow [with LDOM]” in transfeminine individuals, Friedman said at the meeting.

Pericardial effusions are generally associated with much higher antihypertensive doses of minoxidil and not with the low doses used for alopecia, he emphasized, noting a 2024 cross-sectional study that screened patients on LDOM and those not on minoxidil for pericardial effusions.

Spironolactone isn’t appropriate for everyone. At higher doses and in older patients, spironolactone may require monitoring for hypotension and, less commonly, hyperkalemia. “And it should be used cautiously in patients with renal disease,” Friedman told Medscape Medical News.

“There are also emerging data suggesting that spironolactone may influence estradiol levels in some patients, which reinforces the need for individualized management alongside the patient’s endocrinologist,” he said.

A retrospective analysis that Friedman and colleagues conducted using the Humana insurance database, published in 2020, showed no association between spironolactone and breast cancer recurrence.

Oral 5-alpha-reductase inhibitors are also in the toolbox, particularly for transmasculine patients, but their use should be delayed for at least 2 years after the initiation of testosterone therapy to allow for secondary sex characteristic development, according to Friedman.

As with minoxidil, limited published guidance about AGA in TGD patients prioritizes the use of topical finasteride over the oral version when finasteride is chosen, but “the evidence supporting oral therapy [in the general population] is substantially stronger,” Friedman said in the interview. “Although transgender-specific data are sparse, the available evidence in transmasculine patients demonstrates clinical improvement without meaningful changes in testosterone levels or sexual desire.”

Not every patient should start with oral therapies for AGA, he added, “but I do think we should be willing to escalate earlier when topical therapy is unlikely to meet a patient’s goals.”

Minoxidil treatment, he noted at the meeting, can cause a temporary increase in hair shedding during the first several weeks, but this shedding has been shown in recent research to predict treatment efficacy. Setting expectations ahead of time is important, he said.

So is the use of clinical photography, regardless of the selected treatment. Hair growth is so gradual and changes “so subtle” that without photography, patients often struggle to recognize improvements, he said at the meeting.

Small studies of young adults undergoing testosterone therapy have shown 5%-17% developing mild AGA, as noted in a 2021 review article in Pediatric Dermatology on dermatologic considerations for TGD youth. Minoxidil and low-level light treatment appear to be safe in this population at any time during testosterone therapy, Friedman said.

Advice on Hair Removal in Transfeminine Patients

The most definitive hair-removal procedures — electrolysis (most effective for blonde hair) and laser treatment (best for light skin and dark hair) — are both costly, and there is no clear evidence for superiority of one over the other, according to Friedman.

Electrolysis is operator-dependent and is “a little tricky logistically,” said Steve Daveluy, MD, professor of dermatology at Wayne State University in Detroit, Michigan, and another speaker at the meeting. “Even if the patient’s insurer approves it, most medical offices don’t offer it.”

Therefore, some dermatologists are “trying creative ways to make it accessible, like having a trained professional who does electrolysis come to their clinic 1 day a week to perform the treatment,” Daveluy said. “The clinic pays them directly and then bills the insurer.”

Asked about the safety and efficacy of home electrolysis devices, he said he hasn’t yet had enough experience with his patients to render a definitive answer. “But if they’re not having problems with it, it’s probably safe to do,” he said. “I’d maybe have them come in and show me.”

Another speaker at the meeting, John Trinidad, MD, a dermatologist and director of underserved populations at Massachusetts General Hospital in Boston, cautioned that his “only caveat” would involve use of home electrolysis for presurgical hair removal, such as before vaginoplasty. “I wouldn’t trust using the machine” for this indication, he said. “I’d counsel the patient to see someone trained in electrolysis and laser hair removal.”

Topical eflornithine is “often overlooked” as an adjunctive treatment for transfeminine patients, Friedman said in the interview. “It slows the rate of facial hair growth, making shaving easier and enhancing the results of laser hair removal or electrolysis.”

And it can be valuable for individuals who face financial barriers to procedural care. Access to eflornithine has become more challenging since the original branded formulation was discontinued, and it is now only available only via compounding, but “nevertheless, for carefully selected patients, it remains another useful tool that can meaningfully improve gender affirmation and quality of life,” he said.

Friedman, Trinidad, and Daveluy reported no relevant financial disclosures.