Alopecia and Hair Growth in Gender-Affirming Care for Transgender Patients

Conclusions

• Pattern hair loss in gender-diverse patients is strongly influenced by sex hormones, with testosterone promoting androgenic alopecia and estrogen plus anti-androgens often reducing hair loss or increasing hair density.
• Hair loss and hair growth can both be gender-affirming, so treatment should be guided by each patient’s goals rather than assuming that all alopecia is unwanted.
• The BASP classification appears to be a more practical and reliable way to grade pattern hair loss across genders than older male-only or female-only scales.
• Trans men on testosterone commonly experience frontal/temporal scalp hair thinning and many desire more facial hair, making both scalp-loss and facial-hair management important parts of care.
• Topical and oral minoxidil are effective options for hair growth, and oral minoxidil may offer similar efficacy to topical treatment with easier use and lower cost barriers for some patients.
• Small trans-specific trials suggest oral or sublingual minoxidil can improve scalp hair growth in transgender people receiving testosterone, though quality-of-life effects may be harder to detect in small studies.
• Finasteride can improve androgenetic alopecia in trans men on stable testosterone, but timing, fertility potential, and possible effects on masculinization should be discussed carefully.
• Feminizing hormone therapy with estradiol and anti-androgens can improve scalp hair growth in transfeminine patients who have androgenic alopecia.
• Future topical antiandrogens such as clascoterone may become valuable because they may improve scalp hair without broadly blocking systemic testosterone effects.
• Facial hair growth is a major gender-affirming goal for many trans men, and topical minoxidil or facial-hair transplantation can help when testosterone alone is insufficient.
• Dermatologists have an important role in using individualized, evidence-based medical and surgical approaches to support both hair restoration and gender affirmation in transgender and gender-diverse patients.