Case Report: Long-Term Management of Androgenetic Alopecia in a 56-Year-Old Male with Hair Transplant History

At our dermatology clinic in Houston and Katy, Texas, we see many patients with long-standing hair loss who have undergone multiple therapies, including hair transplants and regenerative procedures. This case illustrates the importance of ongoing maintenance for androgenetic alopecia (AGA) and the role of platelet-rich plasma (PRP) therapy in long-term hair restoration care.

Patient Presentation

A 56-year-old male presented for follow-up of generalized hair loss that had been gradually worsening over several years. His history included:

• Two prior hair transplants, with the most recent performed in 2023

• Platelet-rich plasma (PRP) treatments following transplantation

• Use of topical minoxidil in the past

• Current regimen of oral minoxidil 2.5 mg twice daily

The patient denied any scalp symptoms such as itching, scaling, or tenderness.

Clinical Examination

On exam, the patient demonstrated patterned thinning of the vertex and frontotemporal scalp consistent with androgenetic alopecia. No scarring or active inflammation was noted.

Treatment Plan

Maintenance Therapy

The patient was counseled that continued maintenance is critical even after hair transplantation to preserve existing native hair and optimize graft survival.

Platelet-Rich Plasma (PRP) Injections

• The patient elected to restart PRP therapy every 6 weeks.

• A baseline set of scalp photos was taken for monitoring.

• A total of 7 cc of PRP was injected subdermally into the scalp following sterile venipuncture, centrifugation, and preparation.

• Pain control was provided with a Zimmer cooling device, and the patient tolerated the procedure well without complications.

Adjunctive Care

• Continued oral minoxidil 2.5 mg BID and optional topical minoxidil foam.

• Recommended hair vitamins (Inner Glow) for nutritional support.

• Counseling on post-procedure care:

  • Wash hair with sulfate-free shampoo the same day.

  • Avoid hair dyeing for 2–3 days.

  • Continue prescribed hair loss medications and supplements.

Patient Counseling

The risks and benefits of oral minoxidil, PRP injections, and long-term management of AGA were reviewed, including:

• Oral minoxidil side effects: unwanted hair growth, swelling, dizziness, low blood pressure.

• PRP side effects: mild pain, swelling, rare infection, incomplete improvement.

• Long-term expectations: AGA is genetic and progressive, requiring ongoing therapies for best results.

Conclusion

This case underscores that androgenetic alopecia requires lifelong management, even after hair transplantation. By combining oral minoxidil, nutritional support, and maintenance PRP injections, patients can slow progression, enhance transplant results, and achieve fuller, healthier hair.

If you are experiencing male hair loss in Houston or Katy, Texas, our clinic provides advanced therapies including oral and topical medications, PRP, Alma TED, low-level laser therapy, supplements, and surgical options tailored to each patient’s needs.