Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2025;15(1):4698 1 Clinical and Trichoscopic Evaluations of Topical Finasteride 1%, Topical Spironolactone 5%, and Minoxidil 5% in Female Pattern Hair Loss Treatment Naglaa Mohamad Al Sayed1, Eman Hamed El Morsy1, Tarek Mahmoud Hussein1, Eman Mohamed Hassan1 1 Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Alexandria University, Alexandria, Egypt Key words: Finastreide, Spironolactone, FPHL Citation: Al Sayed NM, El Morsy EH, Hussein TM, Hassan EM. Clinical and Trichoscopic Evaluations of Topical Finasteride 1%, Topical Spironolactone 5%, and Minoxidil 5% in Female Pattern Hair Loss Treatment.DermatolPract Concept. 2025;15(1):4698. DOI: https://doi. org/10.5826/dpc.1501a4698 Accepted: August 20, 2024; Published: January 2025 Copyright: ©2024 Al Sayed et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Dr. Eman Mohamed Hassan, Faculty of Medicine, Department of Dermatology, Venereology and Andrology, Alexandria University, El Azarita 21131, Alexandria, Egypt. E-mail: dr_eman_mh@yahoo.com Introduction: Female pattern hair loss (FPHL) is one of the most common forms of diffuse alopecia in females. Despite the availability of multiple treatment options, FPHL management poses challenges for the dermatologist. Objectives: We aimed to compare the efficacy and safety of topical finasteride 1% solution and spironolactone 5% solution to minoxidil 5% solution in the treatment of FPHL clinically and tricho- scopically. Methods: Forty-five adult female patients diagnosed with FPHL were divided into three groups of 15 each. Group A was treated with topical finasteride 1%, group B used topical spironolactone 5%, and group C was treated with topical minoxidil solution 5 %, all groups were treated for 16 weeks. Results: By the end of 16th week, significant improvement on the Sinclair scale was observed in groups A and C, but the difference between the three groups was statistically insignificant. Trichoscop- ically, hair density significantly increased in groups A and C. There was a significant reduction in the number of patients with yellow dots, peripilar sign, and single hair follicular units (FU) in group A. In group C, a significant reduction in the number of patients with yellow dots and single hair FU was documented. No trichoscopic changes were detected in group B. Conclusions: Topical finasteride is as safe and effective as topical minoxidil in FPHL. Both treatments showed greater effectiveness clinically and trichoscopically than topical spironolactone. The use of topical finasteride may be another solution for the treatment of FPHL in minoxidil non-responders or in the presence of intolerable side effects. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2025;15(1):4698 Introduction Female pattern hair loss (FPHL) is a common hair disorder that has a negative psychological impact on female patients. It is distinguished from other hair disorders by progressive miniaturization of the hair follicle (HF) with transformation of terminal hair into vellus hair [1]. Hair shaft diversity, yel- low dots and peripilar pigmentations are known trichoscopic features of FPHL [2]. Androgenic and nonandrogenic factors, including genetic predisposition, are suggested in the patho- genesis of FPHL. However, the relation to androgens is not completely understood [3,4]. Topical and systemic treatment options are available, yet incomplete satisfactory results are obtained. Topical minoxidil 2% solution or 5% foam are the only FDA-approved therapeutic options for FPHL. Increased angiogenesis and prostaglandin synthase-1 are suggested mechanisms of action [5]. Reports on the efficacy of oral fi- nasteride as a selective 5α-reductase type II enzyme inhibitor in FPHL are conflicting; additionally, its teratogenic effect limits its use. To overcome this issue, topical formulation has been proposed [6]. Spironolactone, another antiandrogen drug, has been used as an off-label indication for FPHL. Top- ical spironolactone may maximize its absorption with the advantage of minimizing oral side effects [7]. Because of the paucity of clinical studies addressing the efficacy and safety of topical formulations in the treatment of FPHL, the selec- tion of the treatment is challenging for physicians. Objectives The present study aimed to evaluate the efficacy and safety of topical formulation of finasteride 1% solution and spirono- lactone 5% solution compared to minoxidil 5% solution in the treatment of FPHL, both clinically and trichoscopically. Methods The current prospective randomized study was conducted in the Hair Outpatient Clinic, Dermatology Department, Fac- ulty of Medicine, Alexandria University. Study approval of the local medical research ethics committee was obtained, in addition to written informed consent from all patients (IRB NO: 00012098-FWA NO: 00018699). Study Participants and Treatment Protocol Forty-five adult female patients aged >18 years participated in the present study. They were diagnosed as FPHL accord- ing to history and clinical and dermoscopic evaluation [8]. Exclusion criteria: hair growth-promoting drugs in the preceding three months, any systemic disease, including hy- perandrogenism, or local scalp diseases. Pregnant or lactat- ing females were also excluded. The participants were randomly divided into three equal groups using the sealed envelope method. Group A applied finasteride 1% solution, group B applied 5% spironolactone solution, and group C applied 5% minoxidil solution, all for four months. Solutions were dispensed in identical 60 ml dropper bottles. Patients were asked to apply one dropper (1ml) of the prepared solution on a dry clean scalp, followed by gentle massage for the frontal and vertex area. The solu- tions were applied twice per day for 16 weeks. The patients were asked to return empty bottles every four weeks to en- sure their compliance to treatment. Patient Evaluation Clinical Assessment Participants were graded from 1–5 on the Sinclair scale. Global photography of vertex and frontal views, with hair parted in the center, were taken at baseline and at the end of the treat- ment period. The photos were evaluated by two independent blinded investigators. Quartile grading scale of improvement was used at the end of the study as follows; (0–24%) poor improvement, (25–50%) mild improvement, (51–75%) mod- erate improvement, and (76–100%) great improvement. The degree of patient satisfaction was reported as dissatisfied, slightly satisfied, moderately satisfied, and highly satisfied. Trichoscopic Assessment For uniformity of assessment, a fixed target area of 1 cm2 was selected on the frontal area, and the site was maintained by measuring 9 cm from the glabella. Trichoscopic examination was performed with a handheld DermLiteaVIdermatoscope (3Gen) at a 10-fold magnification. Hair diversity >20% was a preliminary diagnostic criterion for FPHL. Dermoscopic images were assessed by an independent investigator before and after treatment for hair density, yellow dots, peripilar sign, honeycomb hyperpigmentation, and percentage of sin- gle hair follicular units (FU). For better assessment of the single hair FU, it was further subdivided into (25%–50%), (51–75%), and (>75%) involvement of the scalp. Safety Assessment No side effects were reported. Statistical Analysis of the Data Data were fed to the computer and analyzed using IBM SPSS software package version 20.0. (IBM Corp). Significance of the obtained results was judged at the 5% level [9]. Results The present study included 45 adult female patients with FPHL, with an age range of 23 to 43 years. FPHL was graded according to the Sinclair scale. The patients were randomly Original Article | Dermatol Pract Concept. 2025;15(1):4698 3 divided into three equal groups (n=15 each). No significant differences among groups regarding demographic and clini- cal data were detected (Tables 1 and 2). Clinical Evaluation Although there was improvement on the Sinclair scale by the end of 16th week, the difference between the three groups was statistically insignificant (P =0.244). Nonetheless, ac- cording to the evaluation of each group separately, a signif- icant improvement on the Sinclair scale was documented in both groups A and C over the treatment period (P =0.046 and P = 0.025, respectively) (Table 2). Trichoscopic Evaluation Before the start of the treatment, concerning yellow dots, peripilar sign, honeycomb hyperpigmentation and single hair FU%, no significant differences were observed between the threegroups, nor at the end of the treatment. However, some changes in the trichoscopic features were noticed in each separate group by the end of the study (Tables 3 and 4). Table 2. Comparison between the Three StudyGroups according to the Sinclair Scale. Sinclair Scale Group A (n=15) Group B (n=15) Group C (n=15) χ 2 MCp Stages before treatment 1 0 (0%) 0 (0%) 0 (0%) 1.574 0.894 2 2 (13.3%) 1 (6.7%) 3 (20%) 3 8 (53.3%) 10 (66.7%) 8 (53.3%) 4 5 (33.3%) 4 (26.7%) 4 (26.7%) Stages after treatment 1 0 (0%) 0 (0%) 0 (0%) 5.564 0.244 2 2 (13.3%) 2 (13.3%) 4 (26.7%) 3 12 (80%) 9 (60%) 11 (73.3%) 4 1 (6.7%) 4 (26.7%) 0 (0.0%) MH (p0) 14.0*(0.046*) 2.500(0.317) 16.500*(0.025*) χ 2: Chi squared test. Abbreviation: MC: Monte Carlo; MH: Marginal Homogeneity Test. p: p-value for comparing between the three studied groups p0: p-value for comparing between before and after treatment in each group *: Statistically significant at P≤0.05 Table 1. Comparison between the Three StudyGroups according to Demographic Data. Demographic data Group A (n=15) Group B (n=15) Group C (n=15) Test of sig. p Age (years) Median (Min. – Max.) 35 (24–42) 34 (25–43) 34 (23–43) F = 0.053 0.948 Mean ± SD. 32.87 ± 5.88 33.27 ± 6.35 32.53 ± 6.23 Family history Negative 5 (33.3%) 5 (33.3%) 4 (26.7%) χ 2 = 0.301 MCp = 1.000 Positive 10 (66.7%) 10 (66.7%) 11 (73.3%) Duration (years) Median (Min. – Max.) 5 (2–10) 5 (1–10) 5 (1.5–10) F = 0.120 0.887 Mean ± SD. 5.13 ± 2.50 5 ± 2.59 4.70 ± 2.33 Abbreviations: SD: Standard deviation; χ2: Chi squared test; MC: Monte Carlo; F: F for One way ANOVA test; p: p-value for comparing between the three studygroups. Table 3. Distribution of all Studied Cases according to Trichoscopic Findings. Before treatment No. % Yellow dots 26 57.8 Peripilar sign 28 62.2 Honeycomb pigmentation 11 24.4 Single hair FU 25–50% 8 17.8 50–75% 13 28.9 >75% 24 53.3 4 Original Article | Dermatol Pract Concept. 2025;15(1):4698 Table 4. Comparison between the Three StudyGroups according to TrichoscopicFindings. Group A (n=15) Group B (n=15) Group C (n=15) χ 2 p Yellow dots Before treatment No 7 (46.7%) 8 (53.3%) 4 (26.7%) 2.368 0.306 Yes 8 (53.3%) 7 (46.7%) 11 (73.3%) After treatment No 14 (93.3%) 11 (73.3%) 11 (73.3%) 2.585 MCp = 0.339 Yes 1 (6.7%) 4 (26.7%) 4 (26.7%) McNp0 0.016* 0.250 0.016* Peripilar sign Before treatment No 3 (20%) 7 (46.7%) 7 (46.7%) 3.025 0.220 Yes 12 (80%) 8 (53.3%) 8 (53.3%) After treatment 1.800 0.407 No 9 (60%) 9 (60%) 12 (80%) Yes 6 (40%) 6 (40% ) 3 (20%) McNp0 0.031* 0.500 0.063 Honeycomb pigmentation Before treatment No 12 (80%) 11 (73.3%) 11 (73.3%) 0.350 MCp = 1.000 Yes 3 (20%) 4 (26.7%) 4 (26.7%) After treatment No 13 (86.7%) 11 (73.3%) 13 (86.7%) 1.176 MCp = 0.700 Yes 2(13.3%) 4 (26.7% ) 2 (13.3%) McNp0 1.000 1.000 0.500 Single hair FU Before treatment 25–50% 2 (13.3%) 3 (20.0%) 3 (20.0%) 0.882 MCp = 0.975 50–75% 4 (26.7%) 5 (33.3%) 4 (26.7%) >75% 9 (60.0%) 7 (46.7%) 8 (53.3%) After treatment 25–50% 3 (20.0%) 4 (26.7%) 5 (33.3%) 4.155 MCp = 0.386 50–75% 9 (60.0%) 4 (26.7%) 6 (40.0%) >75% 3 (20.0%) 7 (46.7%) 4 (26.7%) MHp0 0.008* 0.317 0.014* χ 2: Chi squared test. Abbreviation: MC: Monte Carlo; MH: Marginal Homogeneity Test; McN: McNemar test. p: p-value for comparing between the three studied groups p0: p-value for comparing between before and after treatment in each group *: Statistically significant at P≤0.05 In group A, a significant reduction in the number of pa- tients with yellow dots and peripilar sign as well as single hair FU% was noted. In group C, a significant reduction in the number of patients with yellow dots and single hair FU% was documented. Nevertheless, no changes were detected in group B regarding the four trichoscopic features. Addition- ally, there were no noticeable changes concerning honey- comb pigmentation among the three studied groups. Before the start of the treatment, the mean hair density showed no significant difference between the three groups (P =0.404). Nevertheless, a significant difference was reported between the groups by the end of the treatment (P < 0.001). In de- tail, at the end of the study, hair density was significantly higher in group A than in group B (p<0.001) and in group C than in group B (p<0.001). Nonetheless, both group A and C showed comparable results (p=0.915). Regarding hair Original Article | Dermatol Pract Concept. 2025;15(1):4698 5 Table 6. Comparison between the Three StudyGroups according to Degree of Improvement and Patient Satisfaction Group A (n=15) Group B (n=15) Group C (n=15) χ 2 p Degree of improvement Poor 1 (6.7%) 11 (73.3%) 2 (13.3%) 22.418* MCp < 0.001* Mild 5 (33.3%) 4 (26.7%) 5 (33.3% ) Moderate 9 (60%) 0 (0%) 8 (53.3%) Significance between groups MCp1<0.001*,MCp2=1.000,MCp3<0.001* Patient satisfaction Dissatisfied 2 (13.3%) 11 (73.3%) 2 (13.3%) 18.800* 0.001* Slight 5 (33.3%) 4 (26.7%) 6 (40%) Moderate 8 (53.3%) 0 (0%) 7 (46.7%) Significance between groups MCp1<0.001*,MCp2=1.000,MCp3=0.001* χ 2: Chi square test. Abbreviation: MC: Monte Carlo. p: p-value for comparing between the three studied groups p1: p -value for Chi square test for comparing between group Aand group B p2: p-value for Chi square testfor comparing between group Aand group C p3: p-value for Chi squaredtestfor comparing between group Band group C *: Statistically significant at P≤0.05 Table 5. Comparison between the Three StudyGroups according to Hair Density. Hair density Group A (n=15) Group B (n=15) Group C (n=15) F p Before treatment Median (Min. – Max.) 95 (80 – 110) 93 (80 –110) 95 (83 – 115) 0.927 0.404 Mean ± SD. 92.6 ± 8.98 92.40 ± 7.26 96.13 ± 8.98) After treatment 24.687* <0.001* Median (Min. – Max.) 135 (100 – 165) 98 (80 – 110) 130 (95 – 160) Mean ± SD. 134 ± 18.82 97.67 ± 8.07 131.67 ± 18.29 Significance between groups p1<0.001*, p2=0.915, p3<0.001* t (p0) 6.908*(<0.001*) 2.134(0.051) 6.086*(<0.001*) Abbreviations: SD: Standard deviation: Paired t-test; F: F for One way ANOVA test, Pairwise comparison between each 2 groups was done using post-hoc test (Tukey). p0: p-value for comparing between before and after treatment in each group p: p-value for comparing between the three studied groups p1: p-value for comparing between group Aand group B p2: p-value for comparing between group Aand group C p3: p-value for comparing between group Band group C *: Statistically significant at P≤0.05 density in each group separately, significant increase in the hair density was detected in groups A and C at the end of the treatment (p0<0.001 for each), while group B lacked this finding (p0=0.051) (Table 5). Photographic Evaluation A significant difference in the degree of improvement be- tween the three groups was observed at the end of the study. The degree of improvement was significant in groups A and C in comparison to group B, while no significant difference was detected between groups A and C (Table 6). Patient Satisfaction A significant difference was observed between the three groups regarding patient satisfaction level (P = 0.001), with a higher degree of satisfaction in both groups A and C (moderate degree in 53.3% and 46.7%, respectively) (Table 6). 6 Original Article | Dermatol Pract Concept. 2025;15(1):4698 its oral from. Its efficacy was investigated in previous studies on male androgenetic alopecia, while there is a paucity of studies concerning its efficacy and safety in FPHL [13]. In the present work, group A received topical finasteride 1% twice per day for 16 weeks and showed significant im- provement clinically on the Sinclair scale as well as tricho- scopically. Moderate improvement was detected in 60% of patients, and moderate satisfaction in 53.3% was also re- ported. Mazzarella et al. used 0.005% finasteride solution twice daily versus placebo for 16 months in 52 patients, including 24 premenopausal women. A reduction in hair shedding with increased hair density was demonstrated [14]. Recent data have confirmed the efficacy of topical finas- teride versus placebo in improving hair count at 24 weeks even more; the clinical improvement by topical finasteride Safety Assessment No side effect was detected in any groups, except for mild temporary scalp irritation in two patients in group C. Figures 1–3 present pre- and post-treatment of FPHL. Discussion The efficacy and safety of topical finasteride and spironolac- tone and minoxidil solutions in the treatment of FPHL were evaluated in the present study clinically and dermoscopically, with a superior effect of finasteride and minoxidil over spi- ronolactone. The baseline data between the groups did not differ significantly, as previously reported [10-12]. The con- cept of applying topical finasteride is highly supported due to its limited systemic absorption, hence fewer side effects, than Figure 1. (A) A 31-year-old femalein group A: pre-treatment (Sinclair 3); (B) Post-treatment (Sinclair 2: moderate improvement); (C) Dermoscopic findings at baseline (10X) showed peripilar pigmentation (red circle), yellow dot ( blue circle), hair shaft diversity, and single hair/follicular unit (FU); (D) Dermoscopic findings after four months of treatment showed increased hair density and decreased single hair FU. Original Article | Dermatol Pract Concept. 2025;15(1):4698 7 spironolactone [7]. Similarly, Abdel-Raouf et al. found that on applying spironolactone 1% gel for 12 months, anagen hair increased significantly, with a reduction intelogen and vellus hairs [10]. Conversely, Berardesca et al. mentioned that top- ical spironolactone has a slow onset of action, which might need more than 12 weeks to give significant effect [17]. The difference between the current study and the previous results may be due to the larger sample size or the longer duration of treatment. In addition, specific dermoscopic features (yellow dots, peripilar sign, and honeycomb pigmentation) were not evaluated in the previous studies, unlike the current work. In the present study, group C, who received topical mi- noxidil, showed moderate improvement in 53.3% of patients and moderate degree of satisfaction in 46.7 % by the end of the treatment, with clinical improvement on the Sinclair scale. was comparable to oral 1mg finasteride. However, tricho- scopic findings were not assessed, as they were in the present work [15]. In the present study, topical finasteride was used in a rel- atively higher concentration (1%) than previously reported. Nonetheless, there is no agreement on theoptimum concen- tration, vehicle type, and/or amount and frequency of appli- cation, which necessitate further standardization [16]. In the group B, 73.3% of the patients showed poor improvement and reported being dissatisfied, besides not showing clinical improvement on the Sinclair scale. Their trichoscopic findings did not demonstrate any significant changes at the end of the treatment. Ammar et al. reported a significant decrease in vellus hair, hair shaft diversity, and increased upright hair after three months of 5% topical Figure 2. (A) A 35-year-old female patient in group B: pre-treatment (Sinclair 4); (B) Post-treatment (Sinclair 4: poor improvement); (C) Dermoscopic findings at baseline (10X magnification) showed peripilar pigmentation (red circle), yellow dot (blue circle), honeycomb pigmentation (green stars); (D) Dermoscopic findings after four months of treatment showed no improvement in hair density with single hairFU and honeycomb pigmentation. 8 Original Article | Dermatol Pract Concept. 2025;15(1):4698 Trichoscopy offers a wide range of add-on findings to emphasize the clinical assessment of hair disorders. In a healthy person, 2–4 terminal hairs are detected in each fol- licle [22], while the predominance of single hair per FU in the frontal area was documented as a principal feature of FPHL [23]; 53.3% of patients in the current work presented with single hair FU at baseline (>75% involvement), which indicates the process of miniaturization targeting the termi- nal hair in FPHL. Yellow dots represent hair follicles lacking hair. This may reflect the presence of large active sebaceous lobules in relation to miniaturized hair follicle, developing in- traepidermal sebum lacunae [24]. In the current study, 57% of all patients had yellow dots, compared to a wide range of incidence in other studies [23,25-29]. Different genetic Increased hair density was dermoscopically observed in the current work. This was in agreement with Esmat et al., who reported that the number of hair follicles increased af- ter a 4-month period in a group that received 5% topical minoxidil. They reported 80% improvement and 90% pa- tient satisfaction [18], in accordance with Oslen et al., who demonstrated hair regrowth by the end of 16 weeks [19]. A longer period of follow-up than ours (48 weeks) was as- sessed by Lucky et al., with superior effect of minoxidil 5% over minoxidil 2% in FPHL [20]. The difference in response to topical minoxidil among patients in different studies may be explained by defective sulfotransferase enzyme. Differences in sample size, duration of treatment, or vehicle may be other explanations [21]. Figure 3. (A) A 29-year-old female patient in group C: pre-treatment (Sinclair 4); (B) Post-treatment (Sinclair 3: moderate improvement); (C) Dermoscopic findings at baseline (10X magnification)showed yellow dot (blue circle), hair shaft diversity, and single hair FU; (D) Dermoscopic findings after fourmonths of treatment showed increased hair density and decreased single hair FU. Original Article | Dermatol Pract Concept. 2025;15(1):4698 9 unexplained. Furthermore, a significant reduction in the pa- tients with peripilar pigmentation was only noted in group A, receiving Finasteride, which raised the question of whether it has an anti-inflammatory effect on hair follicles. The comparison between the three treatments modalities needs further studies. Few studies have reported the compar- ison of two forms of treatment or the efficacy of a combi- nation of only two modalities. Suchonwanit et al. compared 0.25% finasteride with 3% minoxidil versus minoxidil alone for the treatment of postmenopausal FPHL. The combina- tion group showed superior efficacy than did monotherapy in increasing hair shaft diameter at the 24th week, while hair density increased in both groups similarly. Clinical improve- ment was revealed in 93% of patients in the combination group and did not differ from minoxidil group [6]. A prospective study was conducted on 30 postmeno- pausal women with FPHL. The authors suggested that adding topical finasteride (0.25%) to minoxidil (3%) significantly enhanced the efficacy of the latter, in which improvement of hair diameter without significant improvement in the hair density was observed in the combination group compared to topical minoxidil alone [39]. Rossi et al. demonstrated that topical finasteride combined with minoxidil 2% had greater efficacy than did topical 17α-estradiol with minoxidil 2%. However, they included only postmenopausal females and did not assess the trichoscopic findings [4]. Similarly, supe- rior results were documented by Gowda et al. using a com- bination of topical finasteride and minoxidil over topical minoxidil in increasing both hair count and terminal hair in male AGA [40]. Unlike the current results, Abdel-Raouf et al. compared topical spironolactone versus topical minoxidil, with no significant difference in the clinical response after 12 months. However, their combination showed superior significant clinical and histopathological response [10]. In a study by Mohamed et al. [41], 5% minoxidil group and 5% spironolactone group did not show a reduction in peripilar sign, yellow dots, or honeycomb pigmentation among AGA patients, and no difference was reported be- tween groups except in vellus hair reduction, in agreement with Ammar et al. [7]. These data were confirmed by the present results regarding spironolactone group but not in ac- cordance with the minoxidil group. Both studies confirmed that the combination of topical minoxidil and spironolac- tone can boost the potency of topical treatment in androge- netic alopecia in males and females [7,41]. The previous studies suggested that combination treat- ment may give superior results than monotherapy. The present study was designed to compare the three lines of treatment. All patients were diagnosed using trichos- copy and Sinclair scale. The degree of improvement and the degree of patients’ satisfaction were superior in both groups A and C in relation to group B; nevertheless, both background, frequency of washing the scalp, and previous treatments may explain these differences. Kaur et al. re- corded more yellow dots in males than in females, with Inui et al.reporting similar results [30,31]. They explained that yellow dots predominantly consist of sebum and sebaceous hypertrophy, considering the higher androgen levels in males. Perifollicular darkening or “peripilar sign” is described by Deloche, reflecting perifollicular lymphocytic infiltration in early androgenetic alopecia [32]. This sign was recorded in previous studies as well as in the present study (62% of patients) [23,25,31,33]. In the present work,24.4% of patients presented with honeycomb pigmentation, in accordance with Ross et al. (12/46) [34], while lower percentages were documented in other results [25,26,33] and higher percentages were re- ported by Kaur et al. (43%) [30], agreeing with Hu Ruiming et al. (44.5%) [35]. It was previously explained by the me- lanocytic proliferation on sun exposure and skin type [28], which are incapable of explaining the present findings as our female patients were veiled. Concerning the trichoscopic changes after utilization of three different treatments in the current work, some explana- tions should be mentioned. Significant comparable increase in hair density was more noted in groups A and C than in group B, which was associated with significant decrease in the percentage of single hair FU in groups A and C. Both finasteride and spironolactone have an antiandrogenic effect [6,7], which can explain their ability to prevent the transfor- mation of terminal hair into vellus hair, but this was not the case in our patients who used topical spironolactone. This means that spironolactone may need a longer duration or is used more appropriately in mixed formulations to pro- duce significant results. A systematic review on seven pre- vious studies elucidated the efficacy of topical finasteride in increasing the total hair and terminal counts in androgenetic alopecia, supporting the current data [16]. Moreover, the efficacy of minoxidil has been previously highlighted in the improvement of androgenetic alopecia [36]. Enhanced cellular proliferation, DNA synthesis, increased blood flow, and stimulation of growth factors, including vas- cular endothelial growth factor in dermal papilla, are sug- gested factors for minoxidil efficacy [37]. In the present results, it was found that both topical fi- nasteride 1% and minoxidil 5% cause significant reduction in the number of patients with yellow dots. This is in line with El-Garf et al., who reported a significant decrease in the yellow dots in addition to other trichoscopic findings, including peripilar sign and hair shaft heterogenicity, among their patients [38]. Finasteride works through inhibition of 5α- reductase II enzyme, thus affecting local scalp andro- gen level and hence sebum production, while the direct ac- tion of minoxidil on sebum lagoons of yellow dots is still 10 Original Article | Dermatol Pract Concept. 2025;15(1):4698 in premenopausal females or in females with a history of estrogen-dependent tumors. However, it is not recommended to give topical finasteride to patients with tumors for fear of systemic absorption. In the present work, serum DHT and serum androgens were not measured, which is considered a limitation of this work. The small sample size and the short duration of treat- ment are other limitations. References 1. Penha M, Ramos P, De Souza V, Miot H. 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A simple guide to IBM SPSS statis- tics for version 20.0. Student ed. Belmont, Calif.: Wadsworth, Cengage Learning.2013. 10. Abdel-Raouf H, Aly U, Medhat W, Ahmed S, Abdel-Aziz R. A novel topical combination of minoxidil and spironolac- tone for androgenetic alopecia: clinical, histopathological, and physicochemical study. Dermatol Ther. 2021;34(1):e14678. DOI: 10.1111/dth.14678. PMID: 33320406 11. Shin H, Won C, Lee S, Kwon O, Kim K, Eun H. Efficacy of 5% minoxidil versus combined 5% minoxidil and 0.01% treti- noin for male pattern hair loss. Am J Clin Dermatol. 2007;8(5): groups A and C did not differ significantly except for the effect of finasteride treatment on the reduction in the peripilar sign. No serious adverse effects were reported in the present work; only two patients (13%) ingroup C experienced mild skin irritation that lasted for a few hours at the beginning of application of topical minoxidil, in agreement with previous data [10,18,41]. Instead, Blume-Peytavi et al. reported facial hypertrichosis in 6.11% of patients [42]. Tolerable pruritus and irritation were reported in pa- tients applying topical finasteride by Mazzarella et al. and by Lee et al. which was not detected in the current work. In the systematic review by Lee et al., they documented other side effects such as elevated liver enzymes, headache, testicular pain and oropharyngeal pain [6,14,16]. As the efficacy of finasteride in androgenic alopecia is mainly attributed to its inhibitory effect on the 5α-reductase enzyme, consequently blocking the production of dihydro- testosterone (DHT), there is a concern about its systemic ef- fect on serum androgen levels even with its topical use. The pharmacodynamic data from the study by Mazerella et al. revealed no significant change in plasma level of DHT after 16 months of topical finasteride [16]. On the contrary, Piraccini et al. [15] did not exclude the possibility of systemic side effects related to decreased level of serum DHT after topical finasteride application, even with plasma concentration 100-fold less than the oral form. Similarly, Suchonwanit et al. noted a decrease in dihydro- testosterone level from baseline level in postmeno pausal women who received topical finasteride, which might indi- cate its percutaneous absorption [6]. Abdel-Raouf et al. [10] reported minimal side effects in patients receiving spirono- lactone, in agreement with Ammar et al. [7], while no side effect was detected in the present work. Conclusion Taking the current results into account, topical finasteride is as safe and effective a treatment as topical minoxidil in FPHL. Both treatments showed greater effectiveness both clinically and trichoscopically, than topical spironolactone. Thus, the use of topical finasteride may be another option for FPHL in minoxidil non-responders or in the presence of intolerable side effects. Because of the limited available data, further studies with larger sample sizes and long-term follow-up are needed. Additionally, combination therapy of topical treatments should be further evaluated and com- pared to the available data. Studies conducted on females with different age groups are required, as most studies have been conducted on postmenopausal females. There is still uncertainty about the safety of using topical finasteride Original Article | Dermatol Pract Concept. 2025;15(1):4698 11 and diagnostic criteria. Int J Trichology. 2009;1(2):123-30. DOI: 10.4103/0974-7753.58555. PMID: 20927234. 24. Eudy G and Solomon A. The histopathology of noncicatricial alo- pecia. Semin Cutan Med Surg. 25(1), 35-40 (2006). DOI: 10.1016 /j.sder.2006.01.005. PMID: 16616301. 25. Karadag Kose O, Gulec A. Clinical evaluation of alopecias us- ing a handheld dermatoscope. JAAD.2012; 67:206–214. DOI: 10.1016/j.jaad.2011.08.019. PMID: 22024772. 26. Zhang X, Caulloo S, Zhao Y, et al. 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