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Original Article
Access this article online
Website:www.ijtrichology.com
DOI:
10.4103/0974-7753.138584
Quick Response Code:Use of Low‑Level Laser Therapy as
Monotherapy or Concomitant Therapy forMale and Female Androgenetic Alopecia
Andréia Munck, Maria Fernanda Gavazzoni, Ralph M Trüeb1
Institute of Dermatology Prof. R.D. Azulay, Rio de Janeiro, Brazil, and 1Center for
Dermatology and Hair Diseases, Bahnhofplatz, Wallisellen, Switzerland
ABSTRACT

Address for correspondence:Prof. Ralph M. Trüeb,
Center for Dermatology
and Hair Diseases,
Bahnhofplatz 1A, CH ‑ 8304
Wallisellen, Switzerland.
E‑mail: r.trueeb@
derma‑haarceter.ch

Background: Androgenetic alopecia (AGA) is the most common form of hair loss in men
and in women. Currently, minoxidil and finasteride are the treatments with the highest
levels of medical evidence, but patients who exhibit intolerance or poor response to thesetreatments are in need of additional treatment modalities. Objective: The aim was to evaluate
the efficacy and safety of low‑level laser therapy (LLLT) for AGA, either as monotherapy or
as concomitant therapy with minoxidil or finasteride, in an office‑based setting. Materials
and Methods: Retrospective observational study of male and female patients with AGA,
treated with the 655 nm‑HairMax Laser Comb®, in an office‑based setting. Efficacy wasassessed with global photographic imaging. Results: Of 32 patients (21 female, 11 male),
8 showed significant, 20 moderate, and 4 no improvement. Improvement was seen bothwith monotherapy and with concomitant therapy. Improvement was observed as early as
3 months and was sustained up to a maximum observation time of 24 months. No adverse
reactions were reported. Conclusions: LLLT represents a potentially effective treatment
for both male and female AGA, either as monotherapy or concomitant therapy. Combination
treatments with minoxidil, finasteride, and LLLT may act synergistic to enhance hair growth.
Key words: Androgenetic alopecia, concomitant therapy, HairMax Laser Comb®, lowlevel laser therapy, monotherapy

INTRODUCTIONThe ability of lasers to induce hair growth wasincidentally noted as early as 1967 when Mester et al.
used low‑level laser therapy (LLLT) to treat cancer in micewith shaved backs.[1] Since then, hypertrichosis has beenrecognized to be a possible side‑effect of laser treatment.
First described in 2002 with intense pulsed light therapy,[2]this phenomenon has now been widely acknowledged tooccur with an incidence rate ranging from 0.6% to 10%with low fluences and all laser types.[3] It is thought to be
the result of suboptimal fluences that are too low to induce
thermolysis, but high enough to stimulate follicular growth.
Eventually, LLLT has been developed for the treatment of
androgenetic alopecia (AGA). As opposed to other currently
marketed systems, the laser comb utilizes hair parting
teeth for optimal delivery of laser energy to the exposed
scalp. In 2007, the HairMax Laser Comb® (Lexington
International, LLC) received 510 (k) clearance from theFood and Drug Administration (FDA) for the treatment
International Journal of Trichology / Apr-Jun 2014 / Vol-6 / Issue-2of AGA for men, and 2011 for women. This clearance
means that the device is considered a moderate‑risk
medical device by the FDA and is thereby solely screened
for safety. The HairMax Laser Comb® has been tested in
a company‑sponsored study of 110 male patients with theclaim of a significant increase in mean terminal hair density
when compared to a sham device.[4] Avram and Rogers
conducted the first independent blinded study of LLLT
and hair growth with seven patients and found that on
average, there was a decrease in the number of vellus hairs,
an increase in the number of terminal hairs, and an increasein shaft diameter.[5] A consensus written by hair loss experts
states that based on anecdotal experience, LLLT, particularly
650-900 nm wavelengths at 5 mW, may be an effective
treatment option for patients with AGA.[6] In recent times,
Kim et al. reported an increase of hair density with the useof LLLT, when compared to the sham device in a 24-week,
randomized, double‑blind, sham‑device‑controlled trial.[7]To evaluate efficacy of the 655 nm‑HairMax Laser Comb®
either as monotherapy or as concomitant therapy for45

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Munck, et al.: Low‑level laser therapy

treatment of male and female AGA, we performed a
retrospective observational study of global photographic
assessments of patients in an office‑based setting.
MATERIALS AND METHODS

The study design was retrospective and observational.
Patients who had purchased a HairMax Laser Comb®
between July 2011 and July 2013 for treatment of
AGA at the Center for Dermatology and Hair Diseases
Prof. Trüeb were retrieved for assessment of global
photographic images performed at follow‑up visits.
Patients on concomitant treatment had been treating with
topical minoxidil or oral finasteride for at least 9 months,
before starting therapy with the HairMax Laser Comb®.
Patients used the HairMax Laser Comb® at home according
to instructions 3 times weekly between 8 and 15 min
depending on the model purchased (Advanced 7, Lux 9,
or Professional 12). Global photographs were performed
at 3, 6, 12, and 24 months of treatment follow‑up in astandardized manner with a stereotactic camera deviceof Canfield Scientific Inc., in which the patient’s chin andforehead are fixed and on which digital camera and flash
device are mounted, ensuring that view and lighting are thesame at consecutive visits, thus enabling precise follow‑upof the same scalp area of interest with frontal and vertex
views. Global photographs were evaluated by two of
the authors (AM and RMT), and scored as significant,moderate, or no improvement. In the case of diverging
opinions, the inferior score was given.

six male) moderate improvement, and four patients (fourfemale, zero male) no improvement [Figure 1]. Of
32 patients, the HairMax Laser Comb® was used as
monotherapy in six patients (two female, four male), andas a concomitant therapy in 26 patients (19 female, sevenmale). In the monotherapy group, two patients (one female,one male) showed significant improvement [Figure 2], four
patients (one female, three male) moderate improvement,
and zero patients no improvement [Table 3]. In theconcomitant therapy group, six patients (two female, fourmale) showed significant improvement [Figures 3 and 4],
16 patients (13 female, three male) moderate improvement,
and four patients (four female, zero male) no improvement.
There was no statistical significant difference between
LLLT monotherapy and concomitant therapy with either
minoxidil and/or finasteride (P = 0.829), and regarding
male or female AGA (P = 0.091) [Table 4].
Treatment was well tolerated and no serious adverse eventswere reported.
DISCUSSION

Androgenetic alopecia is the most common formof hair loss in men and in women. Currently, topical
2% and 5% minoxidil solution and 1 mg oral finasteride are
Table 1: Improvement of alopecia in relation to thevariables: Age, duration of hair loss, and durationof LLLT
Variables Statistics Total

RESULTS

In total, 32 patients with AGA were involved in the study,of which 21 were females, aged 22-73 (mean: 43.6 ± 15.19
standard deviation [SD]), and 11 were males, aged
20-70 (mean: 39 ± 15.01 SD) total mean: 42 ± 15.1 SD.
The duration of hair loss in years for men and women wasmean 7.1 ± 5.2 SD. The duration of LLLT in months formen and women was mean 8.7 ± 5.2 [Table 1]. The patientcharacteristics, with respect to gender, age, classificationof AGA according to Ludwig and Hamilton-Norwood
scales, duration of hair loss, and concomitant treatments
are recorded in Table 2.
The results for the scoring of the global photographic
assessment in relation to treatment duration with the
HairMax Laser Comb® are demonstrated in Table 3.
In summary, eight patients (three female, five male)
showed significant improvement, 20 patients (14 female,46

Improvement
Number Moderate Significant

Age(years)

n

32

4

20

8

Mean

42.0

33.0

44.8

39.6

Standard
deviation

15.1

6.8

16.4

13.5

Minimum 20.0

25.0

22.0

20.0

Maximum 73.0

40.0

73.0

62.0

Duration nof hair
Meanloss*Standard(years)deviation
Minimum

24

4

13

7

7.1

7.3

7.0

7.4

5.2

3.9

5.8

5.6

0.5

3.0

0.5

1.5

Maximum 20.0

11.0

20.0

16.0

Duration nof LLLTMean(months)
Standard
deviation
Minimum

32

4

20

8

8.7

12.0

8.0

8.8

5.2

8.1

3.7

6.9

2.0

6.0

2.0

3.0

Maximum 24.0

24.0

18.0

24.0

P value of
KruskalWallis test
0.381

0.892

0.549

LLLT – Low‑level laser therapy

International Journal of Trichology / Apr-Jun 2014 / Vol-6 / Issue-2

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Munck, et al.: Low‑level laser therapy

Table 2: Patient characteristics
GenderAge

Classification

Duration of hair loss

Concomitant treatments

Male

25

Hamilton-Norwood III

NOS*

Nil**

Male

54

Hamilton-Norwood IV

20 years

Nil**

Male

34

Hamilton-Norwood IV

10 years

Nil**

Male

70

Hamilton-Norwood III

NOS*

Nil**

Male

28

Hamilton-Norwood IV

9 years

5% minoxidil solution

Male

32

Hamilton-Norwood IIIv

2 years

5% minoxidil solution

Male

56

Ludwig pattern

7 years

5% minoxidil solution

Male

20

Hamilton-Norwood IIIv

18 months

1 mg oral finasteride 1 mg+5% minoxidil solution

Male

34

Hamilton-Norwood IIIv

NOS*

1 mg oral finasteride 1 mg+5% minoxidil solution

Male

38

Hamilton-Norwood V

16 years

1 mg oral finasteride 1 mg+5% minoxidil solution

Male

38

Hamilton-Norwood IV

12 years

1 mg oral finasteride 1 mg+5% minoxidil solution

Female73

Ludwig II

6 months

Nil**

Female62

Ludwig I-II

2 years

Nil**

Female71

Ludwig II

12 years

0.025% estradiol solution

Female38

Ludwig II

NOS*

5% minoxidil solution

Female31

Ludwig II

3 years

5% minoxidil solution

Female39

Ludwig II

NOS*

5% minoxidil solution

Female44

Ludwig I

15 years

5% minoxidil solution

Female30

Ludwig I

10 years

5% minoxidil solution

Female52

Ludwig II

3 years

5% minoxidil solution

Female40

Ludwig I

3 years

5% minoxidil solution

Female40

Ludwig I

30 months

5% minoxidil solution

Female37

Ludwig I

3 years

5% minoxidil solution

Female37

Ludwig I

5 years

5% minoxidil solution

Female25

Ludwig I

11 years

5% minoxidil solution

Female50

Ludwig I

4 years

5% minoxidil solution

Female33

Ludwig II

8 years

5% minoxidil solution

Female22

Ludwig I

NOS*

5% minoxidil solution

Female24

Ludwig I

4 years

5% minoxidil solution

Female69

Ludwig I

8 years

5% minoxidil solution

Female45

Ludwig I

NOS*

5% minoxidil solution

Female53

Ludwig I

NOS*

5% minoxidil solution*NOS – Not otherwise specified; **NIL – Nothing

in a variety of indications more than 30 years,[9] it has only
recently found the attention of the scientific community
for the treatment of AGA.[6,10,11]

Figure 1: Graphic summary of results

the treatments with the highest levels of medical evidence,[8]but patients who exhibit intolerance or poor responseto these treatments are in need of additional treatment
modalities. Although low‑level energy lasers have been
therapeutically used in medicine for photobiostimulation
International Journal of Trichology / Apr-Jun 2014 / Vol-6 / Issue-2

We have chosen the 655 nm‑HairMax Laser Comb® forseveral reasons: First, it represents the device with the mostclinical study reports regarding its efficacy,[4,5,12] secondly,
the cost of the device is affordable, and thirdly, the device
is simple enough for patients to use at home. Finally, thefact that the device is safe, for which it received 510 (k)clearance from the FDA for the treatment of AGA, wasalso an important consideration.
Our study demonstrates clinical efficacy of the device fortreatment of male and female AGA, both as monotherapy
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Munck, et al.: Low‑level laser therapy

Table 3: Scoring of global photographic
assessment in relation to treatment duration
Gender Age Durationof LLLTNo
Moderate
Significant
improvement improvement improvement

Male

25

4 months

X

Male

54

12 months

X [Figure 2]

Male

34

7 months

Male

70

7 months

X

Male

28

4 months

X

Male

32

6 months

X

Male

56

3 monthsMale

20

10 months

Male

34

12 months

Male

38

24 months

Male

38

5 months

Female73

2 months

Female62

06 months

Female71

12 months

Female38

12 months

X

Female31

3 months

X

Female39

7 months

Female44

6 months

Female30

6 months

Female52

6 months

Female40

9 months

Female40

8 months

Female37

9 months

Female37

24 months

X

Female25

9 months

X

Female50

9 months

X

Female33

5 months

X

Female22

6 months

X

Female24

6 months

X

Female69

9 months

X

Female45

18 months

X

Female53

12 months

X

Xa
X [Figure 3]
Xcb

Figure 2: Monotherapy in a 54-year-old male (a) Before treatment,
and improvement after (b) 6 months, and (c) 12 months of low-level
laser therapy

X
X [Figure 4]
X
X
X
X

X
X
X
X
X
X
a

X

b

Figure 3: Concomitant treatment with topical 5% minoxidil in a 55-yearold male adding on low-level laser therapy (LLLT) to 4 year pretreatment
with 5% topical minoxidil solution (a) Before, and (b) After 3 monthsof added LLLTLLLT – Low‑level laser therapy

Table 4: Comparative assessment of efficacy
between monotherapy and concomitant for maleand female androgenetic alopecia
Total(n (%))

Improvement (n (%))

P value of
Number Moderate Significant Fisher test

GenderMale

11 (34.4)

Female21 (65.6) 4 (100.0)0

6 (30.0)

5 (62.5)

14 (70.0)

3 (37.5)

0Concomitant 26 (81.3) 4 (100.0)
therapy

4 (20.0)

2 (25.0)

16 (80.0)

6 (75.0)48bc

Figure 4: Concomitant treatment with topical 5% minoxidil and 1 mg
oral finasteride in a 34-year-old male (a) Before, (b) After 9 months
treatment with 1 mg oral finasteride and topical 5% minoxidil solutionbid, and (c) After 3 months after adding on low-level laser therapy

0.091

Therapy
Monotherapy 6 (18.8)

a

0.829

and as concomitant therapy, in terms of clinically relevant
improvement of appearance of hair. Of 32 patients, eightpatients (25%) showed significant improvement, and20 patients (62.5%) showed moderate improvement inglobal photographic assessments. The effect was observedInternational Journal of Trichology / Apr-Jun 2014 / Vol-6 / Issue-2

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Munck, et al.: Low‑level laser therapy

as early as 3 months of treatment, and was sustained
up to a maximum observation time of 24 months. The
technology appears to work better for some than for others,
and predictive factors which will most benefit from LLLT
are to be determined. It seems though, that patients withintermediate alopecia (Hamilton-Norwood III and IV, andLudwig I and II, respiratory) respond best, since effective
photobiostimulation depends on a minimum of hair for
effective photobiostimulation, and on a maximum of hairfor the laser beam to reach the scalp without absorption
or interference from existing hairs.
The hypothesized mechanisms of action of LLLT are
increased adenosine tri‑phosphate (ATP) production,
modulation of reactive oxygen species (ROS), andinduction of transcription factors. The proposed cellularchromosphere responsible for the effect of visible lightis cytochrome c oxidase (COX) with absorption peaks inthe near infrared, and mitochondria the likely site for the
initial effects. It is believed that LLLT displaces nitric oxidfrom COX allowing an influx of oxygen to bond to COX
and progress forward in the respiratory process to ATP
production and ROS signaling. These effects in turn leadto increased cellular proliferation, modulation in levels ofcytokines, growth factors and inflammatory mediators, andincreased tissue oxygenation. While the effects of thesebiochemical and cellular changes have broadly been studied
in both animal models and clinical studies with patients, andhave shown benefits in diverse conditions, such as increased
healing in chronic wounds, improvements in sports injuries
and carpal tunnel syndrome, pain reduction in arthritis
and neuropathies, and amelioration of damage after heart
attacks, stroke, nerve injury and retinal toxicity,[7,9] theeffects on hair growth stimulation have only recently gained
the attention of the scientific community.

in hair transplant surgery may also reduce postoperative
shedding, reduce healing time, and increase graft patency.
The scientific basis for such an approach is given, but there
is a need for controlled studies with a higher number ofpatients to establish an increase in efficacy of combination
regimens.[13]REFERENCES
1.
2.
3.
4.

5.
6.
7.
8.

9.
10.
11.
12.
13.

CONCLUSIONS

From our own observations, we share with other authors
the opinion that LLLT represents a safe and potentiallyeffective treatment option for patients with AGA who do
not respond or are not tolerant to standard treatment ofAGA.[6,7] Moreover, combining LLLT with topical minoxidil
solution and oral finasteride may act synergistic to enhance
hair growth. Due to the known beneficial effect on woundhealing, it is conceivable that LLLT as an adjunctive therapy

International Journal of Trichology / Apr-Jun 2014 / Vol-6 / Issue-2

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How to cite this article: Munck A, Gavazzoni MF, Trüeb RM.
Use of low-level laser therapy as monotherapy or concomitanttherapy for male and female Androgenetic alopecia. Int J Trichol
2014;6:45-9.
Source of Support: Nil, Conflict of Interest: Ralph M. Trüeb
performs consultant activity for Lexington International LLC. This
study represents an integral part of Andréia Munck’s traineeshipin trichology at the Center for Dermatology and Hair Diseases
Prof. Trüeb.

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