<p>Androgenetic alopecia (AGA) is the most common cause of hair loss. Although oral finasteride is effective, concerns regarding systemic adverse effects frequently limit its use. Observational data on topical finasteride in routine clinical practice remain limited. This retrospective cohort study included adults with AGA who completed at least six months of treatment with topical finasteride 0.25% hydroxypropyl chitosan (HPCH) spray at a tertiary medical center in Saudi Arabia between April and October 2025. Outcomes included investigator-assessed improvement using the Investigator Global Assessment (IGA), patient-reported hair regrowth, adverse events, and adherence among treatment completers. Subgroup analysis compared monotherapy and combination therapy regimens. 59 patients were included (mean age 32.1 ± 8.5 years; 64.4% female). 37 patients (62.7%) received topical finasteride monotherapy, whereas 22 (37.3%) received concurrent platelet-rich plasma, oral minoxidil, or both. Mean IGA scores were 2.0 ± 1.0 for both reviewers, corresponding to mild-to-moderate improvement. Combination therapy was associated with significantly higher IGA scores than monotherapy (2.95 ± 0.49 vs. 2.03 ± 0.73; <i>p</i> &lt; 0.001). Among monotherapy patients, 78.4% (Reviewer 1) and 81.1% (Reviewer 2) achieved at least mild improvement (IGA ≥ 2), whereas 18.9% and 21.6%, respectively, achieved moderate-to-marked improvement (IGA ≥ 3). All treatment completers reported subjective hair regrowth. Local adverse events were infrequent and mild (3.4%), and no systemic adverse events or treatment discontinuations were documented. Self-reported adherence was high among treatment completers. These findings are preliminary and hypothesis-generating. The completer-only design and the use of combination therapy limit the ability to attribute outcomes to topical finasteride alone. Prospective randomized studies with objective trichometric endpoints and structured adverse-event surveillance are needed.</p>