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March 2015 Dermatology Clinic
A woman, aged 31 years, presented with progressive hair loss that spanned the last 5 years. She reported that she had not experienced any excessive shedding. Her medical history was unremarkable, and her social and family histories were noncontributory. The physical exam was notable for a discoid area of alopecia that measured 8 cm x 3 cm; the alopecia was remarkable for sparse hair in the mid-frontal region and a widened hair part that extended posteriorly to the vertex. The exposed scalp did not exhibit tenderness, erythema, pruritus, or scaling. The patient’s eyebrows, eyelashes, and body hair were otherwise completely normal. She had no other nail or skin abnormalities.
This The Clinical Advisor CME activity consists of 3 articles. To obtain credit, read Fleshy papule on the left cheek of a young boy and Annular lesions with dark centers. Then take the post-test here.
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This The Clinical Advisor CME activity consists of 3 articles. To obtain credit, read Fleshy papule on the left cheek of a young boy and Annular lesions with dark centers. Then take the post-test here.
Female pattern hair loss (FPHL), also referred to as female androgenetic alopecia, is a progressive, diffuse, and nonscarring thinning of scalp hair and the most common form of hair loss in women.1,2,3The prevalence of FPHL increases with age, with approximately 50% of women affected by age 70.
FPHL is now the preferred term because most cases are not associated with elevated levels of androgens. A multigenic hereditary component has been implicated. Women who develop FPHL in the absence of elevated androgens have follicles that are hypersensitive to normal androgen levels, resulting in follicular miniaturization, which is the conversion of long, terminal hairs to fine, vellus hairs. Follicular miniaturization is due to shortening of the anagen phase of growth and induction of the telogen phase of senescence and shedding. If hair loss is associated with other signs of hyperandrogenism, such as hirsutism, acne, and irregular menses, the patient should be evaluated for polycystic ovarian syndrome.1,3
There are three main patterns of alopecia. A preserved frontal hairline with thinning throughout the crown of the head, known as Ludwig’s type, can be evaluated with either the three-point Ludwig scale or five-point Sinclair scale. A “Christmas-tree pattern” is seen when the frontal scalp is affected diffusely with a tapering of the hair part posteriorly, as seen in our patient. The Olsen scale stratifies severity of this pattern. Hamilton-type thinning, which is associated with bitemporal recession and is often seen in men, can be present in women with FPHL as well, but this is less common.1
A clinical diagnosis is sufficient but biopsy confirms a diagnosis of FPHL. The hair-pull test is positive in thinning areas. Dermoscopy of the scalp can identify FPHL early due to the variability of diameter and density of hair shafts in these patients.
When considering a diagnosis of FPHL, it is important to rule out chronic telogen effluvium (CTE), alopecia areata incognito (AAI), frontal fibrosing alopecia (FFA), chemotherapy-induced alopecia, newly diagnosed systemic diseases, rapid weight loss, and eating habits.1,3,4Dermoscopy differentiates FPHL from CTE because patients with CTE typically have stable hair density, report hair shedding, and exhibit bitemporal recession that does not result in baldness.1,3As a subtype of alopecia areata, AAI results in acute thinning of hair diffusely, without the patchiness of alopecia areata. Dermoscopy in patients with AAI shows yellow and black dots, broken hairs, or classic “exclamation-point” hairs.1,4FFA is a progressive scarring alopecia that involves recession of the frontal hairline and sometimes alopecia of the eyebrows. Neither terminal nor vellus hairs are seen in the affected area, but erythema and scales may surround remaining follicles.1
If physical examination is indeterminate, a 4-mm punch biopsy with horizontal sections is indicated. In FPHL, histopathology shows an increased number of vellus hairs and a ratio of telogen to anagen that is similar to male pattern baldness. In patients with CTE, biopsy shows normal ratios of terminal to vellus hairs (7 to 1, or greater), whereas patients with FPHL have reduced ratios (4 to 1, or lower). AAI, in contrast to both CTE and FPHL, exhibits perifollicular lymphocytic infiltrates that are responsive to steroid treatment.1,3,4
There are various pharmacological agents available for management of FPHL, but only topical minoxidil is approved by the FDA. Minoxidil induces and prolongs the anagen phase, increasing hair count and shaft diameter. Sustained results can be achieved with topical application of minoxidil (2%) twice daily for an indefinite period.1,3A recent study has shown that 5%-minoxidil foam applied once daily is effective as well.5
The anti-androgen spironolactone is a potassium-sparing diuretic that is not approved by the FDA for FPHL but, in dosages of 50 mg to 200 mg daily, it competes for end-organ androgen receptors and reduces testosterone synthesis. Its use prevents loss of androgen-sensitive follicles and improves hair growth.1,3,6
Finasteride and dutasteride are 5-alpha-reductase inhibitors that prevent the conversion of testosterone to its more active form dihydrotestosterone. Oral finasteride, taken at 2.5 mg to 5 mg daily, improves hair growth.1,7Studies on the safety and efficacy of dutasteride are ongoing. Anti-androgens and 5-alpha-reductase inhibitors are teratogenic in male fetuses; concomitant oral contraception is thus recommended for women of childbearing age.
Low-level laser therapy is another noninvasive management option for hereditary hair loss. Although the exact mechanism by which this therapy stimulates follicular growth is unclear, studies have established a role for infrared wavelengths as a monotherapy or as concomitant therapy with minoxidil or finasteride.2
Hair transplantation from a donor area to the affected area by individual follicular unit is a surgical option. The surgery is dependent on a sufficient donor area, which may be compromised in cases of extreme thinning.8
Our patient said she would begin application of a 2% topical minoxidil solution. She was also given a prescription of spironolactone to be taken at 50 mg twice daily while on an oral contraceptive. At a six-month follow-up visit, the patient reported that she chose to use the 2% topical minoxidil solution alone, and her hair loss continued to progress despite its use.
Eman Bahrani, BA, is a third-year medical student and Maura Holcomb, MD, is a second-year dermatology resident at Baylor College of Medicine in Houston.
This The Clinical Advisor CME activity consists of 3 articles. To obtain credit, read Fleshy papule on the left cheek of a young boy and Annular lesions with dark centers. Then take the post-test here.
References
- Herskovitz I, Tosti A. Female pattern hair loss. Int J Endocrinol Metab . 2013;11(4):e9860. Available at ncbi.nlm.nih.gov/pmc/articles/PMC3968982
- Munck A, Gavazzoni MF, Trüeb RM. Use of low-level laser therapy as monotherapy or concomitant therapy for male and female androgenetic alopecia. Int J Trichology . 2014;6(2):45-49. Available at ncbi.nlm.nih.gov/pmc/articles/PMC4154149
- Sinclair R, Patel M, Dawson TL Jr, et al. Hair loss in women: Medical and cosmetic approaches to increase scalp hair fullness. Br J Dermatol. 2011;165(Suppl 3):12-18. Available at onlinelibrary.wiley.com/doi/10.1111/j.1365-2133.2011.10320.x/abstract
- Werner B, Mulinari-Brenner F. Clinical and histological challenge in the differential diagnosis of diffuse alopecia: Female androgenetic alopecia, telogen effluvium and alopecia areata—part II. An Bras Dermatol. 2012;87(6):884-890. Available at ncbi.nlm.nih.gov/pmc/articles/PMC3699921
- Blume-Peytavi U, Hillmann K, Dietz E, et al. A randomized, single-blind trial of 5% minoxidil foam once daily versus 2% minoxidil solution twice daily in the treatment of androgenetic alopecia in women. J Am Acad Dermatol. 2011;65(6):1126-1134.
- Rathnayake D, Sinclair R. Innovative use of spironolactone as an antiandrogen in the treatment of female pattern hair loss. Dermatol Clin. 2010;28(3):611-618.
- Kohler C, Tschumi K, Bodmer C, et al. Effect of finasteride 5 mg (Proscar) on acne and alopecia in female patients with normal serum levels of free testosterone. Gynecol Endocrinol . 2007;23(3):142-145.
- Caroli S, Pathomvanich D, Amonpattana K, Kumar A. Current status of hair restoration surgery. Int Surg. 2011;96(4):345-351.
All electronic documents accessed on February 27, 2015.
This The Clinical Advisor CME activity consists of 3 articles. To obtain credit, read Fleshy papule on the left cheek of a young boy and Annular lesions with dark centers. Then take the post-test here.
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