CUSTOM DERMATOLOGY SEARCH:
Female Hair Loss
Female androgenetic alopecia is a common and perplexing clinical problem. Although there are no reliable data, Professor Constantin Orfanos of Berlin feels that 20-40% of European women have androgenetic hair loss to some extent.2 Earliest onset is at puberty, while later onset occurs in the second to fourth decade of life. The most common pattern of hair loss is the diffuse parietal thinning of scalp hair with retention of the frontal hairline.3 Most affected women do not have elevated levels of circulating androgens, and they have normal menses, normal pregnancies, and are not virilized.4
Androgen processing in hair follicles appears to be different in males and females even though scalp follicles demonstrate similar metabolic pathways.3 Although young females have twice as much 5-α reductase in frontal hair follicles than in occipital hair follicles, levels in the former are still only half those found in young males. Aromatase converts testosterone to estradiol in both males and females, but young females have higher levels of aromatase in scalp hair follicles than their male counterparts. These differences are thought to explain the milder form of androgenetic alopecia and the sparing of the frontal hairline seen in females.5
Hair braiding, hot combing, chronic illness, crash dieting6 and nutritional alterations, metabolic and endocrine disorders, stress, environmental changes, surgical procedures, and certain drugs can precipitate or exacerbate alopecia.3 Patients should be asked about their use of exogenous estrogens, progesterones, anabolic steroids, and testosterone.
Treatment of female androgenetic alopecia varies from country to country, depending on local preferences and experience, as well as on the availability of some drugs.
Cyproterone acetate (not available in the USA). In Europe, cyproterone is the major drug used for the treatment of androgenetic hair loss in women.8 Professor Orfanos’ preferred treatment is cyproterone acetate 2 mg (together with ethinylestradiol 50 mcg in Diane® or 10-20mg (Androcur®), plus topical application of estrogen containing hair lotions such as Crinohermal®. However, the efficacy of estrogen containing hair lotions remains unproven, and they are not approved for use in many countries, including North America. In Canada, 50-100 mg of Androcur® are given daily from days 5-14 of the menstrual cycle, while doses of 10-20 mg per day are used for acne but not for alopecia androgenetica in females.9
Where cyproterone is not approved (as in the USA), minoxidil (Rogaine®) may be the treatment of choice. Studies have shown that minoxidil can reduce the extent of hair loss to a cosmetically acceptable degree,10 and increase hair weight and number11,12 without causing serious or unexpected medical events.12 In countries where cyproterone is available, minoxidil is less important in treating this condition.
5-α Reductase Inhibitors
Several 5-α reductase inhibitors are in clinical development. Finasteride (Procepia®) is being studied in male alopecia and in post-menopausal patients with androgenetic alopecia.5,9
In the past, hair transplantation was not widely used because female patients with androgenetic alopecia often have fine, thin hair all over the scalp, and hair loss is not as well demarcated as in men. However, advances in technique have allowed many women, previously thought to be ineligible for surgery, to benefit from this procedure.13 The mini- or micrograft technique is useful in women who have very profound thinning in the front of the scalp and have a good density of thick hair in the occiput. Attaining a natural-looking result in female patients is easier because the frontal hairline is usually still present.14 Expectations must be realistic, and the surgeon must explain carefully what can and cannot be achieved.13
Approaches for Patients Unsuitable for Medical or Surgical Treatment
Suggestions kindly provided by Dr. Zoe Draelos, Department of Dermatology, Bowman Gray School of Medicine, Wake Forest University, North Carolina
The contrast between a pale bald scalp and dark hair often accentuates hair loss. The contrast can be minimized by colouring the scalp temporarily with wax crayons or vegetable dyes, or permanently with tattoo pigment.
Cosmetic Hair Techniques 15
Styling should add volume and fullness. Setting tight curls yields more hair fullness; back-combing or teasing can allow the hair to stand away from the scalp creating the illusion of volume. It is important to avoid hair breakage in areas where the hair is already thinned. Styling products such as gels, mousses, and hair sprays also help the hair to stand away from the scalp but lose their hold each time the hair is wetted or combed and need to be reapplied each time the hair is restyled. Permanent hair waving also increases apparent hair volume; but to minimize damage to the hair shaft, this must be performed with care and with as much time as possible between repeats.15
Future breakthroughs in the treatment of female androgenetic alopecia may come from application of molecular biology developments to growth factors and to blocking specific receptors with cytokines or antisense oligonucleotides.5
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Last modified: Thursday, 20-Feb-2014 18:05:14 MST