ANDROGENETIC ALOPECIA IN A MALE

By Gary M. White, MD

Androgenetic Alopecia in a Man


Androgenetic alopecia (AGA) is the gradual conversion of terminal hair into miniaturized hair resulting in the typical bitemporal recession and balding vertex in a man.

AGA and Male Hormones

Clinical

The typical patient with male pattern hair loss has a thinning vertex and bitemporal recession of the hair line. The hairs miniaturize and finally are lost. There has been some data to suggest vertex baldness correlates with increased heart disease. For example, men 55 years and younger with severe baldness are fatter and have an increased risk of ischemic heart disease [Am J Epid 1996;143;651]. Typical onset is anytime after age 30.

Early Onset Androgenetic Alopecia

Onset before age 30 has been defined as premature or early-onset alopecia. Patients with onset between 19 and 30 years of age are felt to have the phenotypic equivalent of polycystic ovary syndrome. Sanke et al found elevated LH, DHEAS, total testosterone, and prolactin as well as decreased FSH and SHBG (sex hormone binding globulin) levels in men with early onset AGA [JAMA Derm 152;986]. Because of this, they suggest this subset of patients may be at higher risk for metabolic syndrome, insulin resistance, cardiovascular disease, and infertility.

Treatment

Both topical minoxidil (OTC) and oral finasteride are able to increase the size of small hairs and prevent further hair loss. Topical minoxidil is effective in the treatment of both the frontal and vertex scalp of patients with AGA [BJD 2015;172;1555]. Minoxidil is available in a 5% solution and is applied BID to the affected areas. One may need to wait 4-6 months to see its effect. If a benefit is seen, the medication should be continued indefinitely.

How to Increase the Benefit of Minoxidil

Finasteride (1 mg/d) is FDA-approved for the treatment of male androgenetic alopecia. For the skin that has lost hair completely however, these medications are ineffective.

In one study [J Am Acad Dermatol 2014;70:489-98], dutasteride 0.5 mg/day increased hair growth and restoration in men with androgenetic alopecia, was more effective than finasteride, and was relatively well tolerated.

Low-Level Laser Light Therapy

Various "hats" that deliver low-level laser light therapy are available in the US without a prescription. For example, some are worn for 25 minutes 3 times per week. A systemic review and meta-analysis found LLLLT to be effective[JAAD 2017;77;136] and the combination of LLLLT and 5% minoxidil to be better than either therapy alone for women with AA [Laser Surg Med 2017].

Sex Reassignment Surgery

A 38-year-old Caucasian male-to-female transsexual candidate presented with AGA on August 12, 1988. Years later after sex reassignment surgery, she showed extensive regrowth of scalp hair (JAAD Sept 2012).

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