FEMALE PATTERN HAIR LOSS
By Gary M. White, MD
Female pattern hair loss (FPHL) is a progressive non-scarring alopecia. It used to be called female androgenetic alopecia, but most women with FPHL have no other signs or symptoms of hyperandrogenism and have normal androgen levels. Note the thinning hair across the top but maintenance of the hair line. One study showed that women who seek treatment for FPHL do not overestimate the severity of their loss. In fact they tend to underestimate it.
- It typically presents as a diffuse reduction in hair over the frontal area and vertex.
- It may have frontal accentuation (Christmas tree pattern).
- It is not strictly inherited, but the high incidence of both FPHL and male androgenetic alopecia in individual families suggest that FPHL and androgenetic alopecia (AGA) share a common genetic background.
- Some studies have shown an association between early-onset FPHL, insulin resistance, hypertension, and increased cardiovascular risk.
- There does appear to be an association with hypothyroidism. Patients should be appropriately screened.
- A small number of studies have shown vitamin D deficiency to be more common in patients with FPHL [Int J Trichology 2016;8:116].
Hair Miniaturization/Hair Thinning by Age
Three stages based upon age of onset:
|Puberty to 40
||Female pattern hair loss
Some have separated the major types of hair loss in women into three stages based upon age. Androgenetic alopecia is a genetically determined androgenetic-mediated hair loss that affects younger women. Female pattern hair loss is a less specific term as the role of androgens is less clear cut. Senescent alopecia refers to age-related hair thinning that is not dihydrotestosterone-mediated.
- See also hair loss in a woman.
- Inquire about signs of menstrual irregularities, infertility, hirsutism, severe acne, galactorrhea, and virilization.
- Blood work can include ferritin, zinc, ANA, TSH, Vitamin D, DHEAS, testosterone, and prolactin.
- For the woman with diffuse thinning hair, consider telogen effluvium, thyroid abnormality, low iron, and a hormone abnormality.
- Sunscreen and hats.
- Topical minoxidil 2-5% is appropriate for patterned hair loss, regardless of age of onset.
- Minoxidil foam is preferred with lower rates of irritation and less interference in hair styling compared with the solution.
- Oral zinc or Vitamin D supplementation is reasonable in patients with low levels of either.
- Neither finasteride nor spironolactone have been proven beneficial for androgenetic alopecia in women.
Mild Disease, e.g., Ludwig stage I or II
Minoxidil 5% daily (almost as good as BID) x 1 year. The FDA has approved in the US a once a day 5% minoxidil foam for women, available OTC. The primary goal is to grow hair, but the secondary goal is just to prevent further hair loss. The patient may need to use minoxidil long-term. The 5% foam is preferred with lower rates of irritation and less interference in hair styling compared with the solution [JAAD 2011;65;1126].
Sulfotransferase enzyme assay before minoxidil may predict the response to treatment. However, it is not yet commercially available [Derm Therapy 2015;28;13].
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 in men[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].
If after 6 months of no growth, hair transplantation may be considered.
Advanced Disease, e.g., Ludwig stage III
There is no hope for regrowth so use of a wig or wiglet ($2000-$10,000) may be considered.
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