A 45-year-old woman comes to you for hair loss. She has thinning hair with maintenance of the hair line. She shows a Christman tree pattern with focal atrichia on trichoscopy. There is no inflammation.

• You ask about any hormonal problems, signs of menstrual irregularities, infertility, hirsutism, severe acne, galactorrhea, and virilization.
• You ask about any triggers of telogen effluvium, thyroid abnormality, low iron.
• You order blood work can include ferritin, zinc, ANA, TSH, Vitamin D, DHEAS, testosterone, and prolactin.

Because the presentation is classic without signs of scalp inflammation, you defer any scalp biopsy. Blood work is normal. You recommend sunscreen and hats, and after discussion of all the options, start minoxidil 0.5 mg/day and spironolactone 50 mg/day. You take a picture and book a return appt. in 3 months.

FEMALE PATTERN HAIR LOSS

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.

• Vitamin D deficiency was much more common compared to patients with alopecia areata with an odds ratio of 3.3. It can cause FPHL with good regrowth after replacement.
• FPHL may rarely occur in men. Both low testosterone and low vitamin D were noted in a significant number of patients.
  
• 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.
• Oral zinc or Vitamin D supplementation is reasonable in patients with low levels of either. Vitamin D deficiency can cause FPHL with good regrowth after replacement.

Clinical

Central scalp hair, with or without parietal loss, is seen in a post pubertal woman. There are 3 phenotypes: diffuse central, central with frontal accentuation (Christmas tree pattern), and male pattern. The male pattern is much less common. Focal atrichia (4 mm areas of hair loss) is more common in late onset FPHL, than in early onset FPHL.

Hair Miniaturization/Hair Thinning by Age

Three stages based upon age of onset:

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.

Workup

• See 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 chronic telogen effluvium, thyroid abnormality, low iron, and a hormone abnormality.
• Scalp biopsy can be considered in atypical cases to confirm the diagnosis.

Treatment

First Line

• Sunscreen and hats.
• Topical minoxidil (e.g., 5% foam Qday) or low dose oral minoxidil
• Spironolatone 50 mg/day initially, going to 100 mg/day
• Oral dutasteride

Other Options

• Low Level Laser Light Therapy
• Oral Finasteride
• Topical finasteride or dutasteride

Advanced Disease

• Wigs or wiglets
• Hair Transplant

RegionalDerm

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