Female-pattern hair loss: therapeutic update

Abstract Female androgenetic alopecia or female-pattern hair loss (FPHL) is highly prevalent and has a great impact on the quality of life. The treatment is a routine challenge in dermatological practice, as many therapeutic options have a limited level of evidence and often do not meet patients expectations. Lack of knowledge of the pathogenesis of the hair miniaturization process and the factors that regulate follicular morphogenesis restricts the prospect of innovative therapies. There is also a lack of randomized, controlled studies with longitudinal follow-up, using objective outcomes and exploring the performance of the available treatments and their combinations. Topical minoxidil, which has been used to treat female pattern hair loss since the 1990s, is the only medication that has a high level of evidence and remains the first choice. However, about 40% of patients do not show improvement with this treatment. In this article, the authors critically discuss the main clinical and surgical therapeutic alternatives for FPHL, as well as present camouflage methods that can be used in more extensive or unresponsive cases.

A case of cicatricial female pattern hair loss / 中华皮肤科杂志

A case of cicatricial female pattern hair loss was reported. A 36-year-old female patient presented with gradually aggravated hair loss for more than 10 years. Skin examination showed diffuse hair thinning on the scalp, thin and soft hairs, and some pencil eraser-sized areas of focal atrichia. TrichoScan examination revealed markedly decreased hair density on the forehead, variability in hair diameter greater than 20%, and increased proportions of vellus hairs. Dermoscopic examination showed increased numbers of vellus hairs, plenty of focal atrichia areas measuring 3 - 5 mm in diameter, loss of some follicular ostia, and confluent white dots. Histopathological examination of vertical and transverse scalp sections showed predominantly distributed miniaturized hair follicles with lichenoid folliculitis around the infundibulum and isthmus, concentrically layered perifollicular fibrosis, a marked decrease in the number of hair follicles compared with healthy people of the same age, increased proportions of vellus hairs, a large number of miniaturized hair follicles and follicular streamers, and formation of follicular micro-scars. The patient was diagnosed with cicatricial female pattern hair loss. She received topical treatment with 5% minoxidil liniment once a day, and alternate treatment with topical tacrolimus ointment and clobetasol propionate ointment, as well as oral spironolactone at a dose of 20 mg twice a day and compound glycyrrhizin capsules at a dose of 50 mg thrice a day. After half a year of treatment, there was no marked aggravation of hair loss, and the follow-up continued.

Utility of trichoscopy to diagnose early female pattern hair loss in resource-poor setting: A cross-sectional study

Background: Trichoscopy is a reliable instrument for diagnosis and for tracking therapy-related changes in female pattern hair loss (FPHL). Videodermoscopic diagnosis of FPHL has been established, which requires fine measurements of hair-related parameters; the method requires an expensive equipment/digital program. Aim: To determine whether a low-cost, simple USB dermoscope can ascertain the hair-related changes in early FPHL. Methods: An age-matched, cross-sectional study was performed over 3 years on subjects with less than 6-month history of hair loss and without an obvious broadening of midline hair parting. Trichoscopic analysis of the frontal and occipital scalp of the study subjects were performed, using a USB-connected dermoscope. The subjects were analyzed for the presence of microscopic hair changes in the form of anisotrichosis, vellus-like hair, single hair follicle unit, peri-pilar sign and yellow dots. Results: A total of 230 cases and 230 controls were analyzed. The dermoscopic hair changes were found to be significantly associated with the frontal scalp zone of cases. Limitations: Histopathological evaluation of the cases was not done. Conclusion: Microscopic changes recorded with the help of a simple USB dermoscope are helpful in establishing a diagnosis of FPHL even in early disease.

Therapeutic Efficacy of a Combination Therapy of Topical 17α-Estradiol and Topical Minoxidil on Female Pattern Hair Loss: A Noncomparative, Retrospective Evaluation

BACKGROUND: A variety of agents have been used to treat female pattern hair loss (FPHL), including topical minoxidil, topical 17α-estradiol, oral anti-androgen agents, and mineral supplements. Compared with these single agent regimens, combination therapies could be a better therapeutic option in expectation of superior treatment outcome. OBJECTIVE: This study was designed to determine the efficacy of a combination therapy consisting of topical 0.025% 17α-estradiol and 3% minoxidil in Korean patients with FPHL. METHODS: Therapeutic efficacy was evaluated in 34 women who applied topical 0.025% 17α-estradiol and 3% minoxidil once daily for more than 6 months. Phototrichogram analysis was performed before and after therapy. The efficacy was evaluated with respect to total hair count, hair caliber (as assessed by phototrichogram analysis), and photographic assessment. RESULTS: Total hair count and hair caliber both increased from baseline to 6 months in patients treated with the combination therapy of topical 0.025% 17α-estradiol and 3% minoxidil (p<0.001). Photographic assessment also revealed significant disease improvement, thus supporting the therapeutic efficacy. CONCLUSION: A combination therapy consisting of topical 0.025% 17α-estradiol and 3% minoxidil can be tried as an effective treatment for FPHL.

Female pattern hair loss.

Female pattern hair loss (FPHL) is a common cause of hair loss in women characterized by diffuse reduction in hair density over the crown and frontal scalp with retention of the frontal hairline. Its prevalence increases with advancing age and is associated with significant psychological morbidity. The pathophysiology of FPHL is still not completely understood and seems to be multifactorial. Although androgens have been implicated, the involvement of androgen-independent mechanisms is evident from frequent lack of clinical or biochemical markers of hyperandrogenism in affected women. The role of genetic polymorphisms involving the androgen and estrogen receptors is being increasingly recognized in its causation and predicting treatment response to anti-androgens. There are different clinical patterns and classifications of FPHL, knowledge of which facilitates patient management and research. Chronic telogen effluvium remains as the most important differential diagnosis. Thorough history, clinical examination, and evaluation are essential to confirm diagnosis. Patients with clinical signs of androgen excess require assessment of biochemical parameters and imaging studies. It is prudent to screen the patients for metabolic syndrome and cardiovascular risk factors. The treatment comprises medical and/or surgical modalities. Medical treatment should be initiated early as it effectively arrests hair loss progression rather than stimulating regrowth. Minoxidil continues to be the first line therapy whereas anti-androgens form the second line of treatment. The progressive nature of FPHL mandates long-term treatment for sustained effect. Medical therapy may be supplemented with cosmetic concealment in those desirous of greater hair density. Surgery may be worthwhile in some carefully selected patients.

Serologic Evaluation in Korean Female Pattern Hair Loss Patients / 대한피부과학회지

BACKGROUND: Female pattern hair loss (FPHL) is the most common type of pattern hair loss in women. It has been suggested that FPHL is associated with several serological abnormalities. OBJECTIVE: The aim of this study is to investigate the clinical characteristics and serological abnormalities of the Korean FPHL patients and to compare them with the data from the Korea National Health and Nutrition Examination Survey V and other relative reports. METHODS: We retrospectively evaluated the age, duration and comorbidities in 264 Korean patients who have been diagnosed with FPHL. Serum levels of serum iron, total iron binding capacity, ferritin, hemoglobin, free thyroxine (T4), thyroid stimulating hormone, testosterone and 25-(OH) vitamin D were being investigated. RESULTS: FPHL was most commonly found in patients aged from 20 to 29 years old and 55% of the patients visited the hospital one year after the onset of FPHL. In FPHL patients, the levels of testosterone, hemoglobin, serum ferritin, 25-(OH) vitamin D, thyroid stimulating hormone were all significantly higher than the average Korean adult women. And, the free thyroxine level was significantly lower than the average Korean adult women. When analyzed according to the menopausal status, premenopausal FPHL patients showed significantly higher serum levels of hemoglobin, ferritin, and 25-(OH) vitamin D than those of the Korean adult women. But, the postmenopausal FPHL patients showed significantly higher serum levels of 25-(OH) vitamin D than those of Korean adult women. CONCLUSION: The levels of ferritin, testosterone and vitamin D of FPHL patients were elevated higher than those of the Korean adult women. To confirm these results in the future, further large scaled evaluation is suggested.

Alopecia androgenética femenina: etiología y diagnóstico / Female androgenetic alopecia: etiology and diagnosis

La alopecia de patrón femenino es un problema clínico cada día más frecuente en las mujeres. El cuadro clínico de la alopecia androgenética femenina (FAGA) típica comienza con una específica “pérdida difusa de cabellos de las regiones parietal y frontovertical respetando la línea de implantación frontal”. Ludwig llamó a este proceso “rarefacción”. En la clasificación de Ludwig se describieron tres grados o tipos progresivos de FAGA. Grado I o mínimo, grado II o moderado y grado III o intenso. Ludwig también describió la alopecia androgenética femenina de patrón masculino que debe ser subclasificada de acuerdo con la graduación de Ebling; es decir, FAGA.M desde grado I a V. Generalmente se observa en mujeres con nivelesde testosterona elevados o con hipersensibilidad del órgano diana a esta hormona. La FAGA.M puede observarse en cuatro situaciones: síndrome de persistencia de la adrenarquía, alopecia por tumor suprarrenal u ovárico, alopecia posmenopáusica y alopecia involutiva. Hay otras propuestas de clasificación como la Olsen que considera la alopecia de patrón femenino de dos tipos: de comienzo precoz o tardío y cada unode ellos con o sin exceso de andrógenos. El diagnóstico debe efectuarse con la historia clínica, exploración con el “signo del arrancamiento”, signo de la tracción”, trichoscan®, tricoscopía, test del lavado y tricograma, y con test bioquímicos, especialmente determinaciones androgénicas. Como en el varón, la alopecia femenina causa importantes problemas psicológicosa la mujer, siendo la depresión el síntoma más constante. Con frecuencia se asocia a efluvio telogénico crónico y alopecia frontal fibrosante.

Female pattern hair loss is a clinical problem which every day is more common in women. The clinical picture of typical female androgenetic alopecia (FAGA) begins with a specific “diffuse loss of hair from the parietal or frontovertical areas with an intact frontal hair implantation line”. Ludwig called this process “rarefaction”. In the Ludwig’s classification three degrees or progressive type of FAGA were described: grade I or minimal, grade II or moderate and grade III or severe. Ludwig also described female androgenetic alopecia of male pattern that should be sub- classified according to Ebling’s degrees; that is to say, FAGA.M from grade I to V. It is usually seen in women with increased testosterone levels, or with a hypersensitivity of the target organ to this hormone. FAGA.M may be present in four situations: persistence adrenarche syndrome, alopecia due to an adrenal or an ovarian tumor, post-hysterectomy and as an involutive alopecia. There were other proposal of classification as the most recent Olsen’s classification of female pattern hair loss (FPHL) with two types: of early and late onset and in each one with or without androgens excess. Diagnosis must be made by clinical history, clinical examination with the “pull-out sign”, “tug sign”, trichoscan®, trichoscopy, wash test and trichograms and laboratory test, especially androgenic determinations. FPHL causes important psychological problems in women, being depression the most constant symptom. Frequently, FPHL is associated with chronic telogen effluvium and frontal fibrosing alopecia.

The Efficacy and Safety of 17alpha-Estradiol (Ell-Cranell(R) alpha 0.025%) Solution on Female Pattern Hair Loss: Single Center, Open-Label, Non-Comparative, Phase IV Study

BACKGROUND: There are several commercially available agents to treat female pattern hair loss (FPHL), including minoxidil solution, anti-androgen agents and mineral supplements. However, these treatments are not always satisfactory. We report the results of a clinical trial of 17alpha-estradiol (Ell-Cranell(R) alpha 0.025%) solution to Korean female patients with FPHL. OBJECTIVE: This study was designed to examine the efficacy and safety of Ell-Cranell(R) alpha 0.025% solution in Korean female patients with FPHL. METHODS: A total of 53 women, 18 to 55 years old, applied topical Ell-Cranell(R) alpha 0.025% solution once daily for 8 months. Efficacy was evaluated by the change of hair counts and diameter, subjective assessment, and photographic assessment by investigators. RESULTS: Hair counts and diameter from baseline to 4 and 8 months after treatment increased in treated patients and these changes were statistically significant (p<0.0001). 17alpha-estradiol (Ell-Cranell(R) alpha 0.025%) solution showed significant improvement by subjective self-assessment and by investigator photographic assessment. Ell-Cranell(R) alpha 0.025% solution was well tolerated over 8-months period. CONCLUSION: This study showed that Ell-Cranell(R) alpha 0.025% solution is a safe and effective agent for Korean women with FPHL.

The Efficacy and Safety of AP-FHG0604T on Female Pattern Hair Loss: A Randomized Double-blind Placebo-controlled Clinical Trial / 대한피부과학회지

BACKGROUND: Hair loss is a very common disorder and the number of patients is known to be increasing. Female pattern hair loss (FPHL) is not only a medical problem but also a very severe psychosocial problem for many female patients. Anti-androgen drugs, mineral supplements and topical minoxidil have all been used for the treatment of FPHL. However they do not always achieve successful results and there is still much need for more effective therapy. OBJECTIVE: The purpose of this 18-week, double-blind, placebo-controlled, randomized clinical trial was to investigate the efficacy and safety of a new topical agent, AP-FHG0604T, in the treatment of FPHL. METHODS: A total of 33 women with FPHL (mean age: 33.4 years old) applied either a topical AP-FHG0604T solution (n=17), or placebo (vehicle for AP-FHG0604T solution; n=16) twice daily. Efficacy was evaluated by phototrichogram, investigator's photographic and patient's subjective assessments. All adverse effects were reported during the study. RESULTS: After 18 weeks of therapy, topical AP-FHG0604T treatment showed a significant improvement compared to baseline values of total hair count, non-vellus hair count, and linear hair growth rate. In the placebo group, non-vellus hair count and ratio of anagen hair significantly decreased. The change rates of total hair count and non-vellus hair count in the AP-FHG0604T group were significantly higher than those in the placebo group. Neither investigator's photographic assessments nor patient's subjective assessments of hair growth showed statistically significant differences between the AP-FHG0604T group or the placebo group. Some patients who used AP- FHG0604T complained of local irritation during the study, but the irritation was so mild that they did not need any treatment for this. CONCLUSION: We conclude that AP-FHG0604T is a safe and efficient topical agent which can be used as another treatment of choice for FPHL, as shown by objective assessment with phototrichogram.