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MODERN MEDICINE
CPD ARTICLE NUMBER THREE: 1 point
The balding woman
BELINDA WELSH, MB BS, MMed, FACD
Premature or extensive hair loss in a woman can cause considerable distress. An important part of management involves
patient counselling regarding pathogenesis and treatment
options so that realistic outcomes can be achieved.
Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012)
^
As evidenced by the amount of
time and money spent at hairdressing salons and on hair care products,
a full, healthy head of hair is crucial
to most women's feelings of attractiveness, their sexuality and even
gender identity. As a result, androgenetic alopecia (hair thinning),
which is a normal physiological
occurrence, can lead to a great deal
of anxiety and distress if it is premature or extensive. This can have a
significant impact on a woman's
self-esteem and psychological wellbeing. Most women tend to present
for treatment if hair loss occurs prematurely or is exaggerated.
Androgenetic alopecia is as common in women as it is men. The pattern of inheritance is polygenic. It
can be inherited from either parent.
This genetic predisposition plus sufficient circulating androgens are
prerequisites for the progressive
miniaturisation of scalp follicles that
characterises this condition.
Thinning of the hair usually begins
between the ages of 12 and 40 years
in both sexes.
The diagnosis of female androgenetic alopecia is essentially a clinical
one, after exclusion of other causes
of nonsearring diffuse hair loss.
Appropriate treatment can be
offered based on an understanding
of the pathogenesis of this condition.
ing of the hair growth cycle. In scalp
hairs, the phase of active growth,
called anagen, lasts two to five
years. This is followed by a transition phase of a couple of weeks,
when the hair spontaneously stops
growing. This phase is known as
catagen. The hair then goes into a
three-month resting phase known
as telogen. The telogen, or club hair,
is retained in the follicle with its
white bulb until the new anagen
phase starts. The new growing hair
then pushes the old hair out, and
the old hair is shed. It is normal to
lose 100 telogen hairs each day.
Pathogenesis
The cause of androgenetic alopecia
in women is the same as in men. In
genetically predisposed areas of the
scalp, terminal hairs are progressively replaced by finer, shorter and
ultimately nonpigmented hairs over
successive growth cycles. This progressive miniaturisation and shortening of the duration of the anagen
growth phase is a consequence of
the action of circulating androgens,
particularly dihydrotestosterone
(DHT).
The en2yme 5a-reductase is found
in the dermal papilla cells and converts testosterone to the more active
DHT. These cells also possess receptors for DHT. The highest levels of
both DHT receptors and 5a-reducThe hair cycle
tase are found in those regions of
the scalp in which androgenetic
To understand the terminology used
alopecia develops.
in describing hair disorders it is necessary to have a basic understandIn men, all follicles that are genetically predisposed to undergo this
process will do so because there is
sufficient circulating testosterone to
Dr Welsh is Consultant Dermatologist, St
act
as substrate for conversion to
Vincent's Hospital, Fitzroy, Visiting
DHT. In premenopausal women,
Dermatologist, Hair Clinic, Skin and
Cancer Foundation, Carlton, and in private however, normal levels of circulating
practice in Footscray and Kew, Australia. androgen will only induce balding in
34
MODERN MEDICINE OF SOUTH AFRICA / APRIL 2003
those who have a strong genetic predisposition. If there is no strong
genetic susceptibility, baldness
develops in women when androgen
production is increased or drugs
with androgen-like activity are
taken. In most cases, women presenting with androgenetic alopecia
will have normal endocrine function,
shown by conventional testing of
plasma androgens.
Clinical features
The pattern of hair loss in women
tends to be different from that in
men. In the 1970s, Ludwig
described three grades of female
androgenetic alopecia (Figures 1 to
3). The age of onset is genetically
determined and can begin at any
age after puberty. The loss tends to
occur in fits and bursts over a period
of years. It is common for people to
go through periods of accelerated
hair loss lasting three to six months
followed by periods of stability lasting six to 18 months.
The usual presentation is diffuse
hair loss that is more marked over
the crown with an intact frontal hair
line (Figures 1 to 3). However, some
degree of frontal and frontoparietal
recession may also be seen in
women.
It has been postulated that the
decline in oestrogen levels after the
menopause, allowing unopposed
androgen stimulation, may account for
the increased frequency of frontoparietal recession (the so-called
male pattern hair loss.) seen with
increasing age in women. This sign,
therefore, is not necessarily a marker for hyperandrogenism; however,
significant frontoparietal recession
should raise suspicion. Hyperandrogenism should be suspected if
the alopecia is of rapid onset (over
months to a year as opposed to slowly over many years) or if there is
associated menstrual irregularity,
hirsutism or acne. An underlying
endocrine abnormality is less likely
if there is a strongly positive family
history of androgenetic alopecia.
I
rn
Figure 1. Androgenetic
Ludwig grade I.
alopecia
-
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Differential diagnosis
In men, the diagnosis of androgenetic alopecia is usually straightforward. In women, however, early
androgenetic alopecia may present
with a diffuse pattern of loss, making it more a diagnosis of exclusion.
The box on page 36 lists other causes of diffuse telogen hair loss that
need to be considered. Drugs should
always be excluded as a possible
cause of diffuse hair loss (Table 1). It
is important to recognise that other
factors, such as iron deficiency, may
coexist and aggravate or even
unmask an underlying tendency to
androgenetic alopecia. Because hair
loss may precede other clinical
manifestations of thyroid disease
(Figure 4), it is always important to
perform screening blood tests.
Zinc is important for healthy hair
growth. Hereditary zinc deficiency,
known as acrodermatitis enteropathica, is due to impaired zinc
absorption from the gastrointestinal
tract. It manifests in infancy and
early childhood and is characterised
by the clinical triad of alopecia, an
acral dermatitis and diarrhoea. In
adults with diffuse hair loss, zinc
deficiency should be considered in
the setting of prolonged parenteral
feeding, malabsorption or diarrhoea,
or if there is other evidence of nutritional disease, such as a high mean
corpuscular volume to indicate
folate deficiency.
Chronic telogen effluvium is a
more recently described cause of diffuse hair loss in women that persists
beyond six months. It may follow an
acute telogen effluvium, but often no
trigger is found. The cause is not
known, but it may be due to a
change in the dynamics of the hair
cycle with shortening of the anagen
Because hair loss may precede other clinical
manifestations of thyroid disease, it is always
important to perform screening blood tests.
H
•
Figure 2. Androgenetic
Ludwig grade II.
alopecia
-
phase. Patients may give a history
of being able to grow their hair very
long in childhood, suggesting a long
anagen phase. Chronic telogen effluvium is not androgen dependent,
does not progress to baldness and
does not respond to oral antiandrogen therapy. It tends to follow a fluctuating course over several years
before resolving spontaneously.
Investigations
Apart from a directed history and
examination, most women do not
require investigation for virilisation.
It is more important to direct investigations toward excluding other
"T*
•
Figure 3. Androgenetic
Ludwig grade III.
alopecia
-
TABLE 1.
Drug c a u s e s of
diffuse t e l o g e n hair
loss
Drugs with proandrogen action
Oral contraceptive pill
Testosterone
Danazol
Anabolic steroids
Drugs with antithyroid action
Carbimazole
Amiodarone
Lithium
Drugs with prothyroid action
Thyroxine
Drugs causing telogen effluvium
Beta blockers (propranolol, metoprolol)
ACE inhibitors (captopril, enalapril)
Anticoagulants (heparin, warfarin)
Oral retinoids (acitretin, isotretinoin)
Allopurinol
Colchicine
Glibenclamide
Cimetidine
Bromocryptine
Levodopa
Sulphasalazine
Procaine penicillin
Gold
Interferon
Amphetamines
Figure 4. Diffuse hair loss secondary
to hypothyroidism.
diffuse hair loss.
Clinical features associated with
hair loss that necessitate androgen
investigations are:
causes of diffuse hair loss, especially
• alopecia of rapid onset
in cases of early androgenetic alope• menstrual irregularity
cia when the pattern of hair loss is
• hirsutism
not readily apparent. Table 2 outlines an approach to women with
• acne.
MODERN MEDICINE OF SOUTH AFRICA
3
The balding woman
continued.
It is useful to warn people that they
may notice increased shedding initially
as resting telogen hairs are stimulated
to re-enter anagen.
Differential diagnosis of diffuse hair loss
Androgenetic alopecia
Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012)
History
Gradual onset. May be cyclic increases in hair shedding. If rapid, consider
virilisation
Examination
Widening of the central parting.
Preservation of Ihe frontal hair line.
Thinning over the crown. Male pattern
can occur in postmenopausal women.
Drug-induced hair loss
History
Hair loss tends to begin six to 12
weeks after siarting drug treatment
Progressive while the drug is continued.
Examination
Usually diffuse loss. Thinning may be
profound. Oral retinoids may induce
straight hair to curl.
Telogen effluvium.
Thyroid disease
History
Dramatic hair loss, about two to three
months after a triggering event, such
as physical or emotional stress. Selflimiting over three to six months.
Examination
No widening of the central parting.
Bitemporal recession can occur.
Thinning not usually marked, but if
present it occurs all over the scalp.
Positive hair pull test equally over the
vertex and occiput.
History
Both hyper- and hypothyroidism.
Antithyroid medications.
Examination
Hair loss may precede other clinical
manifestations. Gradual diffuse loss
seen with both hyper- and hypothyroidism. Loss of Ihe outer third ol the
eyebrows seen in hypothyroidism.
Iron deficiency
History
Iron deficiency may be an aggravating
rather than causative factor, especially in androgenetic alopecia.
Examination
Iron deficiency can occur in the
absence of anaemia in about 20% of
cases. If serum ferritin >60mg/l and
hair loss persists, consider another
cause.
Chronic telogen effluvium
History
Hair loss tends to be distinctive. In
women aged between 30 and 50
years. Patients complain of abruptonset shedding and hair thinning. Hair
blocks shower drain after washing.
Examination
Patients often have a thick head of
hair; significant thinning unusual.
Bitemporal recession. No widening ot
the central parting. Positive hair pull
test equally over the vertex and
occiput. Usually resolves spontaneously over three to four years
The hair pull test
Treatment
The hair pull test is a simple
clinical test that allows you to
determine if abnormal hair loss
is occurring and its distribution.
With the thumb and forefinger, a
clump of hairs is grasped near
the s c a l p . F i r m t r a c t i o n is
applied as the hand slides along
the hair from the base to the tip.
This is repeated at a number of
sites over the scalp.
Normally, after five or six passes only two to five hairs should
have come out. In a telogen effluvium, up to 30 hairs may come
out. Telogen hairs can be recognised by the small white bulb at
the root.
Conservative management
For mild androgenetic alopecia,
camouflage alone may suffice. A
good hairdresser1 can provide advice
about cutting and styling techniques
to minimise the thinned area over
the crown. To give the illusion of
thicker hair, camouflage treatments
that dye the scalp can be used.
Pressurised sprays containing dyes
mixed with a holding hair spray can
be sprayed onto the base of the hair
after it has been dried and styled.
In cases of extensive alopecia, a
wig should be considered. These can
be made from synthetic acrylic fibre
or natural fibre (most commonly
human hair). A good wig can look
very natural and can be styled and
MODERN MEDICINE OF SOUTH AFRICA / APRIL 2003
Systemic lupus
erythematosus
History
Hair loss occurs especially tn the
active phase of the disease
Examination
Diffuse shedding wilh scalp erythema.
Hair is dry. fragile and easily broken
Short unruly 'lupus' hairs may be
seen al the frontal margin.
Diffuse alopecia areata
History
Chronic dltfuse loss is very rare.
There may be a positive past history
or family history of this disease.
Examination
May find exclamation mark hairs.
Would need supportive histology to
distinguish alopecia areata from othei
causes.
Secondary syphilis
Comments
Secondary syphilis is rare.
Examination
Classically causes tne so-called
moth-eaten appearance with patchy
loss.
Traction alopecia
Comments
Traction alopecia is rare. Due to tight
hairstyles.
Examination
May be worse at scalp margins. Short
broken hairs and mild circumscribed
scarring may be seGn.
washed. Hair transplantation can
also be an option in women.
Medical management
Pharmacological treatment options
for women include topical minoxidil
and oral antiandrogens (spironolactone and cyproterone acetate). When
you are prescribing these treatments it is important to counsel
patients realistically: overall the aim
is to reduce hair shedding, any significant regrowth being a bonus.
The effects are generally not noted
for four to six months and tend to
continue for only as long as the
treatment is used. My practice is to
suggest that oral aniiandrogen therapy be continued for at least 12 to 24
months and then tapered off over a
further 12 months. Both anti
I
In cases of extensive alopecia,
a wig should be considered.
TILL DELIVERING W
TABLE 2.
An approach to w o m e n w i t h
diffuse telogen hair loss
Initial investigations
• Full blood examination
• Iron studies including serum ferritin
• Thyroid (unction tests
• Urea electrolytes and liver function tests
Consider if clinically indicated
• Serum zinc
• Antinuclear antibody
• Androgen screen (serum testosterone, serum dihydroxyepiandrosterone sulphate, serum sex hormone binding globulin, free androgen index,
LH: FSH ratio)
• Syphifls seriology
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Scalp biopsy is recommended but not mandatory
androgens tend to be well tolerated, and few
patients have to cease treatment because of sideeffects.
Although finasteride has revolutionised the
treatment of balding in men, unfortunately it has
not proven so useful in women. It is contraindicated in women who are or may become pregnant, because 5a-reductase inhibitors may cause
abnormalities of the external genitalia of male
fetuses. A recent large clinical trial found that
finasteride did not work in postmenopausal
women.
Minoxidil
Minoxidil is a vasodilator originally developed to
treat hypertension but found to induce hypertrichosis. It comes as a 2% and a 5% solution. A more
rapid initial response may be seen with the 5% concentration; however, whether this provides any
additional benefit in the longer term remains controversial. Retinoic acid has been added, theoretically to try to aid penetration, but the benefits are
minimal and it tends to increase irritation.
Minoxidil can be used alone or as an adjunct to systemic antiandrogen therapy.
One millilitre of minoxidil should be applied to
the thinning area and gently massaged into the
scalp twice daily. The scalp should be dry when it
is applied and kept dry for one hour after the application. This can be a drawback for many women
because it can make their hair harder to style.
It is useful to warn people that they may notice
increased shedding initially as resting telogen
hairs are stimulated to re-enter anagen. If this
does occur, it is usually a sign that the patient's
hair will respond. Good responses are also more
likely early in the course of the alopecia.
Hair regrowth can usually be detected at four to
eight months but sometimes not until 12 months,
so it is worth persisting this long. Generally, no further growth is seen after about 12 to 18 months.
Hair loss will stabilise in about 50% of users; significant regrowth can be seen in an additional 10%. If
the treatment is stopped, the new hairs will fall
out, with regression to the pretreatment state in
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APRIL 2003 / MODERN MEDICINE OF SOUTH AFRICA
37
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Connecting you
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w
about six months. For this reason, if the patient feels
she has benefited from minoxidil, it needs to be continued indefinitely to maintain this response.
Pruritus, irritant contact dermatitis and occasionally allergic contact dermatitis may develop with
minoxidil use. Contraindications include any known
hypersensitivity to minoxidil, propylene glycol or
ethanol. Because there is minimal systemic absorption, hypotension is not a problem. Women are more
likely than men to develop hypertrichosis on the face
(in 3 to 5% of cases with 2% solution and higher with
the 5% solution). The hypertrichosis tends to diminish or disappear after about one year, even with continued use, and it resolves within one to six months
after the drug is stopped. The reason for this is not
clear.
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Spironolactone
Spironolactone is a weak competitive inhibitor of
androgen binding. It also decreases androgen production and secretion from the ovaries and adrenals. The
oral dose is 100 to 200mg per day. The therapeutic
benefit tends to plateau at about 12 to 18 months,
after which it is worth trying to slowly titrate to the
lowest efficacious dose.
There have been few trials of this drug in androgenetic alopecia, but clinical experience suggests it tends
to slow progression of balding without significantly
reversing the process. Hair loss is retarded in around
60 to 70% of women; regrowth occurs in onlv 10 to
20%.
As menstrual irregularity can be a side-effect, concurrent administration of the oral contraceptive pill
(preferably one with minimal androgenic effects, such
as those containing desogestrel, norethisterone or
cyproterone acetate) can help control this, Women of
childbearing age should be warned against becoming
pregnant while on spironolactone because of the risks
of feminising a male child. Because this drug inhibits
aldosterone-related potassium excretion by the kidney, patients should be advised to avoid potassium
supplements and excessive intake of beverages that
can act as diuretics (eg tea and coffee). Renal function
should be checked at baseline and at six-monthly
intervals. Other side-effects can include breast tenderness, lethargy and mild postural dizziness, but these
tend to subside after one to two months of treatment.
Simultaneously
looking
at today
and the future,
TABLE 3.
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Women of childbearing age should be
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while on spironolactone because of the
risks of feminising a male child.
P^scrthi
IN SUMMARY
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• Androgenetic alopecia affects the majority of women
progressively as they age.
• Approximately 50% of women will experience significant hair loss by the age of 60. This is a normal physiological occurrence, but it is usually well disguised by
hair styling in women so its frequency is underestimated in the general community.
• The pattern of hair loss in women is commonly diffuse,
but it tends to be most marked over the crown with
retention of the frontal hairline.
• Endrocrine function is normal in most women with
androgenetic alopecia.
• The realistic aim of currently available treatments is to
prevent or delay further hair loss; however, some
improvement may be seen in up to 50% of patients
after six to 12 months of therapy.
(jsrtiHimffl)i)(u ahinyteifndtol tEiw
Lowest dose contraceptionThe OC to start with and stay with.
Cyproterone acetate
Cyproterone actate is a systemic antiandrogen that
inhibits gonadotrophin secretion. The response rates
are similar to those seen with spironolactone and,
again, trial data with this drug in the treatment of
androgenetic alopecia are lacking.
In premenopausal women, to prevent pregnancy
and control menstrual irregularity, cyproterone
acetate should be combined with a low-dose oral contraceptive and given in a dose of 50 to lOOmg on days
five to 15 of the menstrual cycle. Doses lower than
lOOmg per day tend not to work as effectively. In
postmenopausal women or women who have had a
hysterectomy, it may be given continuously or as the
progestogen in a hormone replacement therapy regimen in older women.
The full blood count, electrolytes and liver function
should be checked before treatment and at least
three-monthly during treatment. In patients with
diabetes, carbohydrate metabolism should be monitored carefully. Side-effects can include weight gain,
fluid retention, decreased libido and tiredness.
Contraindications to the use of cyproterone acetate
are listed in Table 3.
Conclusion
Androgenetic alopecia will affect most women as
they age. If it is premature or extensive, it can cause
considerable distress and loss of self-esteem. The
diagnosis is generally a clinical one, after excluding
other causes of diffuse hair loss. An important part of
management involves patient counselling regarding
pathogenesis and treatment options.
Suggested reading
tovcnorpUrt
1. Sinclair RD, Banfield CC, Dawber RPR. Handbook of diseases of the hair and scalp. Oxford: Blackwell Scienc, 1999:4964.
2. Callen AW, Montalto J. Female androgenetic alopecia: an
update. Australas J Dermatol 1995; 36:51-57.
3. Chong AH, Wade M, Sinclair RD. The hair pull test and
hair pluck for the analysis of hair abnormalities. Mod Med
Aust 1999; 42 (10): 105-108.
4. Price VH. Drug therapy: treatment of hair loss. N Engl J
Med 1999; 341:964-974.
CPD
questions
appear
on page
40
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Marr lnt.OC051/0103/ADV-J
QUESTIONS FOR CPD ARTICLE NUMBER THREE
CPD: 1 point
Part 3. Regarding pharmacological treatment of hair
loss in women:
a. Pharmacological agents are usually effective within
three months of starting treatment.
b.
Pharmacological agents tend to work for only as long
Instructions
as they are used.
1. Before you fill out the computer answer form, matk c. Finasteride is effective in treating balding postyour answers m the box on this page. This provides
menopausal women.
you with your own record.
d. Minoxidil should be discontinued if hair loss occurs
early in the course of treatment.
2. The answer form is perforated and bound into this
e. Good responses to minoxidil are more likely to occur
journal. Tear it out carefully.
late in the course of the alopecia.
3. Read the instructions on the answer form and folPart 4. The following statements relate to the manlow them carefully,
agement of hair loss in women:
4 Your answers for the April Issue must reach
a. Topical minoxidil should be discontinued if a
MODERN MEDICINE, PO BOX 2271, Clareinch 7740, by
response is not seen within six months.
July 31, 2003
b. Topical minoxidil commonly causes hypotension.
c. Hair loss is retarded in more than 50% of women tak5. You must score at least 60% In order to be awarding spironolactone.
ed the assigned CPD points.
d. Renal function should be monitored in women taking
spironolactone.
Answer true or false to parts (a) to (e) of the following
e. Cyproterone acetate is contraindicated in women
questions.
who have a history of persistent itch in pregnancy.
Part 1. The following statements are true of hair loss
in women:
a. Androgenetic alopecia is more common in men than
women.
b. It is abnormal to lose any more than 20 telogen hairs
each day.
c. Only 10% of women experience significant hair loss
before the age of 60.
CPD Article 3
d. Hair loss in women tends to be most marked over the
crown.
Part 1
Part 2
Part 3
Part 4
e. Most women with androgenetic alopecia have an
endocrine abnormality.
a Cl}Cy
a ITJIFJ
a
a
Part 2. The following statements are true of the clinib
cal features of androgenetic alopecia in women:
b
b (T)(F)
b (T)Tfj
a. In women, thinning of the hair usually begins before
the age of 40 years.
c [T¥F1
c
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C © ' ©
b. Gradual frontoparietal recession in women is a reliable sign of hyperandrogenism.
d W W
d
d
d
© ©
c. Hyperandrogenism should be suspected if the alopecia is of rapid onset (less than 12 months).
d. Hyperandrogenism should be suspected if hair loss is
e O ©
e ( H
e
© 0
e
associated with menstrual irregularity.
e. Iron deficiency may aggravate androgenetic alopecia.
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