FEMALE HAIR LOSS
NON SCARRING ALOPECIA IN WOMEN
By Dr Paul Charlson GPSI in Dermatology, Yorkshire and Medical Director Skinqure Clinic
Hair loss in women is distressing at any age and is quite a common problem presenting to clinicians. The psychological effects of this problem should not be underestimated.
The majority of patients with hair loss have a non scarring loss. Hair loss is either patchy with scale which is may be tinea capitis or usually non scaly with complete loss of hair in the patches usually alopecia areata or incomplete loss in the patches which suggests trichotillomania.
Diffuse hair loss is the commonest presentation. This is essentially of two types : telogen effluvium and pattern loss.
Telogen effluvium (TE) is when the hair follicles synchronize and enter into the catogen and telogen together. This can occur post partum or after an emotional stress. There is an increase in shedding of the hair at 2-3 months but this can occur up to six months after the stress. In acute telogen effluvium the hair shedding lasts less than 6 months and then recovers. Chronic telogen effluvium is when hair continues to shed over a longer period and tends to be of a more insidious onset.
Examination in TE reveals a normal scalp and often normal looking head of hair. Hair pull tests are useful. A hair pull test is when you take a hair and pull gently. A hair in anagen will stay rooted and one in telogen will come out. If 10% come out this is excellent, 25% is typical and 35% or more suggests a problem (a positive test) [i]. In active TE the hair pull test is positive.
Chronic TE may have a physiological cause. Hypothyriodism is linked to hair loss and needs to be corrected[ii]. Crash dieting can sometimes cause hair loss[iii]. Iron deficiency has been linked to hair loss but this is controversial but there does appear a link between low normal or low serum ferritin and hair loss and low serum vitamin D may also be a factor.[iv] [v] The list of drugs that can cause hair loss is long but includes commonly used drugs such as beta blockers, ACE inhibitors and Warfarin.
Female pattern hair loss (FPHL) refers to gradual thinning of hair over the central scalp. Hair miniatrurisation occurs which results in thinning rather than complete loss. FPHL is the most common cause of hair loss in women with a prevalence ranging from less than 10% of women younger than 50 years of age to 40% of those aged 70 years old. [vi]. Unlike male pattern baldness the role of androgens in FPHL is less clear with several studies showing normal levels of androgens in 70% of cases of FPHL.[vii] Oestrogen may stimulate hair growth but its role is controversial[viii] .
The investigation for non scaring hair loss in women would be blood tests for FBC, Ferritin, TFT and possibly Vitamin D levels. If there are signs of hyperandrogenism:Serum testosterone, SHBG and androgen free index.
If no corrective cause is found as is often the case, treatment requires careful planning. Many cases of FPHL are not androgen related so non androgen related treatment should be tried first. However in those cases who appear to have androgen related loss or non responders, dual treatment of both anti androgen and non androgen treatment should be tried. Although no anti-androgen is approved for use in FPHL, it seems that they work in 60% of patients with probably no long-term harmful sequelae. Most antiandrogen agents are a risk in pregnancy . Therefore, appropriate contraceptive methods should be used during the treatment and for 1–6 months after stopping the medication depending on the drug type.[ix]
The most commonly used non androgen treatment for FPHL is topical minoxidil 2% bd ( licensed for women) but 5% is more effective[x]. Minoxidil does not alter the natural history of hair loss, but rather it can thicken / increase the density of remaining hair. Results should be assessed at 6 and 12 months. 60% of women will get a response [xi] but treatment needs to lifelong.
Hair transplantation is an important treatment for women for whom medical treatment has failed or been ineffective and should not be discounted in advising patients who may go to enormous lengths to treat their problem.It is expensive and donor sites can be limited in women.
Wigs and hair extensions are also a very useful treatment and have been shown to improve the quality of life and self esteem in patients with hair loss.
Other treatments that might be considered but have a lesser place or are without substantial evidence are low level light treatments (LED and laser) and platelet rich plasma (PRP) , the latter may well prove to be a useful treatment.
[i] Olsen EA, Bettencourt MS, Cote NL. The presence of loose anagen hairs obtained by hair pull in the normal population. J Investig Dermatol Symp Proc. 1999 Dec;4(3):258-60
[ii] Freinkel RK, Freinkel N. Hair growth and alopecia in hypothyroidism. Arch Dermatol. 1972 Sep. 106(3):349-52.
[iii] Goette DK, Odom RB. Alopecia in crash dieters. JAMA. 1976 Jun 14. 235(24):2622-3
[iv] Journal of Investigative Dermatology (2003) 121, xvii–xviii; doi:10.1046/j.1523-1747.2003.12581.Decreased Serum Ferritin and Alopecia in Women D Hugh Rushton.School of Pharmacy & Biomedical Sciences, University of Portsmouth, Portsmouth, Hampshire, UK
Rasheed H, Mahgoub D, Hegazy R, El-Komy M, Abdel Hay R, Hamid MA, Hamdy E.
Skin Pharmacol Physiol. 2013;26(2):101-7. doi: 10.1159/000346698. Epub 2013 Feb 20.
[vi] Norwood OT. Incidence of female androgenetic alopecia (female pattern alopecia). Dermatol. Surg. 27(1), 53–54(2001)
[vii] Sinclair RD, Dawber RP. Androgenetic alopecia in men and women. Clin. Dermatol. 19(2), 167–178(2001).
[viii] Yip L, Rufaut N, Sinclair R. Role of genetics and sex steroid hormones in male androgenetic alopecia and female pattern hair loss: an update of what we now know. Australas J Dermatol. 2011;52(2):81–88.
[ix] Expert Review of Dermatology.An Update on Diagnosis and Treatment of Female Pattern Hair Loss. Thamer Mubki; Omar Shamsaldeen; Kevin J McElwee; Jerry Shapiro.Expert Rev Dermatol. 2013;8(4):427-436.
[x] Lucky AW, Piacquadio DJ, Ditre CM, et al. A randomized, placebo-controlled trial of 5% and 2% topical minoxidil solutions in the treatment of female pattern hair loss. J Am Acad Dermatol. 2004;50(4):541–553
[xi] Rogers NE, Avram MR. Medical treatments for male and female pattern hair loss. J. Am. Acad. Dermatol. 59(4), 547–566(2008).