Female pattern hair loss or female androgenetic alopecia (AGA) is the most common hair loss disorder in women. Initial symptoms may develop during the teenage years and lead to progressive hair loss. Female hair loss has main manifestation of diffuse thinning of the upper regions and preservation of the front hair line.
What causes Female Pattern Hair Loss?
Female and male pattern hair loss (AGA) share a final common pathway that causes hair loss but current knowledge suggests that the exact causes are not necessarily the same in both sexes. Although the role of androgens in the cause of male hair loss has been clearly established, the role of androgens in female hair loss is less clear. In fact, female hair loss may develop even in the absence of androgens. However, it is likely that there are other factors that are currently unidentified may play a role in the causes of female hair loss, inclusive of genetic predisposition. This genetic disposition permits normal levels of circulating androgen to act on hair follicle cells, which are specially sensitised by binding to specific androgen receptors.
2 recent studies 2017 and 2016 have identified an increased number of gene loci (N60) associated with male AGA. Hair loss in women is multifactorial with the additional influence of environmental contributing factors. Female pattern hair loss involves progressive hair follicle shrinking. These hair follicles have a shortened hair cycle because of a reduction in the hair anagen phase, which leads to the production of short and fine hair shafts. Furthermore, the shrinking process may be accompanied by a mild inflammatory infiltration. Ultimately, androgens are a key driver of male balding and also involved in the cause of pattern hair loss in some women. However, other non-androgenic factors that are still unidentified likely play a role.
Associated factors to Female Pattern Hair Loss
It is evident that there is a hormonal association to female pattern hair loss. The most common hormonal association is polycystic ovarian syndrome. Other associations include obesity, diabetes, high blood pressure, hyperprolactinemia, and raised aldosterone levels. An association between ferritin levels and female pattern hair loss is controversial. Some studies have demonstrated lower ferritin levels in female patients compared with controls, and anti-androgen therapy seem to work better in patients with ferritin levels N40 μg/l.
Women with increased hair shedding but little or no reduction in hair volume over the mid-frontal scalp could be suffering from several conditions and acute or chronic telogen effluvium (TE) should be considered in particular. It is important to find out when the hair loss started, whether the loss was gradual or involved high amounts of hair as well as any physical, mental, or emotional factors that may have occurred previous. Blood test should be ideally performed to assess for hormonal imbalances or nutritional deficiencies. A history and physical examination should aim at detecting signs associated with conditions like polycystic ovary syndrome. This can often cause an increase in androgens which can lead to signs in increased facial hair. Other important factors include ovarian dysfunction, increased levels of testosterone, mensural irregularities, acne, and infertility.
Furthermore, hair loss may occur in patients who are treated with oral contraceptive medications that contain progesterone with a high androgenic potential such as norethindrone or who recently discontinued an estrogenic oral contraceptive medication that was taken for a long period of time. A physical examination would include scalp analysis. Of the tests include traction test, trichoscope testing and biopsy.
A differential diagnosis of female pattern hair loss includes telogen effluvium, postpartum hair loss, cicatricial alopecia in pattern distribution, and alopecia areata. Dermoscopy is a very useful tool to get the right diagnosis, especially in the early stages of the disease.
Treatment of Femle Hair Loss
Since female pattern hair loss can overlap with other diagnoses, a detailed medical history overview and physical examination should be performed. With the help of other diagnostic tools, other concurrent conditions should be investigated and treated if applicable.
Treatment options for female pattern hair loss:
1) topical treatments
3) regenerative therapy
2) systemic drugs
Because female hair loss is a biological process determined by a sensitivity to androgens that are genetically modulated, most of these drugs act on altering the activity of androgens. Androgen-dependent medications may cause genital abnormalities, making them contraindicated in pregnant women. Hereby, oral contraception therapy may be recommended throughout the entire course of treatment.
Minoxidil is a vasodilator was originally used for the treatment of high blood pressure. Minoxidil can be effective in both sexes, but results can be mixed. Minoxidil is a potassium channel opener and can stimulate hair growth by increasing the anagen phase of the hair cycle. For individuals who have success from minoxidil, the clinical response to 5% topical minoxidil for the treatment of hair loss (androgenic alopecia) is typically observed after 3 to 6 months and approximately 40% of individuals show a improvement.
As mentioned above, results can be mixed but when effective, treatment should be continued indefinitely as with a chronic disease because discontinuation may induce telogen effluvium of the minoxidil-dependent hair within 4 to 6 months. Patients should also be warned that during the first months of treatment, a transient increase shedding may occur. Treatment side effects are uncommon and include allergic or irritative contact dermatitis, which is more commonly related to the solution. Another possible side effect is hypertrichosis (increased hair) of the forehead or face. Additionally, the 5% minoxidil foam provides an alternative option for women who do not wish or are unable to use oral anti-androgen or hormonal contraceptive medications.
Others medicines may include – prostaglandin analog treatments, Ketoconazole, and melatonin.
Regenerative Therapy for Female Hair Loss
Platelet rich plasma (PRP)
Platelet-rich plasma (PRP) is an high concentration of human platelets contained in a small volume of plasma, used for therapeutic means. Platelets produce, store, and release high amounts growth factors capable of stimulating the increase of stem cells and the replication of new tissue cells.
The secretion of these growth factors begins within 10 minutes after clotting. In dermatology and aesthetic medicine, indications range from hair restoration such as nonsurgical therapeutic options for patients with hair loss to skin rejuvenation to chronic wounds. Often PRP is used in hair transplant procedures, by storing the grafts in PRP until they are placed on the scalp and by injecting PRP into the scalp prior to the placement of grafts. Many studies have reported very good outcomes in the treatment of hair loss with PRP therapy. Regrowth rates after 4 treatments of PRP at 3-4 week intervals and examinations showed thickening and regrowth. More information can be found here – PRP.
Regenera Activa Micrograft Transplant
Regenera Activa® is an advanced non-surgical system that works by extracting tiny micro-grafts from the back of your scalp. These micro-grafts are then processed to harvest the regenerative cells. These cells are then injected into the areas of hair loss, where they are used to facilitate repair and stimulate hair regrowth. The result is thicker and stronger hair. More information can be found here - Regenera Activa®.
Microneedling is a minimally invasive dermatologic procedure in which fine needles are rolled over the skin to puncture the superficial layer. Through the physical trauma from needle penetration, microneedling induces a wound healing cascade with minimal damage - that induces collagen stimulation, and increased bloodflow. Microneedling has shown mixed independently but can be used in association with other treatment and as an adjuvant therapy for enhanced drug delivery in the treatment of atrophic scars, AGA, alopecia areata, and pigmentation disorders such as melasma. Although here are only a limited number of studies that have examined this therapy in the use of hair loss, microneedling has been successfully paired with other hair-growth promoting therapies such as minoxidil and platelet-rich plasma treatment.
Finasteride works by inhibiting 5α-reductase, which is responsible to catalyze the conversion of testosterone to the much more active chemical 5 dihydrotestosterone. Finasteride is not FDA-approved for use in women and contraindicated in pregnancy. Long-term studies are lacking and it has been shown to be ineffective of finasteride 1 mg per day taken for 12 months in postmenopausal women for the treatment of androgenic alopecia. In addition, Finasteride 0.05% in a gel formulation has been used for the treatment of pattern hair loss and shown promising results (Hajheydari et al., 2009).
Dutasteride is a 5α-reductase type inhibitor that has not currently been approved in men and women for the treatment of hair loss. Dutasteride can reduce serum dihydrotestosterone levels by N90% and has been used with success at a dose of 0.5 mg daily in male AGA (Jung et al., 2014). Dutasteride has been reported to treat FPHL successfully with no side effects at doses that range from 0.25 to 0.5 mg per day.
Nutritional Supplementation for Hair Loss Treatment
The benefit of oral supplementation with amino acids, biotin, zinc, and other micronutrients in hair loss remains unproven. The deficiency of serum ferritin and vitamin D has demonstrated a relation to hair loss. There are several mechanisms by which both iron and vitamin D have possible effects on hair growth. As the role of iron and ferritin levels increase in nondividing cells, cells such as hair follicles have lower levels of ferritin and higher levels of free iron.
Hair transplant surgery is an option for individual suffering with hair loss who do not have success with therapies. Ideal surgical candidates for hair transplants are women with high hair density in the donor site. The most common problems that are encountered in hair transplantation in women are related to insufficient hair donor areas, the need for magnification to insert the grafts between the existing hair follicles in the recipient area, and temporary worsening of hair loss after the transplant. It is imperative that the correct selection of ideal candidates is performed prior to treatment.
A new and effective trend in hair transplantations is the adjuvant use of PRP. The growth factors and plasma components can be injected directly into the scalp before placement of the grafts or the hair grafts may be stored in PRP until placed on the scalp.
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