By Dr. Tomislav Meštrović, MD, PhD
Female pattern hair loss is a common problem of adult women. It presents with a diffuse and gradual reduction in hair density, most noticeable over the frontal and mid-portions of the scalp. This condition is progressive in nature, which means that without treatment the prognosis is one of continuous hair loss and widespread thinning.
This condition can significantly compromise a woman's body image. One study conducted in Brazil showed that the fear of completely losing scalp hair in a woman was comparable to the fear of developing a myocardial infarction. This emphasizes how important is for women to have access to different treatment options to help tackle this problem.
Despite the high prevalence of female pattern baldness, the adequate management of the problem is still faces several impediments in dermatologic practice. The principal aim of therapy is to increase the hair coverage of the scalp, and also to slow down the progression of hair thinning.
The first-line treatment is the topical use of the drug minoxidil. This has the highest level of evidence for successful alleviation of female pattern hair loss. Minoxidil is a drug which opens the potassium channels and also acts as a vasodilator. It has been reported to enhance the production of vascular endothelial growth factors in cultured dermal papilla cells. In the clinical milieu, minoxidil promotes hair growth by increasing the duration of anagen, that is, the active hair growth phase.
Only the affected areas of the scalp are treated with minoxidil solution at a dosage of 1 mL twice a day for a minimum period of twelve months. This period may be necessary before any signs of its efficacy are observed. Side effects are rarely observed and mostly involve certain forms of contact dermatitis. These are usually linked to the propylene glycol used as a solution vehicle.
Synthetic anti-androgen oral drugs are used to block androgen receptor binding. These include spironolactone, flutamide and cyproterone acetate. Although anecdotal evidence of efficacy is not wanting, especially in cases when biochemical hyperandrogenism is the underlying cause of the hair loss, overall there is not enough reliable evidence to support their routine use.
Finasteride is a competitive inhibitor of type 2 5α-reductase, which is the isotype of the enzyme most commonly found in the hair follicles. This drug can block the intracellular conversion of testosterone to dihydrotestosterone, a process that seems to play a crucial role in the process of hair miniaturization. Although large scale studies regarding its efficacy are thus far limited, smaller case series have demonstrated efficacy in both premenopausal and postmenopausal women with hyperandrogenism.
Counseling and nutritional supplementation
It has long been known that women with female pattern hair loss risk developing a lowered self-esteem with subsequent lower quality of life. it is important, therefore, that adequate counseling about the treatment options is provided so that the expectations are realistic. In extreme cases of anxiety, psychotherapy and the use of anxiolytics may be considered. This is especially so in depressed patients who often perceive even habitual hair shedding as a serious and excessive hair fall disorder.
The potential benefits of nutritional supplementation with biotin, zinc, amino acids and other micronutrients in female pattern baldness is controversial. One study has shown that 6-month supplementation with B-complex vitamins, L-cystine and medicinal yeast resulted in normalization of the rate of hair growth, assessed by in vivo hair growth measurement.
Surgery and other treatment modalities
Hair transplantation is an ideal option for women with pronounced hair loss of limited extent in the frontal scalp, who have high hair density in the donor site (over the occipital scalp). It is ideally combined with pharmacological approaches to prevent further hair loss. Here again, it is important that patients develop realistic expectations of the achievable results before surgery takes place.
Low-level laser therapy has emerged as a novel therapy in recent years, receiving substantial media attention and marketing budgets. This is despite the paucity of independent, peer-reviewed research studies that actually demonstrate its efficacy in female pattern hair loss.
Camouflaging products are successfully used to cover exposed areas on the scalp and hide any visible hair loss. They can also provide lift at the base of the hair shaft, which in turn adds volume. Such products are recommended for women with mild to moderate hair loss and, even more importantly, they are compatible with the topical application of minoxidil.
Hair extensions may be useful as a supportive measure for women with mild hair loss who seek more length and volume. Nevertheless, the selection of appropriate hair is essential to avoid any potential damage that may result when hair extensions are applied to hair that breaks easily.
Finally, ongoing gene discovery research endeavors show much promise as they attempt to pinpoint a number of novel genes responsible for hair growth and hormone-induced hair changes. Consequently, in the not-so-distant future, this may translate to a wide variety of topically delivered treatment options that can target critical pathways and stimulate hair growth.
Reviewed by Dr. Liji Thomas, MD
- Trüeb RM. Female Alopecia: Guide to Successful Management Springer Science & Business Media, 2013; pp. 59-152.
Last Updated: Aug 21, 2016