follow @PCDSUKCreated: 23rd November 2012 | Last Updated: 24th April 2017
Introduction
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This chapter discusses male pattern alopecia (androgenetic alopecia) and female pattern alopecia, and is set out as follows: |
Related chapters |
Aetiology
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Male pattern (androgenetic) alopecia
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Is an androgen-dependent trait. The terminal hair follicle becomes susceptible against dihydrotestosterone, which leads to shortening of anagen phase and miniaturisation of terminal to vellus hair. The development of male androgenetic alopecia is predominantly hereditary. In men, family analyses shows strong concordance rates in twins and increased risk for sons with bald fathers. Moreover, variant regions on the androgen receptor gene and at chromosome are associated with the development of androgenetic alopecia in men
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Female pattern alopecia
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There appears to be a strong genetic predisposition, and hair loss may run in the family. In the majority of cases women have normal levels of androgens in their blood, nevertheless there is a subset of women with alopecia who have associated hyperandrogenism eg secondary to the Polycystic Ovarian Syndrome
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Clinical findings
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Male pattern alopecia
- Recession of the frontal hair line, mainly in a triangular pattern is the characteristic finding, later followed by thinning of the vertex
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Female pattern alopecia
- The Ludwig pattern - is characterised by a diffuse thinning of the centroparietal region with maintaining of the frontal hair line. It is the most common type in women, occasionally also observed in men
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Christmas tree pattern - this is similar to the Ludwig pattern in that the Christmas tree pattern shows diffuse centro-parietal thinning, but additionally, the frontal hair line is breached
Images
Please click on images to enlarge, or choose to download. Images must only be used for teaching purposes and are not for commercial use. Notice and credit must be given to the PCDS and any other named contributor.
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Figure: 1 Male pattern alopecia |
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Figure: 2 Female pattern alopecia |
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Figure: 3 Male and female pattern alopecia |
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Figure: 4 Male pattern alopecia |
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Figure: 5 Male pattern alopecia |
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Figure: 6 Female pattern alopecia |
Investigations
- In women, if there is associated evidence of clinical hyperandrogenism eg acne, hirsutism and irregular periods, further investigations are needed - refer to the related chapter on Hyperandrogenism
Management
Advice
- Provide patient information leaflets
No treatment
- Patients need to give considerable consideration as to whether or not to go down the route of medical / surgical treatment - for many patients the costs of treatment and / or the development of side effects, eg from some of the anti-androgenic drugs, are not worth persevering with if the patient only perceives a small benefit from such treatment
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Hair products containing nanofibres can help stick hair together to give an appearance of thicker hair
Minoxidil
- Is a topical solution, which can be used for mild-moderate alopecia
- Minoxidil does not alter the natural history of hair loss, but rather it can thicken / increase the density of remaining hair
- In men use the 5% solution (or foam), and in women the 2% solution (higher strengths can cause unwanted side effects in women such as hirsutism)
- If using a solution the standard dose is 1 ml twice daily, although it is often easier to use 2 mls once a day. For men the most simple way of using the medication is to use a large tangerine-sized blob of the foam preparation once a day
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The response to treatment should be assessed at six to twelve months - if beneficial treatment needs to be continued to maintain efficacy. Up to 40% of patients may benefit
Other medical treatments
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Men
- Finasteride gives some benefit to approximately two-thirds of male patients. As opposed to Minoxidil, finesteride is used to try and slow the rate of hair loss
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The standard dose is 1 mg per day, although a single dose of 5 mg per week is probably as effective and much cheaper for the patient. The response to treatment should be assessed at six months. If successful, treatment needs to be continued to maintain efficacy. Finasteride reduces PSA levels and so the actual PSA level may be twice as high as what is reported
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Women
- If there is associated hyperandrogenism patients can be considered for treatment with anti-androgens - refer to the related chapter on Hyperandrogenism
Wigs
- Can be considered for patients with moderate to severe alopecia
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Patients can be referred (normally to local dermatology departments) for the provision of wigs, which are of sufficient quality to normally make for a good cosmetic appearance
Surgery - follicular unit transplantation (FUT)
- Can be performed in both male and female patients, although the outcomes appear better for men
- Patients need to have sufficient donor hair - the best site is from the neck region of the scalp
- Outcomes are variable, and depend to a large extent on the skill / experience of the surgeon
- Treatments are very expensive and patients need to give considerable thought before having such a procedure performed
Other resources
- Patient support groups - Alopecia UK