Female Pattern Hair Loss (FPHL)

• Definition: Female pattern hair loss (FPHL) is a form of diffuse hair loss in women, linked to androgenetic alopecia.
• Prevalence: About 40% of women experience signs of hair loss by age 50, and less than 45% maintain a full head of hair by age 80.
• Presentation: Characterized by diffuse thinning on the scalp, often confused with chronic telogen effluvium, which also involves increased hair shedding.

Causes

• Genetics: FPHL has a strong polygenic inheritance, potentially inherited from either parent.
• Androgens: Role in FPHL is uncertain, unlike in male pattern baldness; many women with FPHL have normal androgen levels.
• Oestrogen: The role of oestrogen is unclear, though post-menopausal prevalence suggests it may be involved in hair growth regulation.

Normal Hair Growth Cycle

• Two key 5 alpha-reductase enzyme isoforms convert testosterone to DHT (more potent androgen).
• Normal hair cycle includes
  • growth (anagen – one centimeter per month for about three years)
  • involution (catagen – dies)
  • resting (telogen)
  • shedding (exogen)
  • Cycle restarts with anagen, pushing out the old hair.

Hair Shedding and Miniaturisation

• Shedding: Excessive shedding is a key feature of FPHL, assessed using a hair shedding scale.
• Miniaturisation: Scalp hair tufts lose hairs progressively, eventually revealing bald scalp areas.

Clinical Presentation:

• Gradual onset after puberty
• It’s normal to lose 50-100 hairs daily
• FPHL typically progresses intermittently, often worsening after menopause.
• Pattern: Unlike male pattern baldness, FPHL usually does not lead to complete baldness but rather widespread thinning.
• Frontal Scalp: Loss of terminal hairs with presence of miniaturized hairs in thinning areas.
• Occiput Region: Normal hair density, indicating localized hair loss.
• Hairline: Preserved frontal hairline.
• Central Part: Widening of central part, often described as a Christmas tree pattern.
• Scalp Appearance: Normal appearance without signs of inflammation or scarring.
• Hair Pull Test: Negative, suggesting stable condition without active shedding.
• Psychological Impact: Significant distress including low self-esteem, depression, and social anxiety due to societal beauty standards

Diagnostic Approach:

• Onset: Gradually begins after puberty, typically pointing towards a genetic predisposition.
• Primary Diagnosis: Clinically based on hair loss pattern and history.
• Dermoscopy: Useful for examining hair follicles and confirming miniaturization without the need for a biopsy in most cases.
• Exclusion of Other Causes: Additional tests to rule out other medical conditions that can cause hair loss:
  • Thyroid Studies: To check for thyroid dysfunctions.
  • Full Blood Count (FBC): To identify any underlying systemic conditions.
  • Iron Studies: Including serum iron, total iron binding capacity, and ferritin to exclude iron deficiency.
  • Syphilis Screening: To rule out syphilis which can cause hair loss.
  • Psychiatric Screening: Assess for depressive symptoms and other psychiatric disorders that could be contributing to hair loss.
  • PCOS: Some women with excessive androgen levels may have PCOS, contributing to hair loss.

Treatment Options

Overview:

• Objective: There is no cure for genetic hair loss, but treatments aim to slow or stop its progression, with some potential for hair regrowth.
• Treatment Duration: Continuous treatment for at least six months is necessary to assess effectiveness.

Medications:

• Minoxidil:
  • Action: Promotes the anagen phase by widening blood vessels and enhancing hair follicle function.
  • Forms: Available in 2% and 5% solutions; higher concentration may cause irritation and unintended hair growth on other body areas.
• Spironolactone:
  • Use: Often used to reduce androgen levels which can benefit hair growth in conditions influenced by hormonal levels.
• Finasteride:
  • Efficacy: More effective in regrowing hair at the vertex; however, it is contraindicated in women of childbearing potential due to potential teratogenic effects.

Other Treatments:

• Hair Transplantation: Can restore hair in balding areas but is dependent on the availability of donor hair.
• Red Light/Laser Therapy: Uses low-level lasers to stimulate hair follicles, though efficacy can vary.

Key Considerations:

• Individual Response: Treatment responses can vary significantly; what works for one person might not work for another.
• Long-term Management: Managing expectations is crucial as treatments generally do not restore hair to its original density.
• Side Effects: Monitoring for side effects, especially with systemic treatments like minoxidil and spironolactone, is essential.

Factors Influencing Prognosis:

• Early Onset: Earlier onset can predict a more severe progression.
• Gender: Men are more likely to develop complete baldness compared to women, who typically experience diffuse thinning.
• Surface Area Involvement: Larger areas of scalp involvement at the onset suggest a more aggressive course.
• Family History: A strong family history of baldness indicates a higher likelihood of developing AGA.
• Treatment Choices: The type and effectiveness of treatment significantly impact the course of hair loss.
• Compliance with Treatment: Regular and prolonged use of treatments like minoxidil or finasteride can slow progression.
• Lifestyle Factors: Diet, stress, and scalp care can influence hair health and the progression of hair loss.

Complications of Androgenetic Alopecia

While AGA itself is mainly a cosmetic concern, it can be associated with various complications and linked conditions:

Physical Complications:

• Sun Exposure: Balding areas of the scalp are vulnerable to UV exposure, increasing the risk of actinic keratosis and potentially skin cancers.
• Cardiovascular Risks: Strong correlations exist between early-onset AGA and cardiovascular risks such as hypertension, heart disease, and abnormal lipid profiles.
• Prostate Health: Mixed evidence links AGA to an increased risk of benign prostate hypertrophy and prostate cancer.
• Metabolic Syndromes: Associations include insulin resistance and obesity.
• Urolithiasis and Colon Cancer: Slight increases in risk for these conditions have been observed in individuals with AGA.

Psychological and Social Complications:

• Psychological Impact: Significant distress can arise from societal pressures and personal dissatisfaction with appearance, potentially leading to depression and reduced quality of life.