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Hair loss, thinning of hair and baldness are significant cosmetic problems and can pose serious psychological problems, both for males and females.
Androgenetic (or male pattern) alopecia is a genetically determined disorder characterized by the gradual conversion of terminal hairs into indeterminate, and finally into vellus, hairs. It is an extremely common disorder that affects roughly 50% of men and perhaps as many women older than 40 years. As many as 13% of premenopausal women reportedly have some evidence of androgenetic alopecia. However, the incidence of androgenetic alopecia increases greatly in women following menopause, and, according to one author, it may affect 75% of women older than 65 years.
Signs and symptoms
Signs of androgenetic alopecia include the following:

  1. Gradual onset
  2. Increased hair shedding
  3. Transition in the involved areas from large, thick, pigmented terminal hairs to thinner, shorter, indeterminate hairs and finally to short, wispy, nonpigmentedvellus hairs
  4. End result can be an area of total denudation; this area varies from patient to patient and is usually most marked at the vertex

Males

  1. Men note a gradual recession of the frontal hairline early in the process
  2. Men present with gradual thinning in the temporal areas, producing a reshaping of the anterior part of the hairline

Females

  1. Hair generally is lost diffusely over the crown; this produces a gradual thinning of the hair rather than an area of marked baldness; the part is widest anteriorly
  2. The frontal hairline is often preserved in women
  3. Bitemporal recession does occur in women but usually to a lesser degree than in men

Pathophysiology

Androgenetic alopecia is a genetically determined disorder and is progressive through the gradual conversion of terminal hairs into indeterminate hairs and finally to vellus hairs. Patients with androgenetic alopecia have a reduction in the terminal-to-vellus hair ratio, normally about 4:1. Following miniaturization of the follicles, fibrous tracts remain. Patients with this disorder usually have a typical patterned distribution of hair loss.
Androgenic alopecia is genetically linked and is strongly hereditary. Specific genes and their locations have been identified.

Diagnosis
Laboratory studies
History and the physical examination are the most important aspects of diagnosis in patients with androgenetic alopecia. The following laboratory tests, however, can play a role in patient assessment:

  1. Dehydroepiandrosterone (DHEA)-sulfate and testosterone analysis: In women, if virilization is evident
  2. Iron, total iron-binding capacity, and transferrin saturation: To test for iron deficiency, if telogen effluvium is present
  3. Thyrotropin level: If a thyroid disorder is suspected
  4. Biopsy and histology: A biopsy is rarely necessary to make the diagnosis of androgenetic alopecia. If a single biopsy specimen is obtained, it should generally be sectioned transversely if pattern alopecia is suspected.

Management
The following drugs have been approved by the FDA for the treatment of androgenetic alopecia:

  1. Minoxidil: Androgen-independent hair-growth stimulator
  2. Finasteride: 5-Alpha reductase type 2 inhibitor

Medical Care
Only 2 drugs currently have US Food and Drug Administration (FDA)–approved indications for treatment of androgenetic alopecia: minoxidil and finasteride.
Minoxidil
Although the method of action is essentially unknown, minoxidil appears to lengthen the duration of the anagen phase, and it may increase the blood supply to the follicle.Regrowth is more pronounced at the vertex than in the frontal areas and is not noted for at least 4 months. Continuing topical treatment with the drug is necessary indefinitely because discontinuation of treatment produces a rapid reversion to the pretreatment balding pattern.
Patients who respond best to this drug are those who have a recent onset of androgenetic alopecia and small areas of hair loss. The drug is marketed as a 2% or a 5% solution, with the 5% solution being somewhat more effective. 45% more regrowth occurs with the 5% compared with the 2% solution. In general, women respond better to topical minoxidil than men. The increase in effectiveness of the 5% solution was not evident for women in the FDA-controlled studies. Subsequent studies have shown at best a modest advantage to the higher concentration in women. In addition, the occurrence of facial hair growth appears to be increased with the use of the higher-concentration formulation.
Finasteride
Finasteride is given orally and is a 5-alpha reductase type 2 inhibitor.It is not an antiandrogen. Finasteride has been shown to diminish the progression of androgenetic alopecia in males who are treated, and, in many patients, it has stimulated new regrowth.
Finasteride must be continued indefinitely because discontinuation results in gradual progression of the disorder.
A 10-year follow-up study of men using finasteride 1 mg daily for androgenetic alopecia reported that better improvements were noted in patients older than 30 years or men who had higher androgenetic alopecia grades. Interestingly, the efficacy of the medication was not reduced with time, and in some cases improved later on.
Other drugs
Some drugs are not approved by the FDA but are potentially helpful medications.In women with androgenetic alopecia, especially those with a component of hyperandrogenism, drugs that act as androgen suppressants or antagonists (eg, spironolactone, oral contraceptives) may be beneficial.
Dutasteride is another possible treatment for androgenetic alopecia. This drug inhibits type I and type II 5-a reductaseisoenzymes and is felt to be 3 times as potent as finasteride in inhibiting the type II enzyme and 100 times as potent in inhibiting the type I enzyme. FDA approves the drug for use in treatment of Benign Prostatic Hyperplasia but not for androgenic alopeica
Low-level laser light therapy, in particular a red light hairbrush–like device has been marketed as an over-the-counter technique for hair growth. This devise has approval only pertaining to safety rather than actual efficacy and that the data required for medical devices are quite different from those required to demonstrate the safety and efficacy of drugs. In short efficacy of such a devise is not proven and not approved.
Topical latanoprost 0.1%, a prostaglandin analogue used to treat glaucoma, has been noted to cause an increase in the number, length, and thickness of eyelashes. This medication could be useful for stimulating hair follicle activity and treating hair loss but is rather expensive compared to minoxidil.

 
 
 
 

 

 
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