US Pharm. 2013;38(6):62-65.
ABSTRACT: Alopecia is a common problem in females. Several types of alopecia exist, each having different etiologies and treatment options. Regardless of the cause or type of alopecia, hair loss can have a negative impact on an individual’s self-image; therefore, it is important to address patients’ emotional needs as well as their medical health needs. Although FDA-approved pharmacologic options for female alopecia are limited, several medications are being investigated for their use in this population. Regardless of whether a patient decides to utilize pharmacologic treatment, minimization strategies can help reduce hair loss and alleviate the negative emotional impact of this condition.
Alopecia, more commonly referred to as hair loss, is a problem faced by millions of people in the United States. Alopecia does not refer to normal, everyday loss of hair. It is common for a person to lose around 50 to 100 hairs each day.1 Alopecia suggests an amount of hair loss greater than what is normally expected. Traditionally, more attention has been paid to male-pattern baldness; however, alopecia is common in females as well. More than 21 million females in the U.S. are affected by alopecia.2
Alopecia occurs for many different reasons and presents in various ways. It can occur suddenly or develop gradually over time. Sudden-onset causes include illness, diet, medications, and childbirth.1 Alopecia that has a gradual onset more likely has a genetic component.
Normal Hair Growth
To better comprehend the impact of alopecia, it is important to understand the normal process of hair growth. The hair follicle (the portion below the skin’s surface) is responsible for producing the hair shaft (the portion that is visible). Each follicle undergoes continuous slow growth cycles consisting of growth, resorption, and rest.3 Approximately 80% to 90% of hair is in the growth phase at any given time.4 Hair damage or loss can occur as a result of changes in the hair cycle, hair follicle, or hair shaft.
There are different types of hair and hair follicles, and individuals possess various amounts of each, depending upon age and sex. Vellus hair is lighter-colored, finer, and smaller. It is primarily seen in younger, prepubescent children and in adult females, as it is less obscured by terminal hair in these populations. The growth of terminal hair, which is darker, thicker, and longer, begins to increase during puberty, when androgen production increases. The association with androgen production is believed to explain why females tend to have less terminal hair than males do. An increase in vellus hair occurs in certain types of alopecia.3,5
The diagnosis of alopecia relies heavily on physical examination and a complete patient history. Determining the time frame and pattern of hair loss is important for classification. For example, if the hair loss is gradual in nature, the cause is most likely androgenetic alopecia.3 It also is important to rule out any underlying medical causes, such as thyroid disorder, vitamin D deficiency, or iron deficiency; therefore, pertinent laboratory tests may necessary. If alopecia cannot be diagnosed through clinical examination, a scalp biopsy may be performed to confirm diagnosis.
Types of Alopecia
There are several types of alopecia. This article will discuss the more common forms: androgenetic alopecia, alopecia areata, and telogen effluvium. Some less common forms of alopecia are cicatricial alopecia, in which hair-follicle destruction in otherwise healthy individuals results in scar-tissue formation, and trichotillomania, a largely psychological condition in which individuals pull out their hair.1
Androgenetic Alopecia: Also known as female-pattern or male-pattern hair loss, androgenetic alopecia is the most common type of alopecia. Caucasian females seem to have a higher prevalence, although precise numbers have not been determined.6 This nonscarring, hereditary condition is characterized by the progressive replacement of normal hair growth with smaller, rapid-cycling vellus hair follicles. The first sign of androgenetic alopecia in females is a widening part. The hair may gradually become thinner, which may be evidenced by a smaller ponytail. Unlike males, affected females rarely experience complete hair loss, and their hairline tends to remain intact.1,4
The mechanism of androgenetic alopecia in females is not completely understood. In some cases, androgenetic alopecia in females may be accompanied by an increase in the amount of androgen, possibly resulting from ovarian or adrenal dysfunction.7 However, there may be other non–androgen-related causes contributing to the loss of hair.3
Alopecia Areata: This is an autoimmune condition characterized by sudden, nonscarring loss of hair from the scalp or other parts of the body. For reasons that are unclear, the body’s immune system attacks the hair follicles. This typically results in smooth, round patches of hair loss. It also can cause loss of hair from the entire scalp (alopecia areata totalis) or entire body (alopecia areata universalis).8 No permanent damage to the follicle occurs; consequently, there is a high rate of remission without pharmacotherapy.8 All races are equally affected by alopecia areata.9 Most patients will eventually (≥1 year) experience hair regrowth. Often, patients with alopecia areata will relapse, resulting in more than one episode in a lifetime.
Telogen Effluvium: During stressful times, the body may react by causing more hairs than normal to enter the resting phase. This is a form of alopecia called telogen effluvium. The body sheds a large amount of hair, which generally will regrow in 9 to 12 months without pharmacologic treatment. The hair loss occurring in telogen effluvium tends to be more rapid than in the case of androgenetic alopecia. The instigating factor or event typically occurs 2 to 4 months prior to noticeable hair loss, and the shedding lasts between 2 and 4 months.3 Stressful conditions that can cause telogen effluvium include pregnancy, thyroid disorders (hypothyroidism, hyperthyroidism), systemic lupus erythematosus, severe infections, major surgery, and deficiency disorders (protein, iron). Certain medications also can lead to telogen effluvium (TABLE 1), but spontaneous regrowth usually occurs after the causative agent is discontinued.7
Preventive and Minimization Strategies
Hair, especially in Asian and Caucasian individuals, is generally more elastic when wet, which means that it breaks more easily than when dry. Therefore, it is important to avoid rubbing wet hair with a towel and brushing or combing wet hair. Allowing hair to air dry rather than using a blow-dryer also may be beneficial, because high heat renders the hair brittle and more prone to breakage. Similarly, limiting the use of flat irons and curling irons can also help prevent hair loss.1
Certain products and hairstyles put stress on the hair and cause it to break. Limiting the use of bleaches, dyes, gels, relaxers, and hair sprays can help reduce breakage. Hairpins, clips, and rubber bands can cause breakage when used to hold hair tightly. If these accessories are used, the best choices are hairpins that have a smooth, ball-tipped surface, hair clips with a spongy rubber padding, and hair bands made of fabric. To prevent breakage, hairstyles that pull on the hair, such as cornrows, tight ponytails, and braids, should be avoided.1
Managing Hair Loss
Treatment varies according to the type or cause of alopecia. As mentioned previously, hair regrowth often occurs without pharmacologic intervention. In some instances, medications may be warranted. Commonly used pharmacologic options include minoxidil and corticosteroids, and other medications are being investigated for use in females. Any underlying causes should be corrected. For example, in the case of alopecia related to iron deficiency, the underlying deficiency must be corrected before pharmacologic measures for hair loss are initiated.1 In more severe cases, procedural methods such as hair transplantation, scalp-reduction surgery, laser therapy, or scalp flaps, may be necessary.
Minoxidil: This drug is indicated for androgenetic alopecia in males and females. Although its exact mechanism is unclear, minoxidil prolongs the growth phase of the hair cycle and increases the size of hair follicles. Additionally, minoxidil maintains and thickens the hair already present.5
Minoxidil is available OTC as Women’s Rogaine (2% topical solution), Men’s Rogaine (5% topical foam), and Men’s Rogaine Extra Strength (5% topical solution). A Cochrane review examining evidence-based treatments for female-pattern hair loss found no significant differences between the 2% twice daily and the two 5% daily minoxidil formulations; however, the 5% daily formulations are not FDA approved for women.2,10
OTC 2% preparations of minoxidil should be applied topically twice daily. While some patients may see immediate results, others may require at least 4 months of therapy.10 Common adverse events include itching, burning, or erythema of the scalp. Patients should be counseled to apply the minoxidil solution to a clean, dry scalp and to wait 4 hours before allowing any water to contact the scalp. The minoxidil solution should dry completely prior to the application of any styling agents, such as gel, mousse, or spray. The minoxidil must be completely washed from the hair and scalp before any color treatments, permanent solutions, or hair relaxers are applied.11
Corticosteroids: High-dose corticosteroids, although not curative, have been used off label for management of alopecia areata when spontaneous remission does not occur. Corticosteroids may be administered topically, orally, intralesionally (injected directly into the affected area), or IV. Not all patients respond to corticosteroid treatment. If there is a response, minoxidil may be used in conjunction with the corticosteroid therapy to help prevent relapses.8
Topical preparations such as triamcinolone acetate are associated with the fewest adverse events. They are most effective in patients suffering scalp-hair loss of less than 50%. The most common adverse event with topical therapy is folliculitis.8
Oral prednisone given at 200 mg per week for 3 months is sometimes used. However, this therapy is usually avoided because of the increased incidence of adverse events.8 Adverse events associated with high-dose, long-term oral corticosteroids include increased bone loss and fracture risk, hyperglycemia, immunosuppression, and Cushing’s syndrome.10
Triamcinolone acetate is administered every 2 to 6 weeks as an intralesional injection. This therapy has a high response rate (approximately two-thirds of patients) compared with other routes of administration. Common adverse events include pain, localized skin atrophy, and skin depigmentation.8
High-dose IV methylprednisolone may be used in more extensive cases of alopecia areata. It is administered at a dosage of 500 mg for 3 consecutive days.8 This therapy tends to be highly effective, but it is not commonly used, owing to its invasive nature. Regardless of the route of administration, all corticosteroid therapies are associated with a high rate of relapse.
Additional Management Options: Several pharmacologic options are under investigation for use in female alopecia. Finasteride 1 mg (Propecia) is a 5-alpha-reductase inhibitor used in male-pattern baldness. Research is ongoing about its possible use in females, but its use in females may be limited owing to its contraindication in women of reproductive age. Finasteride is not currently approved for female alopecia, but some small studies have investigated the drug’s effect in females with androgenetic alopecia.12,13 Based on their indirect antiandrogenic effect, estrogens have been studied for use in androgenetic alopecia in females, but insufficient evidence exists to draw any conclusions.12,13 Antiandrogens such as spironolactone have been used alone and in combination with estrogens to address female-pattern hair loss. This approach is more commonly used in Europe, and large peer-reviewed studies showing efficacy are lacking.13,14
Aromatherapy involving the combination of oils such as lavender, thyme, rosemary, and cedarwood has been studied for use in patients with alopecia areata. Improvements in hair growth have been seen after 7 months of therapy in more than 40% of patients studied.15 Other natural therapies, such as zinc, beta-sitosterol, biotin, coenzyme Q10, raspberry ketone, and saw palmetto, have been examined, but conclusive evidence of effectiveness has yet to be produced.16
Hair loss can be a traumatic experience for many females. The psychological impact in females tends to be greater than in males, because females often place more importance on their physical appearance than do males. It is also more socially acceptable and understood when hair loss occurs in males, since hair loss is more recognized in this population. In one investigational study of males and females seeking treatment for hair loss, almost twice as many females (54%) as males (28%) were very to extremely upset about their hair loss.17
Females often utilize hair as a way to alter and enhance their physical appearance, through changing style, length, or color. When hair loss occurs, the ability to alter hair is compromised. In addition, significant hair loss (to the point of patches or complete baldness) can have a detrimental effect on a female’s self-image and self-esteem. The investigational study mentioned above found that females suffering from hair loss tend to have a less positive body image, more social anxiety, poorer self-esteem, and decreased quality of life compared with females without hair loss.17
It is important to understand that not all females will be affected by alopecia to the same degree. Some females may more easily accept hair loss and be less bothered by it. Other females may find it extremely unsettling, even to the point of trauma resulting in psychological illness (e.g., depression, body dysmorphic disorder), which requires additional counseling or treatment.17,18 Cases should be handled on an individual basis, and all the patient’s concerns and/or fears should be addressed.
Female patients have different ways of coping with alopecia. One coping mechanism involves compensating for hair loss by improving other physical aspects of one’s appearance, in an effort to improve self-image. Patients may choose to wear eye-catching clothing, jewelry, or makeup to draw attention away from the scalp. Another method is to conceal the area of hair loss with accessories such as hats, scarves, and wigs.17
Alopecia is a significant problem for many females that should not be casually disregarded. Although FDA-approved pharmacologic options for female alopecia are limited, several medications are being investigated for their use in this population. Whether or not a patient decides to utilize pharmacologic treatment, there are minimization strategies that can help reduce hair loss. Regardless of the cause or type of alopecia, hair loss can significantly damage a patient’s self-image. Therefore, it is important to address both the medical and the emotional health needs of female patients with alopecia.
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11. Micromedex Healthcare Series 2.0. Truven Health Analytics. www.micromedexsolutions.com/home/dispatch. Accessed January 29, 2013.
12. Stout SM, Stumpf JL. Finasteride treatment of hair loss in women. Ann Pharmacother. 2010;44:1090-1097.
13. McElwee KJ, Shapiro J. Promising therapies for treating and/or preventing androgenic alopecia. Skin Therapy Lett. 2012;17:1-4.
14. Scheinfeld N. A review of hormonal therapy for female pattern (androgenic) alopecia. Dermatol Online J. 2008;14:1.
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16. Natural Medicines Comprehensive Database. Stockton, CA: Therapeutic Research Faculty; 2013. http://naturaldatabase.therapeuticresearch.com. Updated April 22, 2013. Accessed April 23, 2013.
17. Cash TF. The psychology of hair loss and its implications for patient care. Clin Dermatol. 2001;19:161-166.
18. DeVillez RL, Jacobs JP, Szpunar CA, Warner ML. Androgenetic alopecia in the female. Treatment with 2% topical minoxidil solution. Arch Dermatol. 1994;130:303-307.
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