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History
A 55-year-old woman presents with an 18-month history of hair thinning over her frontal scalp. She denies any symptoms from her scalp and has not lost hair elsewhere. She takes hormone replacement therapy and is otherwise well. Her brother and father had both suffered with male pattern baldness in their 40s. Her mother has always had a ‘good head of hair’.
Examination
There is diffuse thinning of her hair over the frontal scalp extending to the vertex (Fig. 89.1). The hair that is present is finer in texture and shorter than the hair over the rest of her scalp. The scalp skin appears normal as are her nails.
All Answers
total answers (1)
Medicine
This patient is suffering from androgenetic alopecia. She has noticed gradual thinning of her hair, particularly over the frontal scalp and vertex. The family history of hair loss in men is relevant.
Androgenetic alopecia is a very common, progressive hair loss that occurs predominantly in men (male pattern baldness). This occurs due to the combined effect of genetic pre-disposition and the action of androgens on hair follicles. Dihydrotestosterone (DHT) is believed to shorten the anagen phase (growth phase) causing miniaturization of the hair follicle which then produces finer hairs. The genetic predisposition can be inherited from either parent. In men this can occur at any time after puberty as early as in late teens and is present in 80 per cent by the 7th decade. In women it occurs later and the majority of women will have a normal hormone profile. It is more pronounced after the menopause, most commonly occurring in the 6th decade. Androgenetic alopecia in men is usually demonstrated by a receding anterior hairline, particularly in the parietal-temporal region resulting in the classical M-shape of hair loss. Following this the vertex (crown) may become affected.
In women the pattern of hair loss is different. They commonly exhibit loss over the fron-tal scalp and the parietal and temporal regions are spared. If a young woman presents with this pattern of hair loss then she should be examined for signs of virilization such as clitoral hypertrophy, acne and hirsutism. If present, an underlying systemic endocrine disease should be excluded. Testosterone and dehydroepiandrosterone sulphate levels should be measured.
Treatment options include hairpieces such as wigs/weaves and toupées. Topical minoxidil can be effective in some patients in reducing and partially restoring hair loss. Once dis-continued though, the effect is lost. Finasteride, which inhibits 5--reductase (an enzyme that regulates production of DHT), can slow down hair loss in men. In women who have elevated adrenal androgens, anti-androgen drugs such as spironolactone, cyproterone and cimetidine can be effective. Finally, there may be a role for hair transplantation in some patients.
KEY POINTS
• Androgenetic alopecia is a common, progressive hair loss occurring predominantly in men.
• Genetic predisposition and the effect of androgens on follicles leads to male pattern baldness.
• In women underlying systemic endocrine disease should be excluded.
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