Female pattern alopecia: current perspectives

Abstract

Hair loss is a commonly encountered problem in clinical practice, with men presenting with a distinctive pattern involving hairline recession and vertex balding (Norwood-Hamilton classification) and women exhibiting diffuse hair thinning over the crown (increased part width) and sparing of the frontal hairline (Ludwig classification). Female pattern hair loss has a strikingly overwhelming psychological effect; thus, successful treatments are necessary. Difficulty lies in successful treatment interventions, as only two medications - minoxidil and finasteride - are approved for the treatment of androgenetic alopecia, and these medications offer mediocre results, lack of a permanent cure, and potential complications. Hair transplantation is the only current successful permanent option, and it requires surgical procedures. Several other medical options, such as antiandrogens (eg, spironolactone, oral contraceptives, cyproterone, flutamide, dutasteride), prostaglandin analogs (eg, bimatoprost, latanoprost), and ketoconazole are reported to be beneficial. Laser and light therapies have also become popular despite the lack of a profound benefit. Management of expectations is crucial, and the aim of therapy, given the current therapeutic options, is to slow or stop disease progression with contentment despite patient expectations of permanent hair regrowth. This article reviews current perspectives on therapeutic options for female pattern hair loss.

Keywords: androgenetic alopecia; antiandrogens; female pattern hair loss; finasteride; minoxidil; spironolactone.

Figure 1

Ludwig I–III. Notes: (A) Ludwig I. Mild decrease in hair density on the crown with a barely perceptible increase in the part width. (B) Ludwig II. Moderate decrease in hair density on the crown with noticeable increase in part width. (C) Ludwig III. Severe decrease in hair density on the crown with almost no perceptible part width and thinning of the frontal hairline.

Figure 2

Temporal thinning, early FPHL. Notes: A patient with family history of androgenetic hair loss, no medical history, and no prominent scalp findings except for a bilateral temporal thinning. Abbreviation: FPHL, female pattern hair loss

Figure 3

Scarring Alopecias. Notes: (A) Dissecting cellulitis. Multiple indurated plaques and nodules with serous drainage and crusts and scarring on the scalp. Trapped and broken hairs, loss of follicular ostia, and bogginess are appreciated. (B) Central cicatricial centrifugal alopecia. Patch of alopecia on the central scalp with scarring in a patient with previous history of chemical treatments for many years. (C) Discoid lesions of systemic lupus erythematosus. Scarring alopecia of the scalp with a distinctive background of a faint pink perifollicular erythema.

Figure 4

Lichen Planopilaris. Notes: (A) Lichen planopilaris. Note the striking perifollicular erythema. (B) Telogen effluvium, systemic lupus erythematosus. Decreased hair density in the nuchal area of the scalp with a faint pink erythematous background.

Figure 5

Tinea capitis. Notes: (A) Scaly plaque with broken hairs and mild bogginess on the posterior right scalp (small arrow). Note the significant regional lymphadenopathy (large arrow). (B) KOH preparation. Ectothrix involvement of fungal spores is demonstrated on a KOH preparation of a pulled hair from the scaly plaque of the posterior right scalp.Culture identified Trichophyton tonsurans. Abbreviation: KOH, potassium hydroxide.