Treating female pattern baldness

Many women will seek help from hairdressers before consulting their GP.

Female pattern baldness (FPB), although poorly understood, is very common and a significant cause of distress for many women throughout the world.

In the pre-menopausal age group approximately 10 per cent of women will be affected, but after the menopause this number rises significantly with some studies suggesting an incidence of between 50 and 75 per cent.1

Female pattern baldness is common and can cause significant distress

Hair thinning
A full history should be taken including menstrual, medication and a dermatological history, and a detailed history of any hair products or treatments already tried.

In FPB the scalp will be normal with no skin disease, scaling, irritation or soreness. In FPB, the hair thinning is uniform with no areas of alopecia. If this is not the case then other conditions should be considered.

If scarring appears to be present then an urgent referral to a dermatologist should be made for a biopsy, as scarring alopecia is irreversible.

Diagnosis
If the hair loss appears uniform and the scalp appears normal, the next step is to perform blood tests to exclude other causes. These should include serum ferritin and iron, TFTs, LFTs, FBC, U&E, follicle-stimulating hormone and luteinising hormone, serum testosterone and prolactin.

In cases of hypothyroidism, hair thinning is commonly seen and is especially evident in the lateral third of the eyebrows. In these cases, with correction of the thyroid function hair thickness may improve.

Other causes include chronic renal failure, liver disease, protein deficiency and hyper-androgenic states. If there is doubt regarding an underlying inflammatory scalp problem then a biopsy can also be taken.

Once other causes have been excluded a diagnosis of FPB can be made. Explaining the condition to the patient will require time and empathy.

Treatment
Current treatment options include minoxidil and anti-androgen drugs.

Minoxidil is a piperidinopyrimidine derivative and a potent vasodilator originally used in the treatment of hypertension. When applied topically it increases conversion of fine vellus-type hair to thicker terminal hair.

It is currently available over-the-counter as 2 per cent and 5 per cent topical solutions, but is not available on the NHS. It results in moderate regrowth of hair in 24-59 per cent of patients, with a better response to the 5 per cent solution compared with the 2 per cent strength.

The 5 per cent strength is associated with an increase in the growth of facial hair, an unwanted side-effect in females.

The main side-effect of minoxidil is local irritation and occasionally contact dermatitis at the application site. Patients also need to be advised that any improvement will reverse over a three to six month period if the treatment is stopped.

Other treatments are the anti-androgens, namely cyproterone acetate and spironolactone.

Cyproterone acetate works by suppressing the actions of testosterone and its metabolite dihydrotestosterone.

One study showed improvement in 50 per cent of patients at six to 12 months when taken at a dose of 50-100mg per day.2 There is little evidence to suggest it increases hair growth, its main action being simply a slowing of the progression of hair loss.

A subjective improvement has also been reported with oral spironolactone, but the use of this can be associated with unwanted side-effects, such as irregular menses, mood swings and breast tenderness.3

Unfortunately, the 5-alpha reductase inhibitor finasteride, which has a licence for male pattern baldness seems to help little in females.

For many, treatments will be unsuccessful and wigs and concealment will be the only option.

Managing FPB can be a challenge in general practice. Treatment options are limited, prognosis is poor and the patient expectation is often very high.

It is important in the early stages of management not to create false hope of a cure as this will only add to the anxiety and distress associated with this condition.

  • Dr Stollery is a GP in Kibworth and clinical assistant in dermatology, Leicester Royal Infirmary.

References

1. Norwood OT. Incidence of female androgenetic alopecia (female pattern alopecia). Dermatol Surg 2001; 27(1): 53-4.

2. Callan AW, Montalto J. Female androgenetic alopecia: an update. Australas J Dermatol 1995; 36(2): 51-5.

3. Adamopoulos DA, Karamertzanis M, Nicopoulou S, Gregoriou A. Beneficial effect of spironolactone on androgenic alopecia. Clin Endocrinol (Oxf). 1997; 47(6): 759-60.

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