Androgenetic alopecia

Authors

Beth G Goldstein, MD

Adam O Goldstein, MD, MPH Section Editor

Robert P Dellavalle, MD, PhD, MSPH Deputy Editor

Abena O Ofori, MD

Last literature review version 17.1: January 2009 | This topic last updated: November 18,
2008 (More)

INTRODUCTION — Androgenetic alopecia is the most common type of hair loss, affecting
approximately 30 to 40 percent of adult men and women [1] . The incidence is the same
among men and women, although it may be camouflaged better in the latter. While it often
affects women prior to the age of 40, the incidence increases around the time of menopause.

Hair loss, or alopecia, is classified broadly as either scarring or nonscarring: Scarring alopecia
refers to hair loss associated with fibrosis and scar tissue that replaces and often permanently
destroys the hair follicle. Examples include bullous diseases, chemical alopecia, discoid lupus
erythematosus, folliculitis (severe), lichen planopilaris, dissecting cellulitis, and tumors.
Nonscarring alopecia refers to hair loss without permanent destruction of the hair follicle.
Examples include anagen effluvium, androgenetic alopecia, chemical alopecia, folliculitis
(mild), inherited disorders of the hair shaft, telogen effluvium, alopecia areata, and traumatic
alopecia.

All types of hair loss can be psychologically debilitating. Thus, psychologic support is essential
for all patients with hair loss. This topic discusses androgenetic alopecia. The other causes of
nonscarring alopecia are discussed separately. (See "Nonscarring hair loss" and see "Alopecia
areata").

HAIR GROWTH CYCLE — We have all of our terminal hair follicles at birth. Growth of each of
these follicles on the scalp is cyclic [2] : The growth phase, termed anagen, lasts two to three
years. The involutional phase, termed catagen, lasts two to three weeks. The resting phase,
termed telogen, lasts three to four months. Hair is released from the hair shaft and shed at the
end of telogen, and the next cycle is initiated. Telogen hairs are characterized by a mature root
sheath, or "club," at the proximal end.

In the normal scalp, approximately 80 to 90 percent of follicles are growing (anagen), about 5
to 10 percent are resting (telogen), and 1 to 3 percent are undergoing involution (catagen)
[3,4] . Each day up to 75 hairs in telogen are shed from the scalp and about the same number
of follicles enter anagen [2] .
PATHOGENESIS — Hair "loss" in androgenetic alopecia is due to a genetically determined
shortening of anagen, with subsequent production of a shorter, thinner hair shaft, a process
often called follicular miniaturization. The hair growth cycle continues, but new growth
becomes thinner and shorter as follicles are miniaturized. The mode of inheritance is polygenic
with variable penetrance [5,6] .

Miniaturization is caused by a hormonally-mediated process at the follicular level.

Dihydrotestosterone binds to the androgen receptor in susceptible follicles, and the hormone-
receptor complex then activates the genes responsible for the gradual transformation of large,
terminal follicles to miniaturized follicles [7-10] .

Young men and women with androgenetic alopecia have higher levels of 5-alpha-reductase
(which converts testosterone and other androgens to dihydrotestosterone) and a higher
quantity of androgen receptors, but lower levels of the enzyme cytochrome P-450 aromatase
(which converts androgens such as testosterone and 4-androstenedione to the estrogens
estradiol and estrone, respectively) [2] . These transformations can take place in the hair
follicle itself. In addition, production rates of dihydrotestosterone are higher in men with male
pattern balding than in those without [11] .

Differences in the levels of androgen receptor and steroid-converting enzymes may account
for the different clinical presentations of androgenetic alopecia in men and women. In one
study, for example, both men and women had higher levels of receptors and 5-alpha-
reductase in frontal hair follicles than in occipital follicles, while higher levels of aromatase
were found in the latter [9] . Compared with frontal follicles in men, androgen receptor
content in female frontal follicles was 40 percent lower, 5-alpha-reductase approximately
three times lower, and aromatase content six times greater.

A genetics study raised the possibility that variability in the androgen receptor gene may play
an important role in the pathogenesis of androgenetic alopecia [12] , and two other studies
found an additional association with polymorphisms on chromosome 20p11 [13,14] .

CLINICAL FEATURES — Androgenetic alopecia is characterized by varying degrees of partial

hair thinning primarily from the vertex and frontal areas of the scalp. It is typically more diffuse
and rarely complete in women. Maintenance of the front hair line is normal, with diffuse
thinning typically occurring just behind the frontal hairline or midscalp area to the vertex. The
affected part is usually widened and more obvious. Hair loss usually occurs in an M-shaped
pattern in the frontal hair line in men. Regression of hair in the temporal areas advances to the
midscalp area as the alopecia progresses.

The miniaturized hairs can be of various lengths and diameters since each follicle is in a
different phase of the hair cycle; the presence of uneven lengths and texture is a classic sign of
androgenetic alopecia [2] .

DIAGNOSIS — The diagnosis of androgenetic alopecia is usually straightforward in men.

Diffuse frontal to vertex thinning in women may provide a greater diagnostic challenge.
Examine the scalp for other signs of hair disease, such as scarring or follicular plugging, which
could cause permanent hair loss. Rule out other causes of diffuse hair loss, such as illness (eg,
hyper- or hypothyroidism, iron deficiency [15,16] ), medications (eg, anticoagulants,
anticonvulsants, beta blockers, antidepressants, among others), or trauma. A family history of
similar hair loss is suggestive of androgenetic alopecia.

Although most women with androgenetic alopecia are endocrinologically normal, take a
careful history and look for any signs of androgen excess in women, such as menstrual
irregularities, acne, hirsutism, or other signs of virilization. Often women use techniques to
hide hirsutism; it is important to ask, not just look, for excess hair growth. Given the frequency
with which androgenetic alopecia occurs in women, an extensive hormonal evaluation is not
necessary unless one of these signs or symptoms of androgen excess are present. Laboratory
tests in women with suspected androgen excess should include total testosterone,
dehydroepiandrosterone sulfate (DHEAS), and prolactin levels. (See "Evaluation of women
with hirsutism").

DIFFERENTIAL DIAGNOSIS

Telogen effluvium — Androgenetic alopecia in women may be so diffuse that it can be difficult
to distinguish it from the diffuse hair loss of telogen effluvium. The latter is usually associated
with an acute event, the results of the hair pull are positive (see "Nonscarring hair loss",
section on Telogen effluvium), and a history of a precipitating event or drug is helpful. A biopsy
specimen (4 to 6 mm) from an area of alopecia may be helpful to distinguish the condition (see
below).

Diffuse alopecia areata — Diffuse alopecia areata is usually more acute in onset than
androgenetic alopecia, does not follow a classic distribution, and is associated with hair loss on
other body sites. (See "Alopecia areata").

TREATMENT — Oral finasteride (Propecia) and topical solutions of minoxidil (Rogaine) are the
only drugs approved by the United States Food and Drug Administration for treatment of
androgenetic alopecia in men. Only minoxidil is approved in women. Pictures before initiating
therapy and four months later may be helpful to document any change in appearance.

Topical minoxidil — Minoxidil promotes hair growth by increasing the duration of anagen and
enlarging miniaturized and suboptimal follicles; the mechanism by which this occurs is unclear
[2] . Topical minoxidil is available over the counter in both 2 and 5 percent solutions and as a 5
percent foam. The 5 percent solution appears to cause somewhat more contact dermatitis
than the 2 percent solution [17] , and the 5 percent foam may be somewhat less irritating [18]

Use in men — Both 2 and 5 percent minoxidil have consistently demonstrated benefit in men
with androgenetic alopecia compared with placebo, and the 5 percent preparation is more
effective than the 2 percent solution [17,19] . In the largest controlled trial, for example, 393
men with androgenetic alopecia were randomly assigned to treatment with 5 or 2 percent
topical minoxidil solution or placebo [17] . After 48 weeks of therapy, 5 percent minoxidil was
significantly superior to the 2 percent solution or placebo in terms of change from baseline in
nonvellus hair count (increase in count per square cm of 18.6, 12.7, and 3.9, respectively),
patient rating of scalp coverage and treatment benefit, and investigator rating of scalp
coverage. Treatment with 5 percent minoxidil was also associated with an earlier therapeutic
response and an improvement in the patients' psychological perceptions of hair loss. Patients
treated with 5 compared with 2 percent minoxidil reported more pruritus and local irritation.

Use in women — Two double-blind studies of 550 women ages 18 to 45 years with
androgenetic alopecia demonstrated the efficacy of 2 percent minoxidil in women [20,21] . In
one study, 13 percent of women in the minoxidil-treated group had moderate growth and 50
percent had minimal growth, compared with 6 and 33 percent, respectively, in the placebo-
treated group [20] . Similarly, 60 percent of women in the minoxidil group reported that they
had new hair growth (20 percent moderate and 40 percent minimal) compared with 40
percent (7 percent moderate and 33 percent minimal) of patients in the placebo group.

A randomized trial that compared 5 percent minoxidil, 2 percent minoxidil, and placebo in 381
women with androgenetic alopecia found that 5 percent minoxidil was significantly superior to
placebo for each of the three primary endpoints (nonvellus hair count, patient assessment of
hair growth/scalp coverage, and investigator assessment of hair growth/scalp coverage) [22] .
Two percent minoxidil was also superior to placebo on the end points of hair count and
investigator assessment, but not on the patient assessment end point. In comparing the two
strengths of minoxidil, patient assessment was significantly better and there was a trend
toward higher nonvellus hair counts with 5 versus 2 percent minoxidil. Dermatologic adverse
events including pruritus, dermatitis, scaling, and hypertrichosis (facial hair growth), were
more common with 5 percent minoxidil than with 2 percent minoxidil or placebo (14, 6, and 4
percent, respectively); hypertrichosis occurred in 4 of 153 patients receiving 5 percent
minoxidil.

Finasteride — Finasteride is an inhibitor of 5-alpha-reductase type II, thereby inhibiting

conversion of testosterone to dihydrotestosterone [23] . Taken orally at a dose of 1 mg/day,
finasteride rapidly lowers serum and scalp dihydrotestosterone levels by more than 60 percent
[2] . It has no affinity for the androgen receptor and does not interfere with testosterone
action nor have any steroidal effects of its own [23] .

Use in men — The efficacy of finasteride for treatment of androgenetic alopecia was
demonstrated in two one-year trials of 1553 men ages 18 to 41 years who were randomly
assigned to oral finasteride (1 mg/day) or placebo for one-year, with blinded extension studies
for a second year in 1215 of the subjects [24] . Finasteride treatment resulted in clinically
significant increases in hair count and improved scalp coverage, while treatment with placebo
resulted in progressive hair loss. About two-thirds of men taking finasteride had improved
scalp coverage at two years; one-third had the same amount of hair as they did at the start of
the study. About 1 percent of patients on finasteride lost hair. These results were confirmed in
a second report [25] .

Although treatment for more than two years has not been rigorously studied, the clinical
impression is that scalp coverage continues to increase as the hairs recruited to grow in the
first year continue to get thicker, more pigmented, and longer [2] . This impression is
supported by a randomized trial that followed some men for up to 192 weeks and found that
net improvements in hair weight with finasteride therapy were greater than improvements in
hair count, suggesting that factors other than hair count, such as increased hair length and
thickness, contribute to the beneficial effects of finasteride [26,27] .
The 1 mg dose of finasteride used to treat hair loss is much lower than the typical 5 mg dose
used to treat benign prostatic hypertrophy. (See "Medical treatment of benign prostatic
hyperplasia"). Side effects of the higher dose include decreased libido and ejaculatory or
erectile dysfunction; these are much less common with the dose used for alopecia. In addition,
the serum prostate specific antigen (PSA) may decline by as much as 50 percent in men taking
even the 1 mg dose of finasteride [28] . (See "Measurement of prostate specific antigen").

When the 5 mg finasteride dose was studied for the chemoprophylaxis of prostate cancer, it
reduced the overall incidence of prostate cancer but increased the risk of high grade prostate
cancer [29] . It is unclear whether this has implications for the safety of 1 mg finasteride used
for the long term treatment of alopecia. (See "Chemoprevention strategies in prostate
cancer").

Use in women — Finasteride is contraindicated in women of reproductive potential because of

concerns regarding abnormal genitalia development in the male fetus, and it is recommended
that such women not even touch finasteride pills. Finasteride was used in a research study of
premenopausal women with female pattern hair loss who were also receiving oral
contraceptives [30] .

One study that evaluated the use of finasteride in postmenopausal women with androgenetic
alopecia found no evidence of benefit with finasteride compared with placebo [31] . However,
in the subset of women with hair loss in the setting of hyperandrogenism, there have been
reports of improvement with finasteride [32,33] .

Combination and comparison with minoxidil — In a small study, finasteride 1 mg was superior
to minoxidil 2 percent; this study also showed a trend toward better results with combination
therapy with finasteride and minoxidil compared with finasteride alone [34] . While there are
no direct head-to-head comparisons between finasteride and minoxidil 5 percent, clinical
observations suggest that finasteride is easier for patients to use and thus may increase
compliance with therapy, which may lead to better outcomes.

Other 5-alpha-reductase inhibitors — Dutasteride, an inhibitor of both types I and II 5-alpha-

reductase, is FDA approved for the treatment of benign prostatic hyperplasia. (See "Medical
treatment of benign prostatic hyperplasia").

A randomized, placebo-controlled trial in 416 men compared a range of doses of dutasteride

with finasteride 5 mg daily [35] . Hair growth showed a dose-response effect with dutasteride,
and after 12 and 24 weeks of therapy, dutasteride 2.5 mg daily was more effective than
finasteride. However, this is a high dose of dutasteride; the standard dose for benign prostatic
hyperplasia is 0.5 mg daily. In this study, 13 percent of men treated with dutasteride 2.5 mg
daily reported decreased libido.

Longer term studies of safety and efficacy are needed before this high dose of dutasteride can
be recommended for the treatment of hair loss in men. Dutasteride has also been tried in
women [36] , however, like finasteride, it is contraindicated in women of reproductive
potential.
Spironolactone — Evidence from case reports suggest that women with androgenetic alopecia
who do not respond to minoxidil may benefit from the addition of spironolactone [37-39] .

An observational study in women not being treated with minoxidil found that 35 of 40 women
treated with spironolactone 200 mg daily had either stabilization of hair loss or hair regrowth
[40] . The study found nearly identical results in 40 women treated with the antiandrogen
cyproterone acetate.

In women who do not response to minoxidil alone, we typically add spironolactone at a dose
of 100 to 200 mg per day.

Surgery — Referral to a dermatologist or plastic surgeon may be appropriate in selected

patients. Available procedures include hair transplantation or flaps, and scalp reduction.

Light therapy — Treatments with low-energy laser light or other lights have been marketed for
androgenetic alopecia. There is not adequate evidence for the efficacy of such treatments [41]

Patient education — Discourage use of hair treatments and tonics; they are unproved, often
expensive, and possibly damaging to remaining hair.

Minoxidil — Patients considering use of minoxidil should be advised of the following: Explain
that minoxidil solution is available over-the-counter and is to be used for an indefinite time,
and that it is not usually covered by insurance. Once stopped, any hair regrowth will be lost.
Emphasize that minoxidil is a scalp treatment, not a hair treatment, and must be used exactly
as prescribed for maximum benefit. A normal, healthy scalp is required to use this medication.
Apply 1 mL twice a day to involved areas on a dry scalp. The solution can be applied by
dropper or pump spray device to the scalp and spread lightly with a finger; massage is not
needed. Explain that minoxidil solution must be used twice a day for at least four months
before evaluating the initial response to therapy. Hair shedding usually decreases within two
months of starting treatment. Hair growth may be seen within four to eight months and
stabilizes at 12 to 18 months. Cosmetically significant hair growth occurs in only 30 to 40
percent of patients with vertex hair loss. The best results are obtained if the baldness pattern
is present for less than five years, involves a vertex location, and is less than 10 cm in diameter.
Treatment must be continued indefinitely; once discontinued, any hair maintained or regrown
as a result of the medication will be lost. The most common side effects, although infrequent,
are contact and irritant dermatitis [42] . Neither 5 percent nor 2 percent solution of minoxidil
alters systolic or diastolic blood pressure, pulse rate, or body weight when applied daily [43] .
Nevertheless, patients with a history of cardiovascular disease should be educated to watch
for tachycardia, edema, or weight gain because systemic absorption can occur if the scalp skin
barrier is not intact. Topical minoxidil 5 percent solution is more effective than the 2 percent
solution in men; there are limited data in women that also suggest greater efficacy of 5
percent minoxidil; however, a small number of women appear to develop facial hair growth
with the higher concentration solution [22] .
INFORMATION FOR PATIENTS — Educational materials on this topic are available for patients.
(See "Patient information: Hair loss in men and women (androgenetic alopecia)"). We
encourage you to print or e-mail this topic review, or to refer patients to our public web site,
www.uptodate.com/patients, which includes this and other topics.

SUMMARY AND RECOMMENDATIONS The diagnosis of androgenetic alopecia in men is

usually straightforward. In women, if there are other signs of androgen excess, measure levels
of testosterone, dehydroepiandrosterone sulfate (DHEAS), and prolactin. (See "Evaluation of
women with hirsutism"). In the absence of direct comparisons, finasteride 1 mg every day is
preferable to minoxidil for treatment of androgenetic alopecia in men. Most men taking
finasteride will stop losing hair, and about two-thirds of men will have increased hair coverage
after two years on finasteride. Finasteride is contraindicated in women of reproductive age,
and finasteride pills should not even be touched by such women; finasteride does not appear
to work in postmenopausal women except perhaps in the subset of women with
hyperandrogenism. Minoxidil 5 percent applied twice a day is more effective than minoxidil 2
percent in men. Even in men with vertex hair loss (where minoxidil works best), only 30 to 40
percent will have cosmetically significant hair growth. Limited data suggest that minoxidil 5
percent is more effective than minoxidil 2 percent in women with androgenetic alopecia [22] .
We recommend the use of minoxidil 5 percent; however, a small number of women may
develop facial hair growth with this. Women who do not respond to minoxidil may benefit
from the addition of spironolactone 100 to 200 mg per day. There are limited data on
combination therapy with minoxidil and finasteride [34] ; however, in men who do not
respond to therapy with either agent alone, it is reasonable to try combination therapy. Hair
transplantation, flaps, and scalp reduction surgery may be appropriate in selected patients.

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