FPHL is a gradual onset, slowly progressive nonscarring alopecia, which can be seen any time after menarche, but is most common in females aged 20 – 40 years. It results from a progressive reduction of successive hair cycle time leading to miniaturization of hair follicles. These changes are mediated through interaction between androgens, their respective receptors and enzymes like 5α reductase and p450 aromatase. Androgens definitely take part in the pathogenesis of the androgenetic alopecia in males, but their role in female alopecia is less certain and needs further investigation.
Three types of FPHL patterns have been described.
1. Diffuse central thinning (Ludwig type): The diffuse hair loss is concentrated over frontoparietal region leading to thinning/rarefaction over central scalp with intact frontal hair line [Figure 1]. Ludwig graded it into three stages depending upon whether the central thinning is mild (stage I), moderate (stage II), or severe, that is, near-complete baldness of the crown (stage III).
Figure 1: FPHL: diffuse loss with central thinning and intact
2. Frontal accentuation (Olsen type): It leads to widening of central parting line and thereafter to chrismas-tree pattern.
3. Frontotemporal recession/vertex loss (male pattern/Hamilton type): It leads to recession of frontotemporal hairline or bitemporal recession and/or thinning at vertex.
The first two types are common and the third type is seen infrequently. The first type is often confused with CTE. Hyperandrogenism is seen in <40% of cases, and may manifest through hirsutism, severe or recalcitrant acne, oligomenorrhea, infertility, acanthosis nigricans, and galactorrhea. Hormonal screening is indicated in cases with features of hyperandrogenism as well as in women in whom FPHL is abrupt, rapidly progressive, severe, or associated with severe bitemporal recession, to rule out any underlying cause for androgen excess like polycystic ovarian disease (PCOD), and ovarian or adrenal tumors. Minimum tests for hormones include total and free testosterone
and/or dehydroepiandrosterone sulphate (DHEA-S). A more complete screening panel for hyperandrogenism consists of free and total testosterone, DHEA-S, LH, FSH, T3, T4, TSH, prolactin, and ultrasound for ovaries and adrenal glands. High levels of testosterones (2.5x
normal or >200 ng/dl) or DHEAS (>2x normal or >700 µg/dl in premenopausal and >400 µg/dl in menopausal women) should alert the physician to the possibility of androgen secreting tumor.
Specific Treatment Options
1. Telogen effluvium
TE does not require specific drugs as the condition is self-limiting and usually resolves in 36 months if the trigger is removed. Complete recovery may take one year
2. Female pattern hair loss
1. Minoxidil topical solution 2% for mild to moderate FPHL (Ludwig stage I and II) without hyperandrogenism.
2. Minoxidil 2% plus antiandrogens/finestride for mild to moderate FPHL (Ludwig stage I and II) with hyperandrogenism.
3. Hair prosthesis (wig, hair extension, hairpiece) and hair cosmetics (tinted powders, lotions sprays) for severe FPHL (Ludwig stage III)
and as adjuvant to medical therapy in mild to moderate cases. Severe cases do not respond to minoxidil and antiandrogens and surgery is not
possible as the entire scalp including the donor area is susceptible and suffers from hair loss.
4. Hair transplantation ideal candidate for hair transplantation are moderate cases of FPHL (Ludwig stage II) who have high-density donor
hair (>40 follicular unit/cm2) in some areas and extensive loss or thinning at frontal or mid frontal scalp only. Women with mild FPHL
(Ludwig stage I) are not optimal candidate as the difference between pre and post transplantation hairs is difficult to appreciate.
5) Scalp Micropigmentation Hair Density Treatment can be a great option for those women with balding spots or thinning hair. Scalp Micropigmentation Hair Density is a treatment whereby the technician implants pigment in the scalp where thinning hair or bald spots reside, and fills the area, thus darkening the specific area of the scalp. The result is the appearance of a denser, thicker amount of hair. The treatment is semi to permanent depending on the clinic and the types of pigments used. Pigments can last 2-10 years with a touch up done every 7 years on average. The treatment is inexpensive and longer lasting than the above options. The treatment is relatively painless and can usually be completed in one day.
Visit www.scalpesthetica.com for more information about Scalp Micropigmentation hair density treatments for women.
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Article Source: Diffuse hair loss in an adult female: Approach to diagnosis and management by Shyam Behari Shrivastava