Alopecia androgenetica in womenL64.-

The emergence of the genetically determined characteristic pattern of the hair coat in women realized by androgens. Frequently accompanying seborrhoea (Alopecia oleosa, Alopecia seborrhoica). In contrast to alopecia androgenetica in men, alopecia androgenetica in women is considered pathological.

Prevalence in European women (all ages): Approximately 42%.

Incidence in European women after age 65: Up to 75%.

What we see is visible hair thinning as a result of follicular miniaturization and a decrease in the anagen-telogen ratio. The etiology is poorly understood, but is most likely multifactorial and polygenetic.

Causes include increased androgen production (see below adrenogenital syndrome, congenital; PCOS), the use of androgens or anabolic steroids and increased sensitivity of the testosterone receptors on the hair follicle. Hyperprolactinemia, a shift in the testosterone/oestrogen ratio in favor of testosterone (see also alopecia androgenetica in men) are also discussed.

Patients with breast cancer who have to take aromatase inhibitors(letrozole, anastrozole, exemestane) have a certain risk of developing male-type hair loss (usually prominent loss in the frontotemporal region). This hair loss is due to an inhibition of the endocrine receptors. The result is an increase in dihydrotestosterone levels, which can lead to androgenetic alopecia (Freites-Martinez A et al. 2018).

A distinction is made between a female and a male alopecia pattern:

• Female (androgenetic) alopecia pattern: Diffuse hair thinning, beginning between the ages of 20 and 40, especially in the parietal region in varying degrees with persistent frontal hairline. No significant dandruff formation; no or only insignificant itching. According to the androgenetic alopecia of the man, there are 4 stages:
  • Stage 0: Normal hair growth.
  • Stage I: Beginning hair thinning in the parting area; only visible when the hair is parted; frontal hairline of 1-3 cm width already visible. Hair plucking test positive.
  • Stage II: Prominent, visible thinning of hair in the parting area. Frontal hairline of 1-3 cm width clearly marked.
  • Stage III (rare): Pronounced baldness in the frontoparietal region, the frontal hairline remains.
• Male alopecia pattern (rather rare in women): Baldness corresponding to alopecia androgenetica in men with receding of the forehead-hairline; especially in women during or immediately after menopause. In case of additional signs of virilization a subtle hormone analysis should be performed. Staging see below. Alopecia androgenetica in men.

• Clinic with typical alopecia pattern, medical history (increased effluvium). Determination of effluvium activity with clinical depilation test.
• Trichogram: Detection of the telogenic effluvium.
• Endocrinological clarification:
  • Exclusion of hyperandrogenemia (with hirsutism, seborrhoea, acne). Hormone analysis: On the 2nd-5th day of the cycle: testosterone, DHEAS, estrogen, prolactin, LH, FSH).
  • Exclusion of hyperprolactinaemia (see prolactin below) which may also be induced by medication (neuroleptics, psychotropic drugs, etc.).
• Hair calendar: Weekly exact counting of the hairs lost during hair washing; up to 100 are acceptable.
• Additionally: Histology, blood count, blood sugar, antinuclear antibodies, thyroid antibodies, zinc and iron in serum, ferritin.

• Drug-induced alopecia ( alopecia medicamentosa): (diffuse, acute onset of anagen effluvium; the association with the causative therapy is usually demonstrable).
• Pityriasis amiantacea: (Oily scaling covering the scalp; hair can be pulled out in tufts).
• Psoriasis capitis: (here the plaque-like psoriasis capitis is less responsible than the diffuse so-called seborrhoid psoriasis capitis. Usually marked itching, fine silvery scaling of the hair base).
• Alopecia, postmenopausal, frontal, fibrosing (Kossard): (frontal linear alopecia; perifollicular erythema at the border hairs; usually evidence of keratosis follicularis).
• Alopecia specifica diffusa: (diffuse, small-spot alopecia; no pruritus; alopecia is usually detected incidentally; serologic workup is required).
• Effluvium in systemic diseases (infectious diseases, collagenoses, lymphomas, tumors of different genesis): the connection with the respective underlying disease is demonstrable.
• Anagen (dystrophic) effluvium (anagen effluvium): during periods of physical stress, periods of fever.
• Alopecia areata diffusa: (diffuse anagen effluvium; no local preference; hair plucking test is positive).

Effluvium, chronic telogenic: Persistent, phasic worsening, permanent, diffuse hair loss with loss of 100-200 hairs/day over years. No evidence of endogenous or exogenous causes (diagnosis of exclusion). Does not result in visible balding. Telogen cut-off, premature (immediate telogen release, so-called "shedding" e.g. with minoxidil therapy). Marked and sudden hair loss associated with therapy.

• Acute telogen effluvium: (febrile illnesses, injuries, severe surgical procedures, crash diets, emotional stress).
• Chronic telogen effluvium in endogenous disorders:(iron deficiency, zinc deficiency, nutritive disorders, thyroid disorders; hyperprolactinemia).

Reminder. Treatment should take place as early as possible to stop irreversible follicular regression!

According to guidelines, the use of 2% minoxidil solution 2x/day or 5% minoxididl as a foam 1x/day is recommended for women. Hair transplantation is also recommended in cases of pronounced hair loss, provided that sufficient own donor hair is available.

Currently, successes with low level laser therapy and injections of platelet-rich plasma from autologous blood (PRP) are described. Controlled clinical studies are still lacking for the latter two procedures.

Local circulation-enhancing measures, e.g. scalp massage and external therapy.

• Local application of Minoxidil in a 2% solution (Regaine women 2% solution, 2x/day ). If necessary, Regaine 5% (1x/day). Note: Minoxidil 5% is now also available in a foam formulation.
• Patients with breast cancer who have to take aromatase inhibitors benefit from a 5% minoxidil local treatment when male type alopecia occurs (Freites-Martinez A et al. 2018).
• Estrogen-containing tinctures for the scalp, such as 17-alpha estradiol (e.g. R087), alfatradiol (e.g. Ell-Cranell alpha). If necessary, short-term estradiol and glucocorticoids, topical (e.g. Crinohermal fem), salicylic acid (e.g. Alpicort F) and anti-inflammatory or hyperemic additives. The effectiveness is controversial. Subjective improvements have been reported from external applications of organ extracts (e.g. Thymuskin Hair Treatment Shampoo).
• Supporting: Treatment of accompanying dandruff and seborrhea with degreasing shampoos (e.g. Stieproxal, Stieprox, Preval Shampoo, Ket Dandruff Shampoo) The use of shampoos containing tar is also recommended (e.g. Tarmed® Shampoo).
• Experimental: The local therapeutic approach with a 0.1% melatonin solution is currently considered experimental.
• Experimental: Thymuskin is said to have shown a beneficial effect on hair growth in small study cohorts.

• Antiandrogens in collaboration with the gynaecologist. The contraindications of such a therapy must be taken into account in particular: pregnancy, liver tumours, previous thromboembolic processes, smokers > 35 years, cardiovascular diseases, lipid metabolism diseases, severe liver metabolism disorders, severe obesity.
• Mild to moderate alopecia: premenopausal: combination preparation with ethinylestradiol and cyproterone acetate (e.g. Diane 35, day 1-21, 7 days break) or ethinylestradiol and chloromadinone acetate (e.g. neo-unomine 1 tbl. day 1-22, 6 days break). Additionally, if necessary, cyproterone acetate (e.g. Androcur 10) 5-10 mg/day on day 1-15.
• Severe alopecia: premenopausal: ethinylestradiol and cyproterone acetate (e.g. Diane 35) in combination with cyproterone acetate (e.g. Androcur) 50 mg/day on days 1-10. In case of therapy failure Diane 35 and additionally cyproterone acetate depot (e.g. Androcur) 300 mg i.m. once a month on the 4th to 7th day of the cycle. Alternative preparations to the cyproterone acetate in Diane 35 are dienogest (Valette) or drospirenone (Yasmin).
• Perimenopausal (after hysterectomy) and 4 years after menopause: Cyproterone acetate (e.g. Androcur) 25-100 mg/day continuous.
• Supportive therapy: Biotin (vitamin H), e.g. Bio-H-Tin improves hair and nail quality and reduces effluvium, 1 time per day 1 tbl. p.o. for at least 6-8 weeks. If necessary also mixed preparations such as Pantovigar 3 times/day 1 Kps. over 3-6 months. The effectiveness of these preparations is controversially discussed.
• In the case of additional iron or zinc deficiency, corresponding substitution: e.g. zinc orotate 20 mg once/day; ferro sanol duodenal once/day 100 mg p.o.
• In experimental applications, approaches with finasteride ( off-label use!) are still being examined.

• Measures to promote circulation such as scalp massage or use of the plum blossom hammer have reduced effluvium in individual cases.
• Effective in small studies: Cimicifuga racemosa (CiMi hair tonic) locally for 6-12 months.
• Sabalis serrulatae fructus extracts of saw palmetto fruit (Serenoa repens) are alternative therapies that can be used in postmenopausal androgenetic alopecia.
• Currently, further studies are expected in androgenetic alopecia (of men) with extracts of green tea (epigallocatechin-3-gallate), extracts of fruits of saw palmetto (Serenoa rep ens), and Citrullus colocynthis and Cuscuta reflexa (Rondanelli M et al. 2016).
• The combination of Ginkgo biloba, snowball bark,grape procyanidins is offered as a stimulus. PHYTOCYANE, not recognized as a drug.

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