You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.



Update on Female Pattern Hair Loss: Advances in Diagnosis and Treatment

  • Authors: Antonella Tosti, MD; Lakshi M. Aldrege, MSN, ANP-BC; Amy J. McMichael, MD
  • CME / CE Released: 2/28/2016
  • Valid for credit through: 2/28/2017, 11:59 PM EST
Start Activity

Target Audience and Goal Statement

This activity is intended for dermatologists, primary care providers, OB/GYNs, nurses, and pharmacists.

The goal of this activity is to provide clinicians with current perspectives on the identification and treatment of female pattern hair loss (FPHL) and communication strategies for patients with FPHL.

Upon completion of this activity, participants should be better able to:

  1. Describe the prevalence, pathogenesis, diagnosis, and clinical presentation of female pattern hair loss
  2. Outline the psychological and quality-of-life effects of hair loss in women and how these effects inform management strategies
  3. Review the available treatments for female pattern hair loss


As organizations accredited by the ACCME, Rutgers, The State University of New Jersey, and Medscape, LLC, require everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Rutgers, The State University of New Jersey, and Medscape, LLC, encourage Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


  • Antonella Tosti, MD

    Activity Chair and Professor, Department of Dermatology & Cutaneous Surgery, University of Miami, Miami, Florida


    Disclosure: Antonella Tosti, MD has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Aclaris Therapeutics, Inc., DS Laboratories, Incyte Corporation, Kythera Biopharmaceuticals, Polichem, Procter & Gamble

    Dr Tosti does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Tosti does intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

  • Lakshi M. Aldrege, MSN, ANP-BC

    Nurse Practitioner, Dermatology Service, VA Portland Health Care System, Portland, Oregon


    Disclosure: Lakshi M. Aldrege, NP has disclosed the following relevant financial relationships:
    Served as a speaker or a member of a speakers bureau for: AbbVie Inc., Celgene Corporation, Eli Lilly and Company, Novartis Pharmaceuticals Corporation, Pfizer, Inc.

    Ms Aldrege does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Aldrege does intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

  • Amy J. McMichael, MD

    Professor, Department of Dermatology, Wake Forest University Health Sciences, Winston-Salem, North Carolina


    Disclosure: Amy J. McMichael, MD has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Allergan, Covance Inc., eResearch Technology, Inc., Galderma Laboratories, LP, Guthey Renker, Incyte Corporation, Johnson & Johnson, KeraNetics LLC, Merck & Co., Inc., Merz Inc., Proctor & Gamble, Samumed, LLC
    Received grants for clinical research from: Allergan, Proctor & Gamble, Samumed LLC
    Other: Royalties from: Informa Healthcare, UpToDate

    Dr McMichael does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr McMichael does intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.


  • Shari J. Dermer, PhD

    Scientific Director, Medscape, LLC


    Disclosure: Shari J. Dermer, PhD has disclosed no relevant financial relationships.

CE Reviewer/Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC

    Lead Nurse Planner, Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.

  • Patrick Dwyer

    Director, CME, Center for Continuing and Outreach Education at Rutgers Biomedical and Health Sciences


    Disclosure: Patrick Dwyer has disclosed no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed for relevance, accuracy of content, and balance of presentation by Robert A. Schwartz, MD, MPH, Professor & Head, Dermatology, Professor of Medicine and of Pediatrics, Rutgers New Jersey Medical School, Newark, NJ.

Disclosure: Robert A. Schwartz, MD, MPH has disclosed no relevant financial relationships.

Field Testers

This activity has been pilot-tested for time required for participation by Steven M. Draikiwicz, MD and Daniel Grabell, MD.

The field testers have disclosed no relevant financial relationships.

Accreditation Statements

    For Physicians

  • Rutgers, The State University of New Jersey is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

    Rutgers, The State University of New Jersey designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Contact This Provider

    For Nurses

  • Medscape, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

    Awarded 1.00 contact hour(s) of continuing nursing education for RNs and APNs; 1.00 contact hours are in the area of pharmacology.

    Contact This Provider

    For Pharmacists

  • Medscape, LLC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

    Medscape designates this continuing education activity for 1.00 contact hour(s) (0.100 CEUs) (Universal Activity Number: 0461-9999-16-050-H01-P)

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; clinicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive CME/CE Credit, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.


Update on Female Pattern Hair Loss: Advances in Diagnosis and Treatment


Management of Female Pattern Hair Loss

Treatment Options

Medscape: Let’s start off by discussing medical nonsurgical treatments for female pattern hair loss (FPHL) and the evidence to support their use. What are the FDA-approved treatments for FPHL?

Lakshi M. Aldredge, NP: Currently there are only 2 FDA-approved treatments for FPHL: minoxidil 2% solution and 5% foam.[35,53,54] Numerous other treatments are used off-label, but these are the primary formulations used.

Medscape: What specific patient populations were included in the clinical trials?

Ms Aldredge: The majority of studies were in men, but there is evidence of benefit with topical minoxidil use in several studies in FPHL.[37,53,54 ] It is a potassium channel opener, but the mechanism of how it works in FPHL and in male pattern hair loss is still unknown.[20] Data from a small study of FPHL in 381 patients[55] found that the 5% foam formulation used once a day had greater efficacy and better tolerance than using the 2% formulation of the solution twice a day.[37] In a group of 7 studies in patients with FPHL there was an increase of 13.28 in the total number of hair count/cm2 compared with placebo.[56] There is good data supporting the use of minoxidil once a day in the 5% foam preparation vs the 2% formulation twice daily.[37]

Medscape: What about adverse effects? Were there any adverse effects with either of these formulations?

Ms Aldredge: The most common side effects with minoxidil, which were relatively rare, were scalp pruritus or itching, irritation, and rare folliculitis.[20,37] Side effects were less apparent with the 5% foam formulation than with the 2% solution.[20,37]

Medscape: Was that attributed to the formulation itself?

Ms Aldredge: Absolutely. The foam formulation does not contain propylene glycol, which is in the solution and is the cause of the irritation and erythema.[20,37]

There was also some facial hypertrichosis when the topical solution dripped onto patients' foreheads.[20,37] Again, this was rare and was controlled if the 2% topical formulation was used in combination with a shower cap or the application of petroleum jelly to protect the skin that was not intended to be exposed to minoxidil.

Medscape: What about other medical treatments that are used in male patients that may be used off-label in female patients?

Ms Aldredge: Finasteride is a treatment that has been used for some time; again, studies were primarily in male patients. It has been shown to reduce hair loss and stimulate hair regrowth at a dose of 1 mg daily.[47,57] In one controlled study in women it yielded no benefits in postmenopausal women,[34] which is the largest population with FPHL. An uncontrolled study showed improvement in approximately 52% of premenopausal women taking a higher dose -- 2.5 mg of finasteride -- who were also taking oral contraceptives.[41] Overall, data in women has been somewhat inconsistent. For the use of dutasteride and finasteride, which are both 5-α-reductase inhibitors, the data for FPHL is inconsistent. These agents are less predictable in women than in men.

Medscape: Are there any safety issues associated with these particular agents when used in women compared with, for example, their use in men?

Ms Aldredge: The safety issues are primarily related to menstrual irregularities. There were complaints of dizziness, hot flashes, nausea, depression, and some hirsutism.[20] We also know 5-α-reductase inhibitors are teratogenic and need to be used in conjunction with oral contraceptives in women of childbearing potential.[34]

Medscape: Are there any other oral medications used off-label for FPHL?

Ms Aldredge: One of these is spironolactone, an anti-androgenic drug, which has been used off-label in dermatology for numerous other conditions such as acne.[20] Spironolactone has been used in women with polycystic ovarian syndrome, in which there are rich data.[20,58-60] Unfortunately, there are few studies that included patients with FPHL. There is a case report of 4 patients who had hair loss that was reduced by 50% to 63% with spironolactone at a dose of 200 mg per day.[49] In 80 women with biopsy-proven FPHL who were given 200 mg of spironolactone daily there was approximately a 44% improvement in hair regrowth.[50]

Medscape: What about any safety issues with spironolactone?

Ms Aldredge: Safety issues are dose-dependent and primarily related to renal side effects such as postural hypotension, hyperkalemia, and headache.[20] There have been some anecdotal reports of weight loss and there is increased urinary frequency. It is also teratogenic, so it is important that patients are on birth control if they have child-bearing potential.[20]

Medscape: What about laser or light therapy for FPHL?

Ms Aldredge: Laser therapy is really interesting and kind of exciting. Several studies have looked at laser therapy for hair loss. In 2007, the HairMax laser comb was approved for male pattern hair loss, and in 2011 it was approved for FPHL.[61] This is a low level light therapy device. Although the exact mechanism of how it improves hair growth is not fully understood, it did prove efficacious at 8 to 15 minutes of exposure 2 to 3 times per week in a controlled study in men and a prospective study in men and women.[62,63] There are some recent data and anecdotal reports that laser therapy really does seem to be helpful. The safety profile is pretty good; there are few side effects -- some scalp irritation and erythema, but otherwise no significant side effects. It certainly is safer to use from a pregnancy and lactation perspective. There is definitely some excitement about the use of laser therapy in the arena of hair loss treatment.

Medscape: Are there any other modalities that you think are worth mentioning?

Ms Aldredge: Well, there are some new emerging data about topical 5-α-reductase inhibitors. Dutasteride mesotherapy injected under the scalp and that has shown some significant improvement, but the tolerability is variable.[46] You have to cover a large surface area with multiple injections, which can be painful. The topical preparation of liposomal dutasteride was also effective.[64] A topical preparation of 0.1% finasteride in combination with topical 5% minoxidil showed some efficacy and was relatively well-tolerated, with few side effects in male patients.[65] Topical finasteride by itself was less efficacious than in combination therapies. I think we are going to see some emerging data about topical 5-α-reductase inhibitors in the near future.

Developing a Treatment Strategy

Medscape: Do things such as your patient’s age factor into your treatment plan? For example, would you treat a younger woman in her 20s to 30s differently than a 60 -year-old woman?

Ms Aldredge: Age definitely plays a huge role, primarily because of the treatment options that are available. The topical agents are all going to be fine regardless of age. In the younger patient, if you are thinking about spironolactone or even finasteride, you have to think about their teratogenicity.[20,34] You must make sure that the patient is not planning on starting a family and that she is going to be on oral contraceptives as well.

You need to know about other conditions patients may have. This may be a factor, especially in elderly people. In postmenopausal women, pregnancy might not be a factor, but they may have other conditions for which they are being treated such as hypertension or potentially breast cancer and that will play a role in how you treat them. Regardless of the different ages and other considerations, topical agents are going to be the first-line and mainstay of treatment in all age groups.

Medscape: What about the extent of hair loss? Does that factor into how you might approach a treatment plan?

Ms Aldredge: Yes, I think so. If a young woman comes in with excessive hair loss, I will be more aggressive with them. I am definitely going to use a multimodal approach. I would recommend a topical agent, and I would recommend starting spironolactone and an oral contraceptive.

I would certainly give them the option of seeing someone about hair transplantation if their hair loss has been going on for some time. Hair transplantation is more successful in men than in women because there are more donor sites in men than in women.[20] I would also talk to them about camouflage techniques such as wigs or cosmetics to cover up areas of exposed scalp.

Managing Patients’ Expectations

Medscape: How do you address patients’ concerns when they initially come to your practice with complaints of hair loss?

Ms Aldredge: These are troubled patients because hair loss is extremely distressing emotionally. The first thing I do with these patients is reassure them that I am there to help them. You also need to acknowledge how problematic this condition is and how emotionally distressing it is for them because it is such a highly visible condition.

The second thing I think it is important to do is examine the patient to identify whether they have FPHL vs a scarring alopecia or telogen effluvium. It is important to ensure the correct diagnosis of FPHL or to identify whether it is some other form of hair loss so that the proper treatment can be initiated.

The next step is to explain what the diagnosis is and that this is a relatively common condition. Dermatology providers may see patients with FPHL who are younger women -- under 30 years of age – with their first onset occurring between age 20 and 30 years. The majority of FPHL patients, however, are postmenopausal women.

It is important to talk about treatment goals and expectations; patients need to know that FPHL is a difficult condition to correct. Because we do not understand the pathophysiology of FPHL we do not have targeted therapies. It is also important for women to understand that this is different from male pattern hair loss.

Many women do not want to accept the fact that this is something that happened naturally. They think it must be the result of a medication or an infection, or that there is something going on metabolically, and therefore they want to have blood tests done. I would recommend obtaining a basic workup that includes iron, thyroid stimulating hormone, and vitamin D levels, because we know that if those levels are low we need to correct them.

Medscape: How do you discuss treatment expectations with patients?

Ms Aldredge: I talk to my patients and tell them that this is going to be a long journey -- that there are no immediate fixes. Patients can expect to see some improvement realistically in 4 to 6 months and it may be minimal. To halt further thinning of the hair, or further hair loss, is really a treatment success. Prevention of further loss, not necessarily hair regrowth, is a realistic treatment goal.

Medscape How do you talk to your patients about adherence?

Ms Aldredge: That is a great point and something you really need to talk about. Topical treatments can be effective, but they have to be used consistently, or patients are not going to get the maximum benefit. In addition, if they use it as directed for some time and then suddenly stop, it can actually make the condition worse. I always emphasize that topical therapy is lifelong therapy, and it needs to be used as directed in order to get the maximum benefit.

You need to remind patients that it is really difficult to remember to put something on your scalp once or twice a day. It is important to have a candid discussion and ask, "Are you honestly going to want to put something on your scalp twice a day?" I offer tips to help patients remember to apply their medication: make it a part of your routine. After you brush your teeth is the first time that you apply the topical agent, and after you take your contact lenses out at night or wash your face when you are getting ready for bed is the second time that you apply it. Make it a part of your daily routine because this will help with adherence.

The other thing that you need to recognize is that every time a patient has to use a topical medication, for example for any skin condition such as psoriasis or atopic dermatitis, it is a reminder that they have a horrible skin condition for which there is no cure. You have to transform the negative connotation that comes with applying something to your skin or scalp consistently to something positive. I have patients use a mantra such as "I am applying this and my skin is going to get better." I think those are some key concepts that improve adherence and make the application of topical agents less cumbersome.

  • Print