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.