Improving Patient Outcomes in Female Pattern Hair Loss Through Communication

Introduction

Female pattern hair loss (FPHL), also known as androgenetic alopecia, is a common form of nonscarring hair loss affecting the vertex and frontal scalp of women. The process causes progressive thinning of the hair in these areas of the scalp with decreased density and miniaturization of the hair shafts. The age of patients affected can range from the teenage years to the 70s, with post-menopausal women most affected. In the following cases, we will review the prevalence, pathogenesis, and clinical presentation of FPHL. Available treatments will be discussed and psychological and quality of life effects will be demonstrated.

CASE 1: Presentation

Dorothy T. is a 57-year-old woman who is 9 years post-menopause. She started noticing mild hair loss in the crown of her scalp approximately 8 years ago. Her hair stylist remarked 1 year ago that the hair in her frontal scalp appeared to be thinning as well. She has no scalp symptoms and has not tried any treatments thus far.

History and Examination. Her history shows that the patient is generally healthy with no history of medical problems and is not currently taking any medications. A complete blood count (CBC) with differential and a comprehensive metabolic panel that the patient had at her primary care doctor’s office several months ago revealed results within normal limits.

Dorothy’s family history is positive for mild balding of the vertex in her father and her older brother, but neither is completely bald. The patient noted a significant amount of stress in the last 10 years due to both of her children moving out of state and her mother becoming more frail and unable to care for herself.

On examination, there was mild widening of the midline part from her frontal scalp to the vertex. Her scalp was normal with no redness or scales. A pull test of approximately 30 hairs per pull in all quadrants of her scalp was negative at 0 to 1 hairs per pull. Her frontal hairline was intact. Dermatoscope examination of her scalp showed perifollicular hyperpigmentation, as well as a number of yellow dots (pilosebaceous units) with only 1 hair. There was also miniaturization of the hair shafts in her frontal scalp. The rest of Dorothy’s skin exam was unremarkable.

After the exam, it was clear that Dorothy has typical FPHL. No further laboratory tests were needed for this diagnosis, as she is a healthy individual with a straightforward health history.

Analysis

FPHL usually affects women in their 20s to 70s and its prevalence increases with advancing age and in women who have reached menopause.^[8,9] The gradual loss of hair over time, with a predominant pattern of diminishing hair density in the region of the central scalp and the temporal region is typical in FPHL.^[10] Although a history of FPHL is not noted, there is a history of hair loss among first-degree male relatives. A high prevalence (40% to 50%) of FPHL among female members of the same family suggests a role for a genetic component of this condition,^[6,8] but a similar relationship has not been established between female and male relatives. Because Dorothy is in good health and her laboratory tests did not reveal any conditions that would predispose her to hair loss, it is reasonable to assume that her hair loss is due to FPHL.

Treatment goals and options. Goals of treatment were discussed with Dorothy. The most likely outcome of treatment is slowing the process of hair loss, although many patients see a mild increase in density as measured from midline part photographs. There is rarely a return to pre-hair loss levels of density. When it does occur, it is welcome and is due to differential responses to treatment. The discussion also included patient education about the importance of medication compliance. Improvement in hair density, in general, is more likely to occur in those patients who are compliant with their medication regimen.

Discussion of treatment options began with topical treatment, minoxidil 5% foam applied once daily, and systemic medication, finasteride 2.5 mg taken orally once daily.^[35,38] Dorothy was somewhat hesitant to use minoxidil because she heard that she would have to use this medication for the rest of her life. She was also worried about possible facial hair growth with minoxidil.

Discussing Treatment Options and Quality of Life

Dorothy’s concerns regarding the long-term use of minoxidil were addressed. FPHL is a chronic condition and medication will be necessary until Dorothy is no longer worried about her hair loss. The possibility of mild growth of intermediate hairs around the hairline was discussed. She was told that terminal hairs would not develop in a secondary male characteristic manner.

Discussion regarding application of the medication included the following recommendations: daily application to the scalp in 5 parts from the frontal midline part to the crown, followed by 2 lines on either side from the fronto-temporal scalp to the vertex and in the pre-auricular scalp to the vertex on each side.

Dorothy was informed that the use finasteride in women is an off-label use of this medication. Possible side effects are breast tenderness and enlargement.^[20] Additionally, this class of drug -- a 5-α reductase inhibitor – is teratogenic, so women of childbearing age must use oral contraceptives.^[11,34,38]

Low-level laser light treatment was a therapeutic modality that Dorothy brought up during her appointment. She was interested in beginning this treatment since it is approved by the FDA and has no known side effects.^[20] She plans to research which light therapy best fits her budget and seems the most effective. She was considering the newest version -- the laser band.^[61]

Surgical options for hair restoration were discussed, since hair transplantation techniques have improved over the last decade. The patient deferred this treatment for now; it is not covered by insurance and is more costly than she can afford at this time. Dorothy opted to keep the contact information for a dermatologic surgeon who performs this surgery for a later time.

Lastly, the patient was informed about cosmetic options -- hair fiber agents that can be applied to the frontal and parietal scalp to camouflage the thinning on the vertex and frontal scalp.

Analysis

Minoxidil 5% foam applied once daily is approved for the treatment of FPHL.^[35] This formulation was found to be equally as efficacious as the 2% solution, which is applied twice daily, with less local irritation.^[37] Significantly more patients in the 5% foam treatment group reported that "the treatment does not interfere with styling my hair" than those in the 2% solution treatment cohort (P = .002),^[37] which can be an important factor when adherence is essential to treatment success.

Finasteride is approved for the treatment of male pattern baldness, and as noted above its use in women is off-label.^[38] This medication is, however, used in women with FPHL based on data from several uncontrolled studies in premenopausal and postmenopausal women.^[11,39-41]

Laser light therapy is a relatively new treatment modality for FPHL. Several laser devices have been approved for the treatment of hair loss in men and women,^[20] including a hair band, a comb-based, and a helmet-based device.^[20,61,62] These treatments offer an alternative non-systemic approach that can be combined with other therapies or used on their own.

Surgical hair restoration, in particular follicular unit transplantation, in women can be beneficial in patients with male pattern and frontal loss patterns provided that there are sufficient donor hair sites.^[36] Donor site availability in women is typically more limited than in men because of the more diffuse pattern of FPHL.^[20]

Conclusion

Choice of treatment should balance efficacy, safety, patient preference, quality of life issues, and cost factors. Clinicians and patients should set realistic treatment goals and reevaluate treatment choices if these goals are not met with persistence and adherence to therapy.

CASE 2: Presentation

Suzanne M. is a 23-year-old woman who presents to the dermatologist with a history of thinning hair since age 15 years. She noted thinning on the vertex and frontal scalp diffusely with maintenance of the frontal hairline. It has been worsening for the last 2 years. She saw a dermatologist 3 years ago who performed a biopsy. The biopsy showed results consistent with FPHL (Table 1). Unfortunately, the patient moved to a neighboring state and was not able to follow up with treatment after the biopsy was performed.

Table 1. Results of Hair Biopsy

History and examination. The patient reported that she had irregular menstrual periods and was on oral contraceptives for 2 years in the past for this. During that time, her hair loss was stable, but she stopped the medication due to headaches. She is not willing to go back on oral contraceptives at this time, but is interested in trying a different long-term option for contraception. Suzanne was in touch with her gynecologist regarding her irregular menstrual periods and hair loss. She reported that her doctor gave her several options for contraception and referred her to a dermatologist for further discussion and treatment of her hair loss.

Suzanne has mild acne and uses a topical benzoyl peroxide wash to help control breakouts. She denies taking any supplements that could possibly contain androgens. She reports that her hair loss has caused her to become depressed since she is the only person her age who she knows with severe hair loss. It has caused her to avoid going out socially, and she does not feel comfortable dating since her hair is so thin.

The patient’s personal history is negative for any laboratory studies from previous physicians. She has a mother with mild facial hair, infertility concerns, and mild hair thinning in a similar pattern.

Examination reveals multiple comedones on her forehead and several erythematous papules on her bilateral cheeks. She has diffuse thinning of the vertex scalp in a Ludwig pattern 2 (mid-level female pattern hair loss scale) with widened part width. Pull test is negative with normal hair shafts, and her posterior scalp hair is normal density. Pretreatment photos were taken.

Analysis

Although the majority of women with FPHL are older, this condition affects as many as 13% of women in their 20s.^[6-8] As in Suzanne’s case, this can be a distressing medical problem that has an impact on patients' quality of life and self-esteem, and may have underlying medical causes.

Suzanne’s medical history includes signs and symptoms that may indicate polycystic ovary syndrome (PCOS): menstrual irregularities and acne,^[11] as well as a first-degree female relative with infertility problems, mild hair loss, and mild facial hirsutism. PCOS is the most common endocrine disorder associated with FPHL.^[11] Hyperandrogenism is a common feature of both PCOS and PFHL, thus in Suzanne’s case laboratory testing for levels of free and total testosterone and dehydroepiandrosterone sulfate (DHEAS) are warranted to rule out PCOS.^[11]

Treatment Options

Treatment options were discussed with Suzanne. A multimodal approach was recommended and agreed upon: minoxidil 5% foam once daily and spironolactone 50 mg twice daily (off-label use). Additionally, Suzanne planned to see her gynecologist to discuss an estrogen-based implantable contraceptive as a method to avoid possible irregular menstrual bleeding due to spironolactone.

Side Effects and Laboratory Monitoring

Treatment recommendations included a discussion of possible medication side effects.

The most commonly observed side effects associated with minoxidil 5% foam are: hypertrichosis, local irritation, and contact dermatitis. Minoxidil is contraindicated during pregnancy and lactation.^[36] Additionally, there is frequently a transient shedding of telogen hair that occurs within the first few months following treatment initiation.^[36] Side effects associated with spironolactone are hypotension, hyperkalemia, fatigue, headache, weight loss, increased urinary frequency, and dry skin.^[20,51] Menstrual irregularities, breast tenderness, and gynecomastia are also associated with spironolactone. This medication is teratogenic and proper contraceptive precautions should be taken in women of childbearing potential.^[20,51]

Baseline laboratory testing for potassium levels; human chorionic gonadotropin (HCG); to rule out pregnancy, and a hepatic panel prior to the initiation of spironolactone was recommended for the patient.^[20]

Analysis

The use of minoxidil 5% foam in patients with FPHL is an FDA-approved use that has demonstrated efficacy.^[35,37] Spironolactone is approved for the treatment of primary hyperaldosteronism and has been used for 2 decades for the management of PCOS.^[20,51,60] Although not approved for use in FPHL, it has been accepted as a treatment for acne, hirsutism, and FPHL due to its antiandrogenic effects in target tissues.^[58] In Suzanne’s case, adding spironolactone serves the dual purpose of providing control for acne and FPHL.

Co-administration of an estrogen-based contraceptive with spironolactone not only protects against pregnancy (spironolactone is teratogenic), but will ameliorate menstrual irregularities.

Laboratory monitoring with spironolactone is not warranted beyond the initial tests mentioned above. Rarely, hepatitis and chloasma have been reported in the literature.^[20]

Abnormal levels of free and total testosterone and didehydroepiandrosterone are indicative of PCOS, and FPHL is commonly associated with PCOS.^[6]

Follow-up

Suzanne will follow up with her dermatologist in 6 months to allow her to be on treatment for at least 2 hair cycles. She was also referred to a psychologist to work with her feelings of depression and address her feelings of low self-esteem and body image.

Suzanne called after her appointment and reported that she had a conversation with her pharmacist when she picked up her oral medication regarding blood pressure control on spironolactone. She wondered if she needed to check her blood pressure regularly now that she is on this medication because the pharmacist mentioned that it can be used in higher doses to treat hypertension. We discussed that as long as the patient has normal blood pressure at baseline and no symptoms while taking the medication, she will not need to monitor her blood pressure more frequently than is recommended by her primary care physician.

Analysis

Follow-up to evaluate treatment is important for several reasons: ensuring that treatment is efficacious, encouraging adherence to treatment, and evaluating for any side effects. It is important that during follow-up visits patients are questioned about medication adherence and the necessity of consistent use of therapy is communicated.

The psychosocial impact of FPHL is burdensome, and many women have impaired quality of life.^[6,30,31] Negative self-image, impaired personal and work relationships, and diminished self-esteem are among some of the reported domains affected by FPHL.^[6,28,31] More than 50% of women with FPHL reported symptoms of depression.^[32] Referral for psychological counseling can prove beneficial.

Safety issues such as hypotension associated with spironolactone are dose-dependent.^[20] Pharmacists may be unaware of the off-label use of low-dose spironolactone in FPHL.^[49,50]

Conclusion

Patients with FPHL may be seen by multiple healthcare practitioners who manage various aspects of their care that can relate to hair loss (eg, contraception, endocrine disorders, and psychosocial issues). Establishing good communication between patients and providers is central to ensuring adherence to treatment and prompt reporting of any side effects. Moreover, communication with patients is important to relay realistic safety concerns and explain individual patient risks.