Non-scarring alopecia in women

Hair loss can be very distressing, but a number of treatment options can improve quality of life. By Dr Paul Charlson

Treatment of hair loss in women requires careful planning (Photograph: iStock)
Treatment of hair loss in women requires careful planning (Photograph: iStock)

Hair loss can have a devastating impact on women, so it is important not to underestimate the psychological effects when managing this condition.
Most women will have diffuse hair loss, which will be either telogen effluvium or female pattern hair loss (FPHL).
Acute telogen effluvium will resolve spontaneously, while chronic telogen effluvium may be addressed by treating the underlying physiological cause.
FPHL, which is common in women aged over 70 years, may respond to non-androgen related treatment such as topical minoxidil. Non-responders and those whose hair loss is androgen-related can try adding an anti-androgen. Other treatment options include hair transplantation and the use of wigs and hair extensions.

Key words
Alopecia, female pattern hair loss, hair loss, telogen effluvium
Hair loss in women is distressing at any age and is quite a common problem presenting to clinicians. The psychological effects of this condition should not be underestimated.
Most women who experience hair loss have a non-scarring loss. Hair loss may be patchy with scale, which may be tinea capitis or, more commonly, non-scaly, with complete loss of hair in the patches, which is usually alopecia areata. They may have incomplete loss in the patches, which suggests trichotillomania.
Diffuse hair loss is the most common presentation. This is essentially of two types – telogen effluvium and FPHL.

Types of hair loss

Telogen effluvium is when the hair follicles synchronise and enter into catagen and telogen together. This can occur postpartum or after an emotional stress. There is an increase in shedding of the hair at two to three months, but this can occur up to six months after the stress.
In acute telogen effluvium, the hair shedding lasts less than six months and then recovers. In chronic telogen effluvium, hair continues to shed over a longer period and this tends to be of a more insidious onset.
Examination in telogen effluvium reveals a normal scalp and often a normal-looking head of hair. Hair pull tests are useful, in which you take a hair and pull it gently. A hair in anagen will stay rooted, while one in telogen will come out. If 10% come out, this is excellent, 25% is typical and 35% or more suggests a problem (a positive test).1 In active telogen effluvium, the hair pull test will be positive.
Chronic telogen effluvium may have a physiological cause. Hypothyroidism is linked to hair loss and needs to be corrected.2 Crash dieting can sometimes cause hair loss.3 Iron deficiency has been linked to hair loss and, although this is controversial, there does appear to be a link between low serum ferritin and hair loss, and low serum vitamin D may also be a factor.4,5
The list of drugs that can cause hair loss is long, but includes commonly used medications such as beta-blockers, ACE inhibitors and warfarin.
FPHL refers to gradual thinning of hair over the central scalp. Hair miniaturisation occurs, which results in thinning rather than complete loss.
This is the most common cause of hair loss in women, with a prevalence ranging from less than 10% of women younger than 50 years of age to 40% of those aged 70 years.6
Unlike in male pattern baldness, the role of androgens in FPHL is less clear, with studies showing normal levels of androgens in 70% of cases of FPHL.7 Estrogen may stimulate hair growth, but its role is controversial.8
Investigation for non-scarring hair loss in women would require blood tests for FBC, ferritin, TFT and possibly vitamin D levels. If the patient exhibits any signs of hyperandrogenism, serum testosterone, SHBG and a free androgen index should also be measured.

Treatment options

If no cause is found, as is often the case, treatment of the condition requires careful planning. Many cases of FPHL are not related to androgens, so non-androgen related treatment should be tried first.
The most commonly used non-androgen treatment for FPHL is topical minoxidil 2% twice daily (licensed for women), although 5% is more effective.9 Minoxidil does not alter the natural history of hair loss, but rather it can thicken or increase the density of the remaining hair. Results should be assessed at six and 12 months. Sixty per cent of women will get a response,10 but treatment needs to be lifelong.
However, in women who appear to have androgen-related loss or who are non-responders, dual anti-androgen and non-androgen treatment should be tried. No anti-androgen is approved for use in FPHL, but it seems they work in 60% of patients, probably without long-term harmful sequelae.11
Anti-androgen agents should not be used in pregnancy, owing to feminisation of the male fetus. Therefore, appropriate contraceptive methods should be used during the treatment and for one to six months after stopping the medication, depending on the drug type.11
Hair transplantation is an important option for women in whom medical treatment has failed or been ineffective, and should not be discounted in advising patients, who may go to enormous lengths to treat their problem. It should, however, be explained that the procedure is expensive and donor sites can be limited in women.
Wigs and hair extensions can also prove very useful in the management of hair loss and can help to improve patients’ quality of life and self-esteem.
Other treatments that might be considered, but have less evidence currently, are low-level light treatments (LED and laser) and platelet-rich plasma, which may prove to be a useful therapy in the future.
  • Dr Paul Charlson is a GP with a special interest in dermatology in Yorkshire and medical director of Skinqure Clinic

Competing interests: Dr Charlson is president of the British College of Aesthetic Medicine and medical director of Skinqure Clinic, which provides aesthetic treatments

Hair loss can be very distressing for women at any age. Most will have a non-scarring hair loss
Diffuse hair loss is the most common presentation
FPHL is the most common cause
The most commonly used non-androgen treatment for FPHL is topical minoxidil 2% twice daily
Hair transplantation, although expensive, can be an option for women in whom medical treatment has failed

1. Olsen EA, Bettencourt MS, Cote NL. The presence of loose anagen hairs obtained by hair pull in the normal population. J Investig Dermatol Symp Proc 1999; 4(3): 258-60.
2. Freinkel RK, Freinkel N. Hair growth and alopecia in hypothyroidism. Arch Dermatol 1972; 106(3): 349-52.
3. Goette DK, Odom RB. Alopecia in crash dieters. JAMA 1976; 235(24): 2622-3.
4. Rushton DH. Decreased serum ferritin and alopecia in women. J Invest Dermatol 2003; 121(5): xvii-xviii.
5. Rasheed H, Mahgoub D, Hegazy R et al. Serum ferritin and vitamin D in female hair loss: do they play a role? Skin Pharmacol Physiol 2013; 26(2): 101-7.
6. Norwood OT. Incidence of female androgenetic alopecia (female pattern alopecia). Dermatol Surg 2001; 27(1): 53-4.
7. Sinclair RD, Dawber RP. Androgenetic alopecia in men and women. Clin Dermatol 2001; 19(2): 167-78.
8. Yip L, Rufaut N, Sinclair R. Role of genetics and sex steroid hormones in male androgenetic alopecia and female pattern hair loss: an update of what we now know. Australas J Dermatol 2011; 52(2): 81-8.
9. Lucky AW, Piacquadio DJ, Ditre CM et al. A randomized, placebo-controlled trial of 5% and 2% topical minoxidil solutions in the treatment of female pattern hair loss. J Am Acad Dermatol 2004; 50(4): 541-53.
10. Rogers NE, Avram MR. Medical treatments for male and female pattern hair loss. J Am Acad Dermatol 2008; 59(4): 547-66.
11. Mubki T, Shamsaldeen O, McElwee KJ et al. An update on diagnosis and treatment of female pattern hair loss. Expert Rev Dermatol 2013; 8(4): 427-36.

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