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Dr. Christopher Tzermias

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Androgenetic Alopecia

Accurate diagnosis is a prerequisite for the effective treatment of male- and female-pattern alopecia.

Since the 1940s it has been recognised that male-pattern hair loss is an androgen-dependent condition. Eventually it was determined that dihydrotestosterone is the key androgen, with which the following are achieved: a) Shortening of the anagen phase and b) Progressive follicular miniaturisation that determines growth, loss and every hair regrowth.

However, the role of androgens in female-pattern alopecia remains unclear. Therefore, this pattern of hair loss cannot be termed as “androgenetic alopecia” in both males and females, while female-pattern hair loss is often hereditary and it may even present a multi-genetic type of inheritance.

androgenetic alopecia

Management strategy

Accurate diagnosis is a prerequisite for the effective treatment of male- and female-pattern alopecia. It is important to exclude other possible causes of alopecia that may present with a similar pattern of hair loss, such as diffuse alopecia areata, secondary hair loss due to metabolic disorders, telogen effluvium and other types of transient alopecia. Once an accurate diagnosis by reviewing the patient’s history achieved clinical findings and laboratory tests, then can be directed treatment for stopping hair loss and stimulate hair growth.

Men may begin to experience male pattern hair loss at any time after puberty. The frequency and intensity increase with age, resulting in almost 80% of Caucasian men diagnosed with male pattern hair loss by their 70s. Alopecia may appear in the temporal, parietal or frontal area of the scalp. In most cases it is described using the Hamilton-Norwood scale. On the other hand, female-pattern hair loss appears usually on the frontal-parietal scalp as diffuse hair loss or in a pattern that resembles a Christmas tree, in which the tree’s base is located at the frontal hairline. Dawber discovered that among pre-menopausal women that did not complain about hair loss, 87% of the clinical sample under study had some degree of alopecia, classified as type Ι-ΙΙΙ according to the Ludwig scale. Male-pattern hair loss may present also in women, with 79% of women after puberty presenting type II androgenetic alopecia according to the Hamilton-Norwood scale, of which 25% develop this type of hair loss by the age of 50 years old and 50% of them by the age of 60 years old.


Medication is the first line treatment for both male- and for the female-pattern alopecia. The purpose of treatment is to delay the progress of hair loss and/or to reverse the follicles’ miniaturisation process. To date, there are two medicinal agents that have been approved by the American Food and Drug Administration (FDA) for this condition: topical minoxidil (biological modulator) and orally administered finasteride (hormonal modulator).

Topically administered minoxidil 2-5% increases the duration of the anagen phase of the hair growth cycle and at the same time it enlarges and strengthens tiny hair follicles and it produces a vasodilating effect. The application of 1 ml on the scalp twice a day results in the best outcome after 26 – 52 weeks, with the crown of the head showing the greatest improvement and the frontal hairline showing the least degree of improvement.

Despite the fact that minoxidil 5% is more effective than minoxidil 2% in terms of increasing the number of hairs and hair thickness in male-pattern hair loss, there are certain dermatological side effects that may occur, the most common of which is irritation of the scalp, and these are more common with minoxidil 5% (this side effect is less common when the drug is administered in the form of foam). To date, only minoxidil 2% is FDA-approved for women. Treatment discontinuation leads to opposite effects of treatment within 4 to 6 months. It is also worth noting that the combination of minoxidil and finasteride sometimes leads to better outcomes as compared to any of these drugs administered on its own.

Finasteride is a 5α-reductase inhibitor, specifically the type II, an enzyme that contributes in the conversion of testosterone to dihydrotestosterone (DHT) and is responsible for hair loss. A reduction of up to 70% of the levels of DHT in both the blood serum and in the scalp is possible to be achieved in men receiving finasteride. According to clinical trials in men with male-pattern alopecia on the top of their scalp, five years after treatment the number of hairs was increased by 65% (as compared to 0% in the placebo group), while further progress of hair thinning was delayed by 90% (as compared to the placebo group). In other clinical trials, the best response was observed at the top of the head and the least degree of improvement was evident at the frontal hairline area.

Finasteride is a teratogen, and it is not effective in post-menopausal women. The side effects of finasteride are only rarely observed in less than 2% of male patients. They are reversible after treatment discontinuation, while in many cases it is possible to resolve all side effects during continuous treatment. In a clinical trial that lasted for 7 years, a reduction of 24.8% was observed in terms of prostate cancer presentation in patients treated with finasteride in comparison to those receiving placebo. Further analyses revealed a reduced number of risk factors related to finasteride in 30% of all cases of prostate cancer and in 27% of cases with more advanced cancer.

Despite the fact that the number of controlled clinical trials for the comparison to other anti-androgens, such as spironolaconte and cyproterone acetate, is limited, the value of these drugs seems to be greater among women with hyperandrogenism.

The good news for many patients suffering from male- and female-pattern hair loss that is resistant to treatment is that surgical methods have shown significant progress, and hair transplantation is a reliable and effective choice. The perfection and global adaptation of follicular units transplantation (FUT) leads to a natural result and good hair density in every session, something that was not possible up until 5-10 years ago. Improvements in surgical approach give to many women, as well as to many men with male-pattern alopecia at initial stages, the opportunity to take advantage of this procedure. Moreover, the “bad” transplantations of the past can now be corrected, so that to give to the patient a naturally-looking result, who decided to treat hair loss before the progression of FUT method.

Certain types of cosmetic products may also provide relief to patients with hair loss in cases that medical treatments are ineffective or contraindicated or in cases these products are chosen as adjunctive therapy. Hair thinning may be covered or camouflaged either using skin dye with special colouring powders or sprays, or with the use of wigs or other similar products. On the other hand, the application of hair extensions in which foreign hair strands are attached to individual hairs of the head, is not recommended in general because of the possible development of permanent cicatricial traction alopecia.


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