Androgenetic Alopecia Clinical Presentation
- Author: Robert P Feinstein, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP more...
The onset of androgenetic alopecia is gradual. Men present with gradual thinning in the temporal areas, producing a reshaping of the anterior part of the hairline. For the most part, the evolution of baldness progresses according to the Norwood/Hamilton classification of frontal and vertex thinning. Women with androgenetic alopecia usually present with diffuse thinning on the crown. Bitemporal recession does occur in women but usually to a lesser degree than in men. In general, women maintain a frontal hairline.
In both males and females with androgenetic alopecia, the transition from large, thick, pigmented terminal hairs to thinner, shorter, indeterminate hairs and finally to short, wispy, nonpigmented vellus hairs in the involved areas is gradual. As the androgenetic alopecia progresses, the anagen phase shortens with the telogen phase remaining constant. As a result, more hairs are in the telogen phase, and the patient may notice an increase in hair shedding. The end result can be an area of total denudation. This area varies from patient to patient and is usually most marked at the vertex.
Women with androgenetic alopecia generally lose hair diffusely over the crown. This produces a gradual thinning of the hair rather than an area of marked baldness. The part is widest anteriorly. The frontal hairline is often preserved in women with this disorder, whereas men note a gradual recession of the frontal hairline early in the process.
Androgenetic alopecia is a genetically determined condition. In 2008, 95 families were studied genetically, and the locus with strongest evidence for linkage to androgenetic alopecia was the 3q26 site on the X chromosome. In addition, an association between androgenetic alopecia and chromosome 20pll and the androgen-receptor gene has been reported.
Androgen is necessary for progression of androgenetic alopecia, as it is not found in males castrated prior to puberty. The progression of androgenetic alopecia is stopped if postpubertal males are castrated. Androgenetic alopecia is postulated to be a dominantly inherited disorder with variable penetrance and expression. However, it may be of polygenic inheritance. It has been noted that follicles from balding areas of persons with androgenetic alopecia are able to produce terminal hairs when implanted into immunodeficient mice. This suggests that systemic or external factors may play a role in androgenetic alopecia. Interestingly, female androgenetic alopecia has been reported in a patient with complete androgen insensitivity syndrome. This suggests that factors other than direct androgen action contribute to patterned hair loss.
As reported in 2005, it was noted in adult mouse skin that the hedgehog (Hh) family of intercellular signaling proteins can stimulate the transition from the resting (telogen) state to the growth phase (anagen) of the hair cycle. Whether this will be helpful in the treatment of androgenetic alopecia remains to be seen.
As to the question of whether iron deficiency plays a role in female pattern hair loss, a study by Olsen et al indicated iron deficiency is common in women but is not significantly increased in patients with female patterns of hair loss or chronic telogen effluvium when compared with control subjects.
Lattouf et al have described a case of connubial androgenetic alopecia in a 52-year-old woman secondary to contact with the skin of her husband who was being treated with topical testosterone for hypogonadism. She developed severe androgenetic alopecia involving the crown and the frontotemporal areas. Her spouse had been applying transdermal testosterone gel to his upper arms once daily. The patient was evaluated for evidence of hyperandrogenism, and no other signs of this disorder were identified. She was advised to ask her husband to apply his testosterone gel on a less exposed area of his body. The authors go on to state that it is possible that cases of connubial androgenetic alopecia may be underreported.
Manabu Ohyama. Hair Follicle Stem Cells-New Insights & Clinical Relevance. AccessMedicine. Available at http://www.accessmedicine.com/updatesContent.aspx?aID=1001537. Accessed: December 3 2009.
Luderer HF, Demay MB. The vitamin D receptor, the skin and stem cells. J Steroid Biochem Mol Biol. 2010 Feb 6. [Medline].
Magro CM, Rossi A, Poe J, Manhas-Bhutani S, Sadick N. The role of inflammation and immunity in the pathogenesis of androgenetic alopecia. J Drugs Dermatol. 2011 Dec. 10(12):1404-11. [Medline].
Brockschmidt FF, Heilmann S, Ellis JA, et al. Susceptibility variants on chromosome 7p21.1 suggest HDAC9 as a new candidate gene for male-pattern baldness. Br J Dermatol. 2011 Dec. 165(6):1293-302. [Medline].
Kure K, Isago T, Hirayama T. Changes in the sebaceous gland in patients with male pattern hair loss (androgenic alopecia). J Cosmet Dermatol. 2015 Sep. 14 (3):178-84. [Medline].
Wang TL, Zhou C, Shen YW, et al. Prevalence of androgenetic alopecia in China: a community-based study in six cities. Br J Dermatol. 2010 Jan 22. [Medline].
Stough D, Stenn K, Haber R, et al. Psychological effect, pathophysiology, and management of androgenetic alopecia in men. Mayo Clin Proc. 2005 Oct. 80(10):1316-22. [Medline].
Lesko SM, Rosenberg L, Shapiro S. A case-control study of baldness in relation to myocardial infarction in men. JAMA. 1993 Feb 24. 269(8):998-1003. [Medline].
Oh BR, Kim SJ, Moon JD, et al. Association of benign prostatic hyperplasia with male pattern baldness. Urology. 1998 May. 51(5):744-8. [Medline].
Arias-Santiago S, Arrabal-Polo MA, Buendía-Eisman A, et al. Androgenetic alopecia as an early marker of benign prostatic hyperplasia. J Am Acad Dermatol. 2012 Mar. 66(3):401-8. [Medline].
Sanke S, Chander R, Jain A, Garg T, Yadav P. A Comparison of the Hormonal Profile of Early Androgenetic Alopecia in Men With the Phenotypic Equivalent of Polycystic Ovarian Syndrome in Women. JAMA Dermatol. 2016 Jun 15. [Medline].
Polat EC, Ozcan L, Otunctemur A, Ozbek E. Relation of urinary stone disease with androgenetic alopecia and serum testosterone levels. Urolithiasis. 2016 May 7. [Medline].
Ludwig E. Classification of the types of androgenetic alopecia (common baldness) occurring in the female sex. Br J Dermatol. 1977 Sep. 97(3):247-54. [Medline].
Hillmer AM, Flaquer A, Hanneken S, et al. Genome-wide scan and fine-mapping linkage study of androgenetic alopecia reveals a locus on chromosome 3q26. Am J Hum Genet. 2008 Mar. 82(3):737-43. [Medline]. [Full Text].
Alsantali A, Shapiro J. Androgens and hair loss. Curr Opin Endocrinol Diabetes Obes. 2009 Jun. 16(3):246-53. [Medline].
Krajcik RA, Vogelman JH, Malloy VL, Orentreich N. Transplants from balding and hairy androgenetic alopecia scalp regrow hair comparably well on immunodeficient mice. J Am Acad Dermatol. 2003 May. 48(5):752-9. [Medline].
Cousen P, Messenger A. Female pattern hair loss in complete androgen insensitivity syndrome. Br J Dermatol. 2010 Feb 1. [Medline].
Paladini RD, Saleh J, Qian C, Xu GX, Rubin LL. Modulation of hair growth with small molecule agonists of the hedgehog signaling pathway. J Invest Dermatol. 2005 Oct. 125(4):638-46. [Medline].
Olsen EA, Reed KB, Cacchio PB, Caudill L. Iron deficiency in female pattern hair loss, chronic telogen effluvium, and control groups. J Am Acad Dermatol. 2010 Dec. 63(6):991-9. [Medline].
Lattouf C, Miteva M, Tosti A. Connubial androgenetic alopecia. Arch Dermatol. 2011 Nov. 147(11):1329-30. [Medline].
Ahouansou S, Le Toumelin P, Crickx B, Descamps V. Association of androgenetic alopecia and hypertension. Eur J Dermatol. 2007 May-Jun. 17(3):220-2. [Medline].
Su LH, Chen TH. Association of androgenetic alopecia with smoking and its prevalence among Asian men: a community-based survey. Arch Dermatol. 2007 Nov. 143(11):1401-6. [Medline].
Schmidt, AN, Taylor BR, King LE, and Tourjee SM. The ProScope HR: A promising diagnostic tool. J Am Acad Dermatol. March, 2010. 62:AB64.
Karadag Köse O, Güleç AT. Clinical evaluation of alopecias using a handheld dermatoscope. J Am Acad Dermatol. 2012 Aug. 67(2):206-14. [Medline].
Headington JT, Novak E. Clinical and histological studies of male pattern baldness treated with topical minoxidil. Curr Ther Res Clin Exp. 1984. 36:1098-106.
Olsen EA, Dunlap FE, Funicella T, et al. A randomized clinical trial of 5% topical minoxidil versus 2% topical minoxidil and placebo in the treatment of androgenetic alopecia in men. J Am Acad Dermatol. 2002 Sep. 47(3):377-85. [Medline].
Scarinci F, Mezzana P, Pasquini P, Colletti M, Cacciamani A. Central chorioretinopathy associated with topical use of minoxidil 2% for treatment of baldness. Cutan Ocul Toxicol. 2011 Sep 23. [Medline].
Rittmaster RS. Finasteride. N Engl J Med. 1994 Jan 13. 330(2):120-5. [Medline].
Rossi A, Cantisani C, Scarnò M, Trucchia A, Fortuna MC, Calvieri S. Finasteride, 1 mg daily administration on male androgenetic alopecia in different age groups: 10-year follow-up. Dermatol Ther. 2011 Jul. 24(4):455-61. [Medline].
Sato A, Takeda A. Evaluation of efficacy and safety of finasteride 1 mg in 3177 Japanese men with androgenetic alopecia. J Dermatol. 2012 Jan. 39(1):27-32. [Medline].
Rogers NE, Avram MR. Medical treatments for male and female pattern hair loss. J Am Acad Dermatol. 2008 Oct. 59(4):547-66; quiz 567-8. [Medline].
Leavitt M, Charles G, Heyman E, Michaels D. HairMax LaserComb laser phototherapy device in the treatment of male androgenetic alopecia: A randomized, double-blind, sham device-controlled, multicentre trial. Clin Drug Investig. 2009. 29(5):283-92. [Medline].
Blume-Peytavi U, Lönnfors S, Hillmann K, Garcia Bartels N. A randomized double-blind placebo-controlled pilot study to assess the efficacy of a 24-week topical treatment by latanoprost 0.1% on hair growth and pigmentation in healthy volunteers with androgenetic alopecia. J Am Acad Dermatol. 2011 Aug 27. [Medline].
Sinclair R, Patel M, Dawson TL Jr, et al. Hair loss in women: medical and cosmetic approaches to increase scalp hair fullness. Br J Dermatol. 2011 Dec. 165 Suppl 3:12-8. [Medline].
Zimber MP, Ziering C, Zeigler F, et al. Hair regrowth following a Wnt- and follistatin containing treatment: safety and efficacy in a first-in-man phase 1 clinical trial. J Drugs Dermatol. 2011 Nov. 10(11):1308-12. [Medline].
Navarro MR, Asin M, Martinez AM, Molina C, Navarro V, Pino A, et al. Plasma rich in growth factors (PGRF) for the treatment of androgenetic alopecia. European Journal of Plastic Surgery. June 21, 2015; Accessed: June 25, 2015.
Wessagowit V, Tangjaturonrusamee C, Kootiratrakarn T, Bunnag T, Pimonrat T, Muangdang N, et al. Treatment of male androgenetic alopecia with topical products containing Serenoa repens extract. Australas J Dermatol. 2015 May 25. (HTML)(/doi/10.1111/adj.12352/full). [Medline].
Fukuoka H, Suga H. Hair Regeneration Treatment Using Adipose-Derived Stem Cell Conditioned Medium: Follow-up With Trichograms. Eplasty. 2015. 15:e10. [Medline].
Lee GY, Lee SJ, Kim WS. The effect of a 1550 nm fractional erbium-glass laser in female pattern hair loss. J Eur Acad Dermatol Venereol. 2011 Dec. 25(12):1450-4. [Medline].