eMedicine Specialties > Dermatology > Diseases of the Adnexa

Androgenetic Alopecia: Differential Diagnoses & Workup

Author: Robert P Feinstein, MD, Associate Clinical Professor, Department of Dermatology, Columbia University College of Physicians and Surgeons
Contributor Information and Disclosures

Updated: Jan 22, 2009

Differential Diagnoses

Alopecia Areata
Anagen Effluvium
Telogen Effluvium

Other Problems to Be Considered

  • Alopecia of senescence
  • Alopecia associated with virilizing disorders of women, in whom it may be seen in association with hirsutism and menstrual problems
  • Anagen effluvium after exposure to toxic chemicals, including chemotherapeutic agents
  • Alopecia associated with hypothyroidism or hyperthyroidism
  • Telogen effluvium: This condition may accelerate androgenetic alopecia, and causes, such as iron deficiency and papulosquamous diseases of the scalp, must be considered.
  • Hypertension and/or smoking: A strong association of androgenetic alopecia with hypertension was noted in a study of 250 white men aged 35-65 years. In this French study, a definite familial tendency to androgenetic alopecia was also described, but no association was noted with diabetes mellitus, hyperlipidemia, or smoking.8  However, a study of 740 Taiwanese men aged 40-91 years indicated an association between androgenetic alopecia and smoking. Smoking status, current amount of cigarette smoking, and smoking intensity were statistically significant in this report.9

Workup

Laboratory Studies

  • The most important aspects are the history and the physical examination.
    • In the case of a woman, if virilization is evident, laboratory analysis of dehydroepiandrosterone (DHEA)-sulfate and testosterone may need to be obtained. Some authors have suggested that total testosterone level alone may be adequate to screen for a virilizing tumor.
    • If a thyroid disorder is suspected, obtaining a thyrotropin level is indicated.
  • If telogen effluvium is present, laboratory analysis of serum iron levels or a biopsy to note an underlying papulosquamous disorder may be indicated. Telogen effluvium may accelerate the course of pattern alopecia. Iron deficiency is a common and reversible cause of telogen effluvium. A normal CBC count does not exclude iron deficiency as a cause of hair loss. While a low ferritin level is always a sign of iron deficiency, ferritin behaves as an acute phase reactant, and levels may be normal despite iron deficiency. Iron, total iron-binding capacity, and transferrin saturation are inexpensive and sensitive tests for iron deficiency.
  • Diffuse alopecia areata may mimic pattern alopecia. The presence of exclamation point hairs, pitted nails, or a history of periodic regrowth or tapered fractures noted on hair counts suggests the diagnosis of diffuse alopecia areata.

Procedures

  • A biopsy is rarely necessary to make the diagnosis. If a single biopsy specimen is obtained, it should generally be sectioned transversely if pattern alopecia is suspected. Some dermatopathologists recommend that if a biopsy is to be performed, a sample should be obtained from 2 sites: one for horizontal sectioning and one for vertical sectioning of the hair follicles. Other dermatopathologists point out that one may commonly obtain sufficient information from serial vertical sections to diagnose the condition.

Histologic Findings

In pattern alopecia, hairs are miniaturized. In evolving-pattern alopecia, the diameter of hair shafts varies. Fibrous tract remnants (so-called streamers) can be found below miniaturized follicles. Although androgenetic alopecia is considered a noninflammatory form of hair loss, at times, a superficial, perifollicular, inflammatory infiltrate is noted. A mildly increased telogen-to-anagen ratio is often observed.

More on Androgenetic Alopecia

Overview: Androgenetic Alopecia
Differential Diagnoses & Workup: Androgenetic Alopecia
Treatment & Medication: Androgenetic Alopecia
Follow-up: Androgenetic Alopecia
References
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References

  1. Stough D, Stenn K, Haber R, et al. Psychological effect, pathophysiology, and management of androgenetic alopecia in men. Mayo Clin Proc. Oct 2005;80(10):1316-22. [Medline].

  2. Lesko SM, Rosenberg L, Shapiro S. A case-control study of baldness in relation to myocardial infarction in men. JAMA. Feb 24 1993;269(8):998-1003. [Medline].

  3. Oh BR, Kim SJ, Moon JD, et al. Association of benign prostatic hyperplasia with male pattern baldness. Urology. May 1998;51(5):744-8. [Medline].

  4. Ludwig E. Classification of the types of androgenetic alopecia (common baldness) occurring in the female sex. Br J Dermatol. Sep 1977;97(3):247-54. [Medline].

  5. 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. Mar 2008;82(3):737-43. [Medline].

  6. 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. May 2003;48(5):752-9. [Medline].

  7. 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. Oct 2005;125(4):638-46. [Medline].

  8. Ahouansou S, Le Toumelin P, Crickx B, Descamps V. Association of androgenetic alopecia and hypertension. Eur J Dermatol. May-Jun 2007;17(3):220-2. [Medline].

  9. Su LH, Chen TH. Association of androgenetic alopecia with smoking and its prevalence among Asian men: a community-based survey. Arch Dermatol. Nov 2007;143(11):1401-6. [Medline].

  10. 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.

  11. 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. Sep 2002;47(3):377-85. [Medline].

  12. Rittmaster RS. Finasteride. N Engl J Med. Jan 13 1994;330(2):120-5. [Medline].

  13. Rogers NE, Avram MR. Medical treatments for male and female pattern hair loss. J Am Acad Dermatol. Oct 2008;59(4):547-66; quiz 567-8. [Medline].

  14. Hamilton JB. Patterned loss of hair in man; types and incidence. Ann N Y Acad Sci. Mar 1951;53(3):708-28. [Medline].

  15. Kaufman KD. Androgen metabolism as it affects hair growth in androgenetic alopecia. Dermatol Clin. Oct 1996;14(4):697-711. [Medline].

  16. Muller SA. Alopecia: syndromes of genetic significance. J Invest Dermatol. Jun 1973;60(6):475-92. [Medline].

  17. Olsen EA. Androgenetic alopecia. In: Olsen EA ed. Disorders of Hair Growth: Diagnosis and Treatment. New York, NY: McGraw-Hill; 1994:257-83.

  18. Olsen EA, Messenger AG, Shapiro J, et al. Evaluation and treatment of male and female pattern hair loss. J Am Acad Dermatol. Feb 2005;52(2):301-11. [Medline].

  19. Otberg N, Finner AM, Shapiro J. Androgenetic alopecia. Endocrinol Metab Clin North Am. Jun 2007;36(2):379-98. [Medline].

  20. Shapiro J, Price VH. Hair regrowth. Therapeutic agents. Dermatol Clin. Apr 1998;16(2):341-56. [Medline].

  21. Sperling LC. Evaluation of hair loss. Curr Probl Dermatol. 1996;8:97-136.

  22. Sperling LC, Lupton GP. Histopathology of non-scarring alopecia. J Cutan Pathol. Apr 1995;22(2):97-114. [Medline].

  23. Stern Rl, Heymann WR. Androgenetic alopecia. Clin Dermatol. 1997;2(32):1-6.

  24. Venning VA, Dawber RP. Patterned androgenic alopecia in women. J Am Acad Dermatol. May 1988;18(5 Pt 1):1073-7. [Medline].

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Further Reading

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Keywords

androgenetic alopecia, common baldness, familial baldness, hereditary baldness, male pattern baldness, female pattern baldness, pattern baldness, hair loss, androgenic alopecia

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Contributor Information and Disclosures

Author

Robert P Feinstein, MD, Associate Clinical Professor, Department of Dermatology, Columbia University College of Physicians and Surgeons
Robert P Feinstein, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Noah Worcester Dermatological Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Leonard Sperling, MD, Chair, Professor, Department of Dermatology, Uniformed Services University of the Health Sciences
Leonard Sperling, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Managing Editor

Edward F Chan, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine
Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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