Emerging Treatments for Female Androgenic Alopecia
Female pattern hair loss (FPHL), medically known as androgenic alopecia (AGA), is one of the most common causes of hair loss in males and females. Research about the condition thus far has concluded that it is caused by genetic factors linked to the irregularities in androgen levels, a hormone responsible for regulating hair growth and sex drive for both sexes.
The symptoms for androgenic alopecia manifest differently in males and females. For men, the condition brings about pattern baldness characterized by thinning hair at the crown of the head and a receding hairline in a distinctive ’ shape. For women, however, the condition results in thinning of hair on various parts of the head and eventual hair loss as a result.
Statistically, 50% of men and women have this condition. However, men are more likely to have androgenic alopecia than women. In the United States, 50 million men were affected by the condition compared to 30 million women. 30% of cases were in women over 30 years of age and the statistic increases with age with 57% of women above 80 years of age affected. Despite the high statistics with older women, AGA can be present in younger women. Given that the onset of the condition typically occurs in the early teens and 20s and the effects intensify with time, it is not uncommon to have the condition in milder forms in the early 20s.
Let’s take a closer look at what androgenic alopecia is, the various contributing factors to its development, and research into new treatment options.
What is androgenic alopecia?
Before delving into what the condition entails, let’s first look at the hair growth cycle. There are three stages to this, namely growth (anagen), the transition between growth and rest (catagen), and resting (telogen). Androgenic alopecia affects the anagen and telogen phases of hair where a variation of the androgen hormone interacts with the hair follicle. In the case of women, the hormone causes a progressive reduction in the size of the hair follicle as well as a reduced hair growth rate.
In females, excess androgen levels in relation to female hormones. There are various types of androgen hormones, including testosterone and DHTA-S. Further, there are several types of testosterone in the bodies, each serving a function. DHT (Dihydrotestosterone) is the hormone that is closely linked to FPHL.
The condition is brought about by genetic and environmental factors. For women with family histories of hair loss, they are simply predisposed to develop the condition themselves. However, the case of AGA involves hormonal dynamics which are influenced by the environment.
Diagnosis and classification were first done using the Ludwig classification system which classified the condition in one of 3 grades by assessing the area of hair preservation in the frontal fringe and upper portion of the scalp. However, this system did not take into account the degree of accentuation or loss over the upper portion of the head which was common in women. The Olsen scale took into account these deficiencies of the Ludwig scale and addressed them. This paved the way for the Sinclair photographic self-reporting classification system.
What causes Female Pattern Baldness?
There is strong evidence that epigenetics is most responsible for triggering FPHL. Various environmental changes subject the body to stress that triggers the activation of AGA for genetically predisposed individuals with a family history of hair loss. Researchers have been able to extensively study several hormones linked to hair growth regulation and DHT (Dihydrotestosterone) has been the closest linked to patterned hair loss.
In hair follicles are DHT receptors. However, DHT itself does not constitute a risk of developing FPHL. Rather, there is a second factor that contributes to hair loss. 5-alpha reductase is an enzyme that converts testosterone into DHT. Women with AGA tend to have higher numbers of DHT receptors and 5-alpha-reductase than women that don’t have the condition.
DHT is known to regulate hair growth by activating genes that shorten the hair growth cycle and reduce the size of hair follicles.
When there is an overflow of DHT in the system, it will bind with androgen receptors on the hair follicles. This binding affects the anagen phase of hair growth, causing the growth cycle to shorten and hair to fall out faster. Additionally, the hair thins at the follicles in each cycle, causing a gradual loss of hair volume and increased falling off. As a result, hair becomes shorter in length, thinner in diameter, and lighter in color. Over time, the continued interaction of DHT with hair follicles leads to a complete halt of hair production.
Androgenic alopecia treatment options
There is no cure for androgenic alopecia, however, there are treatments that reverse the effects. Clinical research has shown that men and women respond differently to AGA treatment options. This is a result of the differences in hormonal dynamics that lead to the conditions between men and women.
Currently, oral finasteride and minoxidil are the only two FDA approved drugs for AGA. Each requires at least six months of use before improvements become noticeable and for continued use indefinitely to sustain the response. For many patients, adherence to treatment plans is the biggest challenge to sustaining the dose and hinders the improvement of their condition.
Minoxidil is an over the counter medication in 2% or 5% concentration with 1 ml doses to be used twice a day. It is a potassium channel blocker that works on the DHT receptors to reduce DHT in the hair follicles. It also works by widening blood vessels, increase blood flow along with oxygen, nutrients, and blood to the scalp and hence, increasing growth rates. Research on the efficacy of minoxidil found that it is an effective treatment in promoting hair growth in both men and women.
Finasteride inhibits the 5-alpha-reductase from converting testosterone into DHT. A daily dose of 1 mg has been shown to successfully reduce scalp DHT levels by at least 64%. Doctors regard Finasteride as the most effective treatment for men with AGA. However, for women, it has been found to have concerning implications. Because they cross the blood-brain barrier, they pose a threat to fetus development, it must be taken with caution and doctor’s advice for pregnant women or women of child-bearing age.
Some treatments combine a variety of treatment methods and found that combinations often work better than single treatment plans. However, they do pose some concerns about side effects, especially for women of child-bearing age. Research is currently looking into treatment options that are most effective with the least amount of side effects.
Low-level laser therapy
Laser therapy has been used extensively in the medical industry to aid in healing by tissue regeneration and pain reduction. Low-level laser therapy (LLLT) is a relatively new approach to treat androgenetic alopecia and research has not yet been able to pinpoint the exact mechanism through which this method is able to achieve results. However, research on the efficacy of this treatment option has been positive in results. The majority of cases that undertook this type of treatment had an overall improvement in regaining hair thickness and hair regrowth. These results should be taken with caution when generalizing or forecasting treatment outcomes as they are based on small samples of individuals.
Oral Finasteride is FDA approved; however, topical Finasteride is yet to become approved. Findings indicate that this is a promising treatment approach that yields increased hair count and decreased hair loss rate. Preliminary research on its efficacy indicates that it is a safe treatment option and promising in terms of reducing AGA symptoms. A study investigating the efficacy of minoxidil and topical finasteride found that this combination increased hair count and significant improvement in patient satisfaction with their hair.
However, because the ideal concentration and frequency of application are not yet determined, largely because most trials use this treatment in conjunction with others. For that reason, research is inconclusive on the treatment’s side effects and the full extent of its use.
Dutasteride is a second generation 5-alpha-reductase inhibitor. When directly injected to the scalp, it has the capability to inhibit the production of DHT from testosterone. As with other treatments, injectable dutasteride was found to be most effective when used in conjunction with other treatment methods. Thus far, findings have indicated its effectiveness in increasing hair count and sustaining hair growth. However, research continues to seek the optimal dosage and frequency of intake.
The two most common types of this category of drugs are Cyproterone Acetate (CA) and Flutamide. Antiandrogen target androgens to reduce their proliferation within the body by suppressing the hormone release and block androgen receptors. By doing this, they aim to reduce the amount of testosterone that is changed into DHT and therefore intervene in the cycle of AGA. Because these drugs are aimed directly to the sex hormone, they are not recommended for men. For women, they are safe but may need additional caution for pregnant women due to the drug’s feminizing effects on the fetus.
Findings are inconclusive on the most effective dosage, but most dosages require at least 5 months of continuous intake to see results. Side effects include irregular menstrual cycles, fatigue, and risk of hyperkalemia in young women.