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Adolescent Androgenic Alopecia

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Adolescent Androgenic Alopecia Pediatric dermatology Series Editor: Camila K. Janniger, MD Adolescent Androgenic Alopecia Patrick Henry McDonough, MD; Robert A. Schwartz, MD, MPH Adolescent androgenic alopecia is pattern hair levels of stress, decreased sense of physical attractive- loss occurring in boys and girls younger than ness, and poorer self-esteem than controls without 18 years, whereas early-onset androgenic alope- hair loss,9 and they have been shown to appear older cia refers to pattern hair loss before 35 years of and less attractive to members of the opposite sex.13 age. A number of studies published in the last The patients most distressed by hair loss tend to be decade have helped to elucidate the prevalence those who are more socially self-conscious and those of adolescent androgenic alopecia, have clarified who have considerable investment in their appear- the genetic as well as physiologic mechanisms ance.9 Given that adolescents place substantial value underlying hair loss, and have revealed the asso- on physical appearance and often are the victims of ciated psychologic and systemic morbidities. teasing based on physical appearance,14 it follows that This article provides an overview of the patho- adolescents with androgenic alopecia should be at physiology, diagnosis, and treatment of adoles- increased risk for experiencing the negative psycho- cent androgenic alopecia. social impacts that can accompany hair loss. Cutis.CUTIS 2011;88:165-168. Pathophysiology Normal hair follicles undergo a 3-phase cycle charac- ndrogenic alopecia encompasses both male terized by a period of growth called the anagen phase, and female pattern hair loss and is a com- a period of involution called the catagen phase, and A mon form of hair loss in both men and a period of rest called the telogen phase after which women. The prevalence of androgenic alopecia varies the hair is shed and a new anagen phase commences. in differentDo populations.1-3 Its onsetNot usually occurs in Regulatory Copy control of each phase of the follicular the third or fourth decades of life in men, with later cycle is exerted by various hormones, most impor- onset in women.1,2,4 Androgenic alopecia does occur, tantly androgens, and through interaction of dermal however, in the pediatric population with hair loss papillae with the germ cells of the hair follicle.15,16 seen as early as 6 years of age; on average, adoles- The length of the anagen phase varies among indi- cent androgenic alopecia presents between 13.5 and viduals, but at any given time, approximately 85% to 15 years of age.5-7 It is suggested that adolescent 90% of scalp hair follicles are in the anagen phase.15 androgenic alopecia is the most common cause In patients with androgenic alopecia, the hair fol- of adolescent hair loss,6 with 1 study reporting licle continues to go through the 3 phases of develop- approximately 15% (77/496) of adolescent boys aged ment; however, there is a decrease in the duration 15 to 17 years with stage 2 or greater hair loss on the of the anagen phase, increase in the duration of the Hamilton-Norwood grading scale.8 telogen phase, and miniaturization of the hair follicle. Androgenic alopecia causes considerable psycho- One study revealed that these changes are mediated social distress in both males and females.9-12 Individu- by inhibitory autocrine factors released by dermal als with androgenic alopecia experience increased papillae cells, likely in response to activation of androgen receptors by androgenic hormones.16 Con- sistent with this idea, other studies have shown that From the New Jersey Medical School, Newark. Dr. Schwartz is from patients with androgenic alopecia have increased Dermatology and Pediatrics. levels of androgen receptor present in the dermal The authors report no conflict of interest. Correspondence: Robert A. Schwartz, MD, MPH, Dermatology, New papillae of frontal hairs (where hair loss is occur- Jersey Medical School, 185 South Orange Ave, Newark, NJ 07103 ring) compared with occipital hairs (where hair loss ([email protected]). is absent).17,18 It also has been shown that men and WWW.CUTIS.COM VOLUME 88, OCTOBER 2011 165 Copyright Cutis 2011. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Pediatric Dermatology women with androgenic alopecia have increased lev- androgenic alopecia should strengthen the clinician’s els of 5a-reductase, an enzyme important in con- suspicion of adolescent androgenic alopecia. verting testosterone to the more potent androgen dihydrotestosterone, in balding portions compared Diagnosis with nonbalding portions of the scalp.17 These stud- Diagnosis of androgenic alopecia usually is made on ies compliment the idea that increased levels of the clinical grounds, though dermatoscopy and biopsy androgen dihydrotestosterone interact with increased can be helpful at times. Dermatoscopy reveals diver- levels of androgen receptor in dermal papillae cells sity in hair diameter24 along with nonscarring hair to cause the release of inhibitory autocrine factors loss with preservation of the ostia,22 while histo- that cause changes in the hair follicle leading to the pathology, though usually unnecessary, documents replacement of large pigmented terminal hairs with an increased density of vellus and telogen hairs, a small achromic vellus hairs. Several genes, including decrease in the telogen to vellus hairs ratio (from a the androgen receptor gene, AR; the ectodysplasin A2 7:1 ratio to approximately a 2:1 ratio), and presence receptor gene, EDA2R; and the aldolase gene, ALD, of follicular fibrous tracts, and superficial perifollicu- which are all located on the X chromosome, have been lar inflammation.25-27 implicated in the pathogenesis of androgenic alopecia. However, genetic mutations at autosomal genes also Systemic Associations are suspected to play an integral role.19-21 The diagnosis of androgenic alopecia in adolescents should prompt investigation of causes of hyperan- Clinical Features drogenemia. Androgenic alopecia can be evident in Adolescent androgenic alopecia differs from adult conditions such as congenital adrenal hyperplasia androgenic alopecia. Adolescents tend to have milder and polycystic ovary syndrome (PCOS). One study forms, with stage 1 hair loss on the Ludwig scale (gen- investigating adolescent androgenic alopecia found eral thinning at the center part) predominating for that 3 of 19 girls carried a diagnosis of PCOS and girls and stage 2 hair loss on the Hamilton-Norwood 6 additional girls had clinical features, such as acne scale (frontotemporal recession with sparing of the vulgaris, hirsutism, oligo-ovulation or anovulation, vertex) predominating for boys.CUTIS In addition, boys and polycystic ovaries, that suggested PCOS. This tend to have a greater incidence of female pattern study also revealed that 1 of 25 boys had adolescent hair loss, defined by diffuse thinning with preserva- androgenic alopecia associated with late-onset con- tion of the frontal hairline, with multiple studies genital adrenal hyperplasia.6 reporting a 20% to 33% incidence of female pattern There appears to be an association between andro- hair loss in male adolescents with androgenic alope- genic alopecia and serious cardiovascular events, pos- cia.5,6 Adolescents with androgenic alopecia also have sibly linked by an increased risk for hyperinsulinemia beenDo found to have a much higherNot incidence of fam- and insulin-resistance–associatedCopy disorders such as ily members with androgenic alopecia, with 72% to obesity, hypertension, and dyslipidemia, in men with 83% of adolescent patients with androgenic alopecia early-onset androgenic alopecia compared with age- having a first- or second-degree relative with andro- matched controls.28,29 Early-onset androgenic alope- genic alopecia.5-7 cia also has been proposed to be a clinical marker of insulin resistance.29,30 The determination of meta- Differential Diagnoses bolic syndrome and ultrasonography of the carotid When making the diagnosis of adolescent androgenic arteries have been suggested as screening methods in alopecia, one must consider alternative diagnoses male and female patients with early-onset androgenic such as telogen effluvium and diffuse alopecia areata. alopecia to detect cardiovascular disease or for early Evidence for telogen effluvium consists of a positive preventive treatment.31 It remains to be examined if hair pull test with more than 6 hairs removed from adolescents with androgenic alopecia should undergo the head when the hair is firmly pulled between the screening for insulin resistance, dyslipidemia, and forefinger and thumb, as well as a history of endocrine early atherosclerosis. abnormalities or changes in the patient’s health or stress level 2 to 3 months prior to the onset of hair Treatment loss.22 Diffuse alopecia areata is an immune-mediated The mainstay of treatment of androgenic alope- hair loss that can present with asymmetric patterns of cia in adults includes oral finasteride and topi- scalp hair loss, with loss of hair of the eyebrows and cal minoxidil. Finasteride, US Food and Drug other parts of the body, and with diffuse pitting and Administration (FDA) approved for use in men longitudinal striations of the nails.22,23 Lack of these only, is a 5a-reductase type II inhibitor that when findings in an adolescent with a family history of given in a dosage of 1 mg daily has been shown to 166 CUTIS® WWW.CUTIS.COM Copyright Cutis 2011. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Pediatric Dermatology increase the number of hairs as well as the weight of cities [published online ahead of print January 22, 2009]. hair in men with androgenic alopecia.32,33 Minoxidil Br J Dermatol. 2010;162:843-847. is a potassium channel opener and vasodilator that is 3. Setty LR. Hair patterns of scalp of white and negro males. applied topically twice daily to the scalp and has been Am J Phys Anthropol.
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