CLINICAL Female pattern hair loss Linda Chan, David K Cook APPROXIMATELY 49% of women will be host of underlying or contributing medical affected by hair loss throughout their and psychiatric conditions. All causes lives, with female pattern hair loss of hyperandrogenism, such as ovarian Background (FPHL) being the most common cause of or adrenal tumours, polycystic ovarian Female pattern hair loss (FPHL) is female alopecia.1 The incidence steadily syndrome and adrenal hyperplasia, can a commonly encountered clinical increases with age in all ethnicities, and induce rapid hair loss in women. The presentation in primary care. Patterned hair loss in women is characterised the age-adjusted prevalence among adult diagnosis of FPHL is associated with by diffuse hair thinning and often Australian women of European descent underlying hypertension in women aged becomes an ongoing cause of is >32%.1–4 This translates to 800,000 ≤35 years and coronary artery disease psychosocial distress. women who suffer from moderate-to- in women aged ≤50 years.7 One study severe FPHL.4 Alopecia is associated with found that patterned hair loss was an Objectives significant psychological distress and independent predictor of mortality from The aim of this article is to present a practical approach for the clinical reduced quality of life. In one survey, 40% diabetes mellitus and heart disease in assessment of female hair loss and of women experienced marital problems both females and males.7–9 Screening to review the up-to-date treatment and 64% had career difficulties that they for metabolic cardiovascular risk factors modalities. ascribed to their hair loss.5 Alopecia can is useful in patients presenting with also be the first symptom of underlying patterned hair loss.3,10 Discussion Alopecia can be the first symptom of systemic illness within the primary 1,6 systemic illness. It is therefore crucial care setting. Risk factors for the primary care physician to be FPHL is a non-scarring alopecia able to differentiate between FPHL characterised by progressive transformation The risk factors for FPHL include increasing and more concerning causes of hair of thick, pigmented terminal hair into age, family history, smoking, elevated loss. Treatment options often involve short, thin, non-pigmented villous hair. fasting glucose levels and ultraviolet light a combination of non-androgenic This undesired process is known as hair exposure of >16 hours/week.8 and androgenic therapy. The use of 1,3,5,6 oral minoxidil in combination with follicle miniaturisation. The trigger oral spironolactone is a novel therapy for miniaturisation remains unclear Psychological morbidity with promising results. The role of but is postulated to be a combination the general practitioner is paramount of genetic predisposition, androgen FPHL is less well understood and accepted in establishing the diagnosis, setting influence and other not yet elucidated by society than alopecia in males. This achievable therapeutic goals and factors. Androgens exert their effect on generates feelings of greater confusion navigating the psychosocial comorbidity hair via circulating levels of testosterone, and distress for female patients. A study associated with this chronic condition. which is produced in females by the showed that 52% of women were very- ovaries and adrenal glands. The free to-extremely upset by their hair loss, testosterone either binds to intracellular compared with 28% of men.1 In another androgen receptors in the hair bulb, questionnaire, 70% of surveyed women causing follicular miniaturisation, or is with hair loss had a negative body image metabolised by enzyme 5-alpha reductase and poorer self-esteem, with poorer into dihydrotestosterone (DHT). DHT sleep, feelings of guilt and restriction and testosterone both bind to the same of social activities.3 Clinicians should androgen receptors, but DHT does so also screen for maladaptive coping with more affinity, leading to increased mechanisms such as compulsive fixing miniaturisation.3,5,6 of one’s hair and underlying psychiatric trichotillomania.1,10,11 Female pattern hair loss and general health Assessment As alopecia is highly visible, a patient may The diagnosis of FPHL is made on clinical 4,5 note hair loss as the first symptom of a grounds. © The Royal Australian College of General Practitioners 2018 REPRINTED FROM AJGP VOL. 47, NO. 7, JULY 2018 | 459 CLINICAL FEMALE PATTERN HAIR LOSS History menopause has occured and, if so, at Treatment Classically, the pattern of alopecia which age; use of hormonal contraception; begins with hair density reduction on the fertility concerns and any previous Key points of counselling and non- mid-frontal hairline. The anterior part gynaecological surgery.1,3,5 A discussion pharmacological treatment options are width then widens, resulting in prominent of pregnancy plans is necessary as some outlined in Figure 2. Pharmacological thinning in a Christmas tree pattern. treatments are teratogenic.1 Generalised and rapid shedding with global hair thinning is unusual and points Family history Table 1. Key features in history taking to other causes such as hyperadrenalism, Fifty-four per cent of patients have a first- and examination for detection of medication exposure, major stressors degree male relative of age >30 years with underlying systemic illnesses1,6,10 or change in hair care practices.1,3,6,10,11 alopecia, and 21% have a first-degree Hair loss over the temporal region is female relative aged >30 years with Underlying systemic diseases that may uncommon in FPHL, compared with male FPHL. An Australian gene-wide study present with alopecia pattern alopecia. If temporal thinning of Caucasian women suggested that • Virilising tumours was the first symptom, telogen effluvium, aromatase gene CYP19A1 may contribute • Polycystic ovarian syndrome frontal fibrosing alopecia, tractional to FPHL.3 • Hyperandrogenism +/– associated alopecia and hypothyroidism should be metabolic syndrome considered.6 Symptoms of scalp pruritus, Examination • Thyroid dysfunction burning and pain point to another General observations for body habitus, • Systemic lupus erythematosus (SLE) • Dermatomyositis diagnosis (Table 1).6 acne, hirsutism and acanthosis nigricans After diagnosing FPHL, concurrent should be made. Focused examination • Iron deficiency +/– anaemia medical illnesses that exacerbate alopecia should identify the calibre of the hairs and • Caloric restriction: anorexia/bulimia should be ruled out to improve overall the location of the affected areas. Findings • Psychiatric disorder: trichotillomania outcome. These include iron deficiency, consistent with FPHL include: • Medication/toxin exposure or ingestion infection, thyroid dysfunction and • loss of terminal hair in the mid-frontal • Infection: syphilis 3,11 nutritional deficiencies. Occupational scalp Red flags on history taking for history and exposure to, or ingestion of, • normal hair density in occiput regions underlying systemic illnesses toxic chemicals should be elicited.10 and preserved frontal hairline1,6 • Generalised and rapid hair shedding • miniaturised hairs: hair of various • Lateral eyebrow hair loss/thinning Gynaecological history lengths and diameters in thinning • Menstrual irregularity, fertility difficulty A detailed gynaecological history is areas3,6 • Severe acne necessary to rule out hyperandrogenism, • widening of central part with diffuse • Marked hirsutism polycystic ovarian syndrome or a reduction in hair density in a Christmas • Associated cutaneous eruption virilising tumour as underlying diagnoses. tree pattern1,11 • New photosensitivity History should include age of menarche; • normal-appearing scalp • Severe fatigue menstrual cycle details; whether • negative hair pull test: hold a bundle of • Weight changes: gain or loss 60 hairs close to the scalp between the • Fevers or chills thumb, index and middle finger. The • Joint and muscle aches test is positive when more than three • Severe psychological stressors hairs can be pulled away.12 Non-classic symptoms and signs that Examination findings suggestive of underlying disorders suggest other types of alopecia are • SLE: isolated parietal alopecia, scarring outlined in Tables 1 and 2. alopecia (violaceous papules, follicular erythema), associated cutaneous malar Laboratory investigations rash, arthralgia Laboratory testing should be considered • Thyroid dysfunction: temporal region in patients with diffuse alopecia, signs of alopecia, lateral eyebrow hair-loss androgen excess and early-onset FPHL. • Trichotillomania: broken hair shafts Recommended tests and rationale are of variable length, diffuse and patchy outlined in Table 3. Note that testing of hair loss androgen levels needs to occur during the • Endocrinopathy: acanthosis nigricans, hirsutism, truncal acne (especially follicular phase, between the fourth and nodulocystic), high body mass index seventh days of the menstrual cycle, and Figure 1. Female pattern hair loss with • Nutritional deficiency: conjunctival Christmas tree pattern oral contraceptives should be discontinued pallor, glossitis, muscle wasting eight weeks prior to the test.1,3 460 | REPRINTED FROM AJGP VOL. 47, NO. 7, JULY 2018 © The Royal Australian College of General Practitioners 2018 FEMALE PATTERN HAIR LOSS CLINICAL Table 2. History and examination findings of common non-scarring and scarring alopecia disorders6,10,11 Non-scarring alopecia Typical history Examination findings Hair pull (common) Female/male pattern Age: puberty or