Management of Female Pattern Hair Loss

Feature Story Management of Female Pattern Hair Loss

Creating and maintaining healthy, normal hair growth and scalp skin is a daily activity that requires a lifestyle change to maintain the benefits of a good hair care program.

By Lawrence Samuels, MD

emale pattern hair loss is the most common cause of size before entering telogen, the resting stage. The lower most hair thinning in women. A woman’s hair is a reflection portion of this telogen follicle consists of the bulge and second- of her personality and plays a major role in her self- ary hair germ. As the hair is shed from the follicle during exogen esteem and attitude. Despite common beliefs, hair loss (shedding), anagen begins again. Fin women and men is not the same. Women generally experi- The stem cells residing in the hair follicle bulge generate all ence fine and thinning hair, while men generally experience the epithelial lineages within the follicle and are responsible different thinning patterns, age of onset, and progression of for hair follicle cycling. The selective destruction of these the hair thinning process. There is miniaturization of the hair extremely quiescent cells leads to loss of the follicle itself. The follicle in both men and women with thinning hair, but the bulge cells give rise to daughter cells, the secondary germ cells pattern of the miniaturization clinically looks different in the that constitute a transient progenitor cell population residing two sexes. adjacent to the bulge during telogen and actually producing With age, this process of miniaturization gradually decreases the new hair shaft at anagen onset. A new secondary germ hair thickness, and the hair shaft becomes thinner. The clinical regenerates from the lower part of the bulge with each new result is the appearance of thinning scalp hair. This miniatur- hair follicle cycle, arising from the bulge at the end of catagen ization process is controlled by hormonal and genetic factors. and remaining during telogen. Progenitor cells are somewhat The incidence of thinning hair in women is less, but there is larger than stem cells, less quiescent and more proliferative. a greater clinical importance and emotional impact when it Some are in the G2 stage of the cell cycle and thus more does occur. Women also demonstrate a lack of response to committed to proliferating and to making new hair follicles. medications like finasteride (Propecia, Merck) that help male There are gradations of progenitor cells, and not all of them pattern thinning, further demonstrating that there are other are restricted to the secondary germ center. An intermedi- hormonal issues at play in female pattern hair loss. ate population midway between the stem cells and the more familiar progenitor cell in both size and proliferative level are Causes of Thinning Hair in Women found primarily within the bulge with only 15 percent in the The hair follicle continually remodels itself during the recurring secondary germ center. cyclical sequence of growth, regression, rest, and shedding. The Hair thinning in women can begin at any age after puberty cycle begins with anagen (growth stage) and eventually pro- and increases post-menopause. Women with thinning hair gresses to the involutional stage of catagen, in which much of have normal hormones except for those with polycystic ovar- the follicle degenerates, undergoing apoptosis and reducing its ian syndrome or clinically significant hormonal abnormalities.

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Sometimes the early sign of thinning hair is increased fall out, lifestyle, sun damage, cigarette smoking, poor nutrition, and but not always. bad hair care products have a negative impact on normal hair Balding is a shortening of the anagen cycle and prolongation growth. Sun damage to the scalp can result in damaged stra- of the latent or telogen phase. The time between shedding of a tum corneum cells, atypical epidermal cells, thinned epidermis, telogen hair and onset of the next anagen hair is prolonged in and damaged dermis. female pattern hair loss. Fine and thinning hair are the result of shortening of the ana- Thinning Hair Treatment Options gen phase of the growth cycle and a lengthening of the telogen There are things women can do to improve and maintain cycle (“miniaturization”). Blocking agents such as hormones and healthy scalp and hair growth. Nutrition plays a role in healthy other agents attach to growth receptors, turning off the growth scalp skin and hair shaft growth. Scalp skin and hair are com- cycle. This increases hair loss, gradually miniaturizing the hair posed of keratin protein, with hair consisting of 97 percent follicle. protein. Keratin proteins are amino acids linked end-to-end and Pattern hair loss represents a loss of activated matrix cells cross-linked with sulfur bonds from the amino acid cysteine. (progenitor cells responsible for immediate hair growth) and Cysteine and glutamic acid make up 30 percent of the amino not the quiescent stem cells. Prostaglandins appear to play acid content of human hair. a role in hair growth with some prostaglandins being activa- Red meat and eggs contain significant cysteine, but many tors (Prostaglandin F2 alpha and Prostaglandin E2) and some people have decreased their intake of red meat and eggs to inhibitors (Prostaglandin D2, which seems to be testosterone lower blood cholesterol levels. It is efficient to take a multivita- responsive). min and an amino acid supplement on a daily basis to improve Drugs or medications (such as antidepressants, BCPs, tricy- scalp skin and hair growth. There are individuals at greater risk clics, thyroid medications, and cancer drugs) may play a role for genetic pattern hair loss or conditions with increased telo- in hair thinning. Once stopped, hair re-growth should occur gen loss, and daily nutritional support for normal hair growth is within a year, or they are probably not the problem. Women important. These patients are at greater risk to have poor hair also use more potentially damaging chemical treatments on growth without adequate nutritional supplements. Sun protec- their hair than men do. There are certain nutritional require- tion is important for normal scalp as well as scalps with pattern ments for normal hair growth. hair loss. The greater the predisposition for pattern hair loss, the more important is the need for preventive sun protection. Effects of Scalp Skin on Hair Growth Contrary to the myth that wearing hats causes hair to fall out, As the science of the dermal papillae and the follicular a hat can help protect the scalp and hair from UV damage that bulge unfold, the integrity of the epidermis, dermis, hair slows down the thinning hair process. follicle, and adjacent fatty tissue and their role in healthy, The greater the significance of female pattern hair loss (finer, normal hair growth has become apparent. There are several thinner hair with more exposed scalp), the less natural protec- observations that would suggest that the scalp is analogous tion the person has from sun damage. Obviously, the front, top, to topsoil: the thicker the topsoil, the better the grass will and vertex of the scalp are the most vulnerable due to their grow. Healthy scalp skin with normal scalp pH and normal proximity to the sun’s rays. thickness of the epidermis and dermis will improve hair There are agents that have been shown clinically and histo- growth and/or decrease hair loss. logically to improve the health of the epidermis, dermis, and Most hair transplant surgeons would agree that preservation hair follicle. Generally these agents have been used on non-scalp of the follicular unit is critical for survival of transplanted hair. skin. They include glypoic complex, minoxidil, retinoic acid, and Normal, healthy hair growth requires healthy intact follicular others. On a clinical basis, there is improvement in skin texture, units. Observations would suggest that normal follicular units skin color, and skin tone with use of these ingredients, and even transplanted to scalp skin that has significant actinic damage, improvement in scalp hair growth. traumatic scar tissue, and the like produce decreased overall These ingredients also cause a flattening of the stratum graft survival as well as poorer follicular growth. The poorer fol- corneum, increased thickness of the epidermis, increased cel- licular unit growth is demonstrated by finer and thinner hair lularity and vascularity of the dermis, an overall thickening of shafts of the transplanted follicular units. the dermis, and the development of larger hair follicles, which Scalp skin can be viewed as a variant of normal skin in that it will create thicker and longer hairs. On a physiologic basis, there has a greater concentration of large, terminal hair follicles. is increased cell growth of the epidermis, improved epidermal Good nutrition and good hair care products can play a exfoliation, increased glycosaminoglycan production, increased major role in hair growth, hair shaft thickness, and the survival collagen synthesis, and stimulation of the hair follicle matrix and growth of transplanted follicular units. Poor health, poor stem cells (increasing the hair growth cycle and shortening the

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resting phase of the telogen cycle), increasing the length, thick- There is an increase in ATP (adenosine triphosphate) and ness, and volume of the hair. protein synthesis, causing an increase in cellular function in the One would hope that hair care products with the right hair root matrix cells, stimulating cell division independent of ingredients, appropriate pH, and proven results will create and hormones. There is improved cell proliferation (growth), mak- maintain a healthy scalp and hair growth. But a person’s over- ing a longer, thicker hair. This is accompanied by an increase in all nutrition and the use of proven follicle stimulators to help protein synthesis necessary for normal hair growth. There is an maintain and prevent pattern hair loss are extremely important. increase in blood circulation, providing a supply of nutrients The scalp and hair have a pH of 4.5 +/- 0.5. Maintaining and oxygen to the hair follicle. the normal pH of the scalp and hair is important for normal structure and function. Shampoos that contain Results of My Glypoic Complex Study ingredients to promote healthy scalp and hair (Glypoic Creating and maintaining healthy, normal hair growth and Complex Volumizing Shampoo, for example) are designed scalp skin is a daily activity that requires a lifestyle change to to clean dirt, sebum, oil, and dead skin cells from the scalp maintain the benefits of a good hair care program. With the and to promote normal scalp skin stratum corneum exfo- right knowledge and products, positive improvements can be liation and maintain the normal acidic pH of the scalp. made. Conditioners that contain ingredients to promote healthy I conducted a prospective open-label study to evalu- scalp and hair (such as Glypoic Complex Volumizing ate the effect of Glypoic Complex Volumizing Shampoo Conditioner) are designed to restore the normal acid pH and Glypoic Complex Volumizing Conditioner, along with of the scalp skin, reduce tangle, and restore the normal aminoplex (amino acid supplement containing 19 L-amino moisture content of the hair shaft. The moisture retention acids) and “pure” 2% minoxidil follicle stimulator (in a of the hair shaft is pH dependent. Acidic pH causes the proprietary formulation) on hair growth and the struc- cuticle cells to flatten and seals the moisture into the hair tural and functional integrity of the scalp epidermis and shaft. Safe chemical treatments to the hair shaft work only dermis of women with fine and thinning hair with Ludwig on the hair shaft above the scalp skin and do not have a type I or type II female pattern hair loss. negative impact on the hair follicle, stem cells of the hair Patients were instructed to use glypoic complex (volumiz- follicle, or the dermal papillae. ing) shampoo and glypoic complex (volumizing) conditioner Minoxidil at a concentration of 2-5% has been documented on a daily basis or whenever their hair was cleansed. Topical in numerous scientific studies and clinical trials to stimulate hair 2% minoxidil was applied twice daily. They were also instructed follicle growth. It has a direct effect on the hair follicle, although on proper scalp sun protection with hats and sunscreen. There the exact mechanism is not well understood. The hair follicle is were no dietary or nutrition restrictions, but the patients took one of the few tissues that contain pluripotential cells that can aminoplex daily. Patients were allowed to use styling products divide and differentiate when influenced by substances pro- and color their hair but were instructed to avoid harsh chemi- duced by cells of the dermal papilla of the hair follicle, matrix cal treatments to the hair. stem cells of the hair follicle, or external, applied follicle stimula- The pretreatment biopsy showed a basket weave, hyper- tors. The hair follicle is a small structure, but due to the large keratotic appearance of the stratum corneum and thinning of number of different cell types involved in its functioning, its the epidermis with some perifollicular and perivascular inflam- complexity is enormous, and there is much to be learned about mation. The biopsy 12 months after beginning the glycolic the function of follicle stimulators. Minoxidil appears to shorten shampoo and conditioner treatments showed a decrease in the the telogen (resting) phase of the hair growth cycle, return- perifollicular inflammation and an increase in the thickness of ing the hair follicle to the anagen (growing) phase. Male and the epidermis. The stratum corneum appeared more compact. female pattern hair loss is characterized by a low anagen:telogen This confirms other studies that indicate that inflammation ratio on scalp biopsy. Minoxidil follicle stimulators increase the plays a role in female pattern hair loss. anagen:telogen ratio, creating thicker, fuller scalp hair. Scientific data suggests that topical minoxidil stimulates matrix stem cells Other Treatments for of the hair follicle to reactivate, thus producing a thicker, longer Female Pattern Hair Loss hair independent of hormonal influences. Low-level laser light therapy is another treatment option. Four distinct effects of follicle stimulator (pure minoxidil) Biostimulation affects the mitochondria and in turn messen- have been elucidated. These effects of pure minoxidil have been ger RNA synthesis, which ultimately leads to enhancement clinically proven to increase the size of the hair root and follicle. of cell proliferation. Early initiation of therapy may be more Minoxidil formulation is critical for penetration (maximize solu- effective than late stage treatment, which may just prevent bility and increase bioavailability, which increases effectiveness). progression.

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If a conservative, non-surgical treatment is not effec- tive for female pattern hair loss, hair transplant surgery is the final option. Follicular unit hair transplant procedures create increased hair density with a natural pattern and appearance. The introduction of follicular unit extraction techniques eliminates the need for surgical excision of donor tissue and suturing of the donor tissue. The ARTAS robotic system (Restoration Robotics) eliminates the surgical fatigue created by manual extraction of the follicular units needed for placement in the recipient area. While there are several medical and surgical treatments available to reverse the clinical appearance of Ludwig Type I and Type II female pattern hair loss, any approach should be decided based on the individual’s needs and comfort level, taking into consideration the emotional impact the condi- tion is having on your patient. n

Dr. Lawrence Samuels, MD is a board-certified dermatologist, a follicular hair transplant special- ist, and the Chief of Dermatology at St. Luke’s Hospital in St. Louis, MO. He is a member of the International Society for Hair Restoration Surgery and provides instruction in dermatology at Washington University Medical School. In 1996, Dr. Samuels developed a line of scientifically advanced skin and hair care prod- ucts called Rx Systems PF® (www.rxsystemspf.com), which are available online and at select spas and salons nationwide.

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