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The therapeutic armamentarium for alopecia has improved, but clinicians must first establish the type of hair loss a patient has and its etiology in order to select appropriate management solutions, says Dirk M. Elston, M.D.
National report - The therapeutic armamentarium for alopecia has improved, but clinicians must first establish the type of hair loss a patient has and its etiology in order to select appropriate management solutions, says Dirk M. Elston, M.D.
Telltale signs of the type of alopecia the patient is suffering from may be determined after the clinician conducts a careful examination of the hair that is falling out, according to Dr. Elston, director, Ackerman Academy of Dermatopathology, New York, and president-elect of the American Academy of Dermatology.
“The appropriate treatment and management approach should be matchedto the cause of hair loss. Non-scarring forms of alopecia must be distinguished from scarring alopecia,” Dr. Elston says.
The most common type of hair loss is androgenetic alopecia, affecting about 50 percent of the population, followed by telogen effluvium. After a simple hair pull, the clinician can establish whether there is trichodystrophy (signifying a hair shaft disorder where the hair shaft is fracturing), telogen effluvium or anagen effluvium.
A 30-year-old male patient with diffuse alopecia areata. (Photo: Dirk Elston, M.D.)
The most common causes of anagen effluvium include alopecia areata, cancer/chemotherapy and syphilis, but telogen effluvium can have a mosaic of different etiologies. These can include physical stress (i.e. major febrile illness, major surgery, rapid weight loss), thyroid abnormalities, drugs (i.e. high doses of vitamin A, blood pressure and gout medications) as well as hormonal causes (pregnancy, birth control pills, menopause).
A closer look
In addition to appropriate blood testing, sometimes a biopsy is necessary to help confirm and/or rule out a suspected diagnosis. According to Dr. Elston, a biopsy is typically needed to establish the cause of scarring alopecia. Another indication for biopsy is diffuse alopecia areata, especially when a patient is not responding to therapy.
“The biopsy is important to confirm the diagnosis and to rule out other important possibilities,” he says. “For instance, lupus panniculitis and metastatic breast cancer may clinically mimic alopecia areata and a biopsy may be required to distinguish between them.”
Depending on the type of hair loss, its severity, and the specific etiology of the alopecia, the standing pharmacological approaches currently employed as well as modern scalp restoration surgery techniques can be effective.
“Once the clinician differentiates the hair loss presented and assesses the severity of hair loss, appropriate therapy can begin,” says Amy J. McMichael, M.D., professor and interim chairwoman, department of dermatology, Wake Forest School of Medicine, Winston-Salem, N.C.
“However, if patients are looking for complete regrowth and they have very severe standing hair loss, pharmacological approaches may prove inadequate, and surgical approaches may be their best option.”
Topical minoxidil and oral finasteride are effective in halting hair loss and for regrowth of lost hair. While higher percentages of minoxidil are often used in men, only 2 percent minoxidil is approved by the Food and Drug Administration for use in female patients.
Dr. McMichael says, however, that female hair loss patients such as those with androgenetic alopecia can achieve good results from a 5 percent solution or foam, applied once or twice daily. A six-month regimen with minoxidil could achieve a decrease in shedding, she says, and may result in an increase in hair regrowth.
“Minoxidil works reasonably well for both men and women, although patients with an apical pattern hair loss (i.e. central scalp) tend to do best. Though not everyone will have an excellent response, up to 80 percent of patients will show some response to the treatment, although not everyone has cosmetically significant growth,” Dr. Elston says.
Oral treatment options
Oral medications for men include finasteride dosed at 100 mg twice daily. Though not FDA-approved for female patients, finasteride can be used off-label, and for women who are not of child-bearing potential, Dr. McMichael often recommends finasteride dosed at 2.5 mg or 5 mg once a day.
“The effect of finasteride appears to take a bit longer and therefore, I generally advise patients to wait about nine to 10 months before they decide that it is not working,” Dr. McMichael says. “We often do a combination therapy with minoxidil and finasteride because these two medications work in different ways and their combined effects may often result in significant improvements.”
Oral spironolactone could also be used in female hair loss patients; however, according to Dr. McMichael, the higher doses required to impact hair loss (i.e. 200 mg daily) can often result in headaches, mid-cycle menstrual spotting and mood changes, making tolerability and adherence difficult.
Flutamide can be used to help improve hair loss, either alone or in combination with minoxidil and/or finasteride. In a recent study with the drug in more than 100 female patients with androgenetic alopecia, it was shown that a 250 mg daily dose was effective in improving hair loss and when the drug dose was decreased over two to three years, patients were able to maintain their hair, even at lower doses (Paradisi R, Porcu E, Fabbri R, et al. Ann Pharmacother. 2011;45(4):469-475).
Though pharmacologic therapy is usually the first line of treatment, many patients will often opt for surgical scalp restoration approaches. Some newer surgical techniques can achieve significant improvements for both male and female patients.
According to Dr. McMichael, new and innovative techniques are now used that make this treatment option appropriate for the individual patient, both men and women, and their particular type of hair loss.
“Physicians need to help patients make sense of what is out there in the lay press, including data about vitamins, supplements and unusual treatments,” she says. “Your job as a physician is to tell them to avoid those pitfalls and adjust to the fact that we are much better at keeping the hair on the head than regrowing it. We have excellent results, but these results should be seen in the long-term and not overnight.” DT
Disclosures: Drs. Elston and McMichael report no relevant financial interests.
A 30-year-old female patient with female pattern hair loss (side view, left, and crown of the scalp). (Photos: Amy J. McMichael, M.D.)