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Treating hair loss in women requires choosing from variety of options


Vancouver, British Columbia - Various factors have to be addressed before a clinician decides what is the best course of management for a woman who is experiencing hair loss, according to an expert.

Vancouver, British Columbia - Various factors have to be addressed before a clinician decides what is the best course of management for a woman who is experiencing hair loss, according to an expert.

“There is variety (in hair loss) in how women present to our office,” explains Jerry Shapiro, M.D., F.R.C.P.C., director of the University of British Columbia Hair Clinic in Vancouver, British Columbia, and adjunct professor at New York University specializing in scalp disorders. “When we think of female-pattern hair loss, we think of the Ludwig’s classification, but there are a variety of ways in which women present.”

The classification has increasing stages, I through III, which correspond to increasing widths of the mid-line part, Dr. Shapiro explains. By the age of 70, 38 percent of women have female-pattern hair loss. Hair loss is categorized as scarring or nonscarring.

Different types

There are different types of hair loss that should be part of the differential diagnoses of the clinician, including trichotillomania, or compulsive hair pulling. A condition such as trichotillomania can be improved with counseling, cognitive behavioral therapy or pharmacotherapy (antidepressants).

Women affected by hair loss who present with a “Christmas tree pattern” of hair loss, where hair thinning is more evident in the frontal portion of the scalp, are good candidates for hair transplantation, Dr. Shapiro tells Dermatology Times.

Techniques and treatments

One of the more effective techniques of hair transplantation is follicular-unit transplantation. It’s key that patients have sufficient hair density in the occipital area of the scalp to yield the necessary number of grafts and have no visible scarring.

Clinicians should take photographs of patients from several views to get a better idea of the pattern of hair loss of the patients, according to Dr. Shapiro. Baseline photographs should be captured, with photographs being taken on subsequent visits for the purpose of comparison. Treatment of up to one year may be necessary before significant improvement occurs.

The Food and Drug Administration (FDA) has approved topical 2 percent minoxidil solution to treat female-pattern hair loss. Some surgeons are using the solution in addition to hair transplantation to optimize the outcome. When patients present with hair loss that involves limited patches that affect less than 50 percent of the scalp, the choice of treatment is intralesional corticosteroid injections.

Other therapies to address hair loss in women include anthralin, psoralen and ultraviolet A (PUVA) therapy, and anti-androgens.


When patients do not respond to topical 2 percent minoxidil formulation, clinicians may consider more aggressive management by using a 5 percent minoxidil formulation, which is not yet approved by the FDA. One clinical trial found increased incidences of hypertrichosis and contact dermatitis in patients who received the 5 percent minoxidil formulation compared to those who received the 2 percent solution.

The role of androgens in alopecia is being studied in an ongoing fashion. In one study of 109 patients, 38.5 percent of women with moderate-to-severe alopecia had biochemical hyperandrogenemia. “It’s important to look for signs and symptoms of androgen excess,” Dr. Shapiro says, adding if patients do have androgen excess, they should undergo a comprehensive endocrine workup.

If the endocrine examination proves that anti-androgens are warranted as a therapy, patients of reproductive age need to be on oral contraceptives while taking the anti-androgens, for the anti-androgen agents are recognized as teratogens.

“Every time you change the birth control pill, you change the endocrine milieu of the hair follicle,” Dr. Shapiro says, advising clinicians not to change a patient’s contraceptive medication. “If you change the endocrine milieu, you can make female pattern hair loss worse.”

One anti-androgen agent that Dr. Shapiro is initiating in some of his pre-menopausal patients who experience hair loss is finasteride, but it is not FDA-approved.

Clinicians should also check for the levels of iron in patients since iron deficiency can be contributing to diffuse hair loss. If the level of iron is less than 70 mg per milliliter, it’s recommended that patients use dietary supplement to increase their ferritin levels.

When women present with a condition such as lichen planopilaris (LPP), dermatologists have traditionally been at a loss to manage the condition, according to Dr. Shapiro. A variety of therapies have been initiated to respond to the condition, with the latest being immunosuppressive drugs such as mycophenolate mofetil and alefacept.

“Many dermatologists don’t have a good feel of what to do to treat LPP,” Dr. Shapiro says, noting patients can have intense pruritus and extreme itchiness.

It is beneficial to employ dermoscopy to enhance clinical features when patients with LPP present to a dermatologist, Dr. Shapiro adds.

Disclosures: Dr. Shapiro is a consultant for Johnson & Johnson and a speaker for Merck.

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