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INTRODUCTION

Female pattern hair loss presents with a diffuse thinning of the mid-scalp with a characteristic maintenance of the frontal hairline. It may also present with the typical bitemporal hair recession seen in male pattern hair loss. Parietal and occipital hairs are usually unaffected. Female pattern hair loss is particularly problematic for women for whom hair loss produces greater social and self-esteem difficulties than for men with male pattern hair loss (Figs. 20.1 and 20.2).

EPIDEMIOLOGY

Incidence: nearly 30% of females older than 30 years.

Age: begins in second and in third decade.

Race: none reported in females.

Precipitating factors: polygenetic inherited predisposition is present. It is not one parent’s fault!

PATHOGENESIS

There is a diminution in the size of affected terminal follicles that regress to become vellus follicles that eventually disappear. There is an increase in telogen hairs and a decrease in anagen hairs. Hormones play a role but the exact pathophysiology is uncertain.

COURSE

Begins in twenties and progresses over decades. The rate and extent of hair loss varies.

KEY CONSULTATIVE QUESTIONS

  • Duration of hair loss

  • Menstrual history

  • Medication history

  • Nutrition, dieting, weight loss

  • Hair care—bleaching, braiding

  • Family history of hair loss

  • History of major unexpected emotional or physical stress

  • Medical history, that is, thyroid disease, iron deficiency

PHYSICAL EXAMINATION

Nonscarring alopecia—no erythema, scale, atrophy in skin with female pattern hair loss

DIFFERENTIAL DIAGNOSIS OF FEMALE PATTERN HAIR LOSS

  • Telogen effluvium

  • Poor hair styling—chemicals, excessive dying

  • Iron deficiency, thyroid disease, chronic medical disease, polycystic or other endocrine imbalance

  • Medication-related hair loss

  • Poor nutrition, weight loss

  • Trichotillomania

  • Diffuse alopecia areata—rare

KEY QUESTIONS TO DISTINGUISH DIFFERENTIAL DIAGNOSIS

  • How long has your hair loss persisted?

  • Changes in diet or weight loss over past 6 to 12 months?

  • Any new prescription, over-the-counter (OTC) medications, or supplements?

  • Any major surgery or unusual emotional stress?

  • Any change in hair care? Chemicals to hair?

KEY POINTS

  • Patients may have a combination of etiologies.

  • If there is any questioning after history and physical examination, scalp biopsy is indicated.

  • Thyroid function tests, iron studies, antinuclear antibody (ANA), rapid plasma reagin (RPR).

  • Referral to gynecologist and/or endocrinologist if appropriate on history and/or examination.

MEDICAL THERAPY

Topical minoxidil (2% and 5% solution) are the only medications for female pattern hair loss approved by the ...

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