PracticalDermatology

Female pattern hair loss is the most common cause of hair thinning in women. A woman’s hair is a reflection of her personality and plays a major role in her selfesteem and attitude. Despite common beliefs, hair loss in women and men is not the same. Women generally experience fine and thinning hair, while men generally experience different thinning patterns, age of onset, and progression of the hair thinning process. There is miniaturization of the hair follicle in both men and women with thinning hair, but the pattern of the miniaturization clinically looks different in the two sexes.

With age, this process of miniaturization gradually decreases hair thickness, and the hair shaft becomes thinner. The clinical result is the appearance of thinning scalp hair. This miniaturization process is controlled by hormonal and genetic factors. The incidence of thinning hair in women is less, but there is a greater clinical importance and emotional impact when it does occur. Women also demonstrate a lack of response to medications like finasteride (Propecia, Merck) that help male pattern thinning, further demonstrating that there are other hormonal issues at play in female pattern hair loss.

Causes of Thinning Hair in Women

The hair follicle continually remodels itself during the recurring cyclical sequence of growth, regression, rest, and shedding. The cycle begins with anagen (growth stage) and eventually progresses to the involutional stage of catagen, in which much of the follicle degenerates, undergoing apoptosis and reducing its size before entering telogen, the resting stage. The lower most portion of this telogen follicle consists of the bulge and secondary hair germ. As the hair is shed from the follicle during exogen (shedding), anagen begins again.

The stem cells residing in the hair follicle bulge generate all the epithelial lineages within the follicle and are responsible for hair follicle cycling. The selective destruction of these extremely quiescent cells leads to loss of the follicle itself. The bulge cells give rise to daughter cells, the secondary germ cells that constitute a transient progenitor cell population residing adjacent to the bulge during telogen and actually producing the new hair shaft at anagen onset. A new secondary germ regenerates from the lower part of the bulge with each new hair follicle cycle, arising from the bulge at the end of catagen and remaining during telogen. Progenitor cells are somewhat larger than stem cells, less quiescent and more proliferative. Some are in the G2 stage of the cell cycle and thus more committed to proliferating and to making new hair follicles. There are gradations of progenitor cells, and not all of them are restricted to the secondary germ center. An intermediate population midway between the stem cells and the more familiar progenitor cell in both size and proliferative level are found primarily within the bulge with only 15 percent in the secondary germ center.

Hair thinning in women can begin at any age after puberty and increases post-menopause. Women with thinning hair have normal hormones except for those with polycystic ovarian syndrome or clinically significant hormonal abnormalities. Sometimes the early sign of thinning hair is increased fall out, but not always.

Balding is a shortening of the anagen cycle and prolongation of the latent or telogen phase. The time between shedding of a telogen hair and onset of the next anagen hair is prolonged in female pattern hair loss.

Fine and thinning hair are the result of shortening of the anagen phase of the growth cycle and a lengthening of the telogen cycle (“miniaturization”). Blocking agents such as hormones and other agents attach to growth receptors, turning off the growth cycle. This increases hair loss, gradually miniaturizing the hair follicle.

Pattern hair loss represents a loss of activated matrix cells (progenitor cells responsible for immediate hair growth) and not the quiescent stem cells. Prostaglandins appear to play a role in hair growth with some prostaglandins being activators (Prostaglandin F2 alpha and Prostaglandin E2) and some inhibitors (Prostaglandin D2, which seems to be testosterone responsive).

Drugs or medications (such as antidepressants, BCPs, tricyclics, thyroid medications, and cancer drugs) may play a role in hair thinning. Once stopped, hair re-growth should occur within a year, or they are probably not the problem. Women also use more potentially damaging chemical treatments on their hair than men do. There are certain nutritional requirements for normal hair growth.

Effects of Scalp Skin on Hair Growth

As the science of the dermal papillae and the follicular bulge unfold, the integrity of the epidermis, dermis, hair follicle, and adjacent fatty tissue and their role in healthy, normal hair growth has become apparent. There are several observations that would suggest that the scalp is analogous to topsoil: the thicker the topsoil, the better the grass will grow. Healthy scalp skin with normal scalp pH and normal thickness of the epidermis and dermis will improve hair growth and/or decrease hair loss.

Most hair transplant surgeons would agree that preservation of the follicular unit is critical for survival of transplanted hair. Normal, healthy hair growth requires healthy intact follicular units. Observations would suggest that normal follicular units transplanted to scalp skin that has significant actinic damage, traumatic scar tissue, and the like produce decreased overall graft survival as well as poorer follicular growth. The poorer follicular unit growth is demonstrated by finer and thinner hair shafts of the transplanted follicular units.

Scalp skin can be viewed as a variant of normal skin in that it has a greater concentration of large, terminal hair follicles.

Good nutrition and good hair care products can play a major role in hair growth, hair shaft thickness, and the survival and growth of transplanted follicular units. Poor health, poor lifestyle, sun damage, cigarette smoking, poor nutrition, and bad hair care products have a negative impact on normal hair growth. Sun damage to the scalp can result in damaged stratum corneum cells, atypical epidermal cells, thinned epidermis, and damaged dermis.

Thinning Hair Treatment Options

There are things women can do to improve and maintain healthy scalp and hair growth. Nutrition plays a role in healthy scalp skin and hair shaft growth. Scalp skin and hair are composed of keratin protein, with hair consisting of 97 percent protein. Keratin proteins are amino acids linked end-to-end and cross-linked with sulfur bonds from the amino acid cysteine. Cysteine and glutamic acid make up 30 percent of the amino acid content of human hair.

Red meat and eggs contain significant cysteine, but many people have decreased their intake of red meat and eggs to lower blood cholesterol levels. It is efficient to take a multivitamin and an amino acid supplement on a daily basis to improve scalp skin and hair growth. There are individuals at greater risk for genetic pattern hair loss or conditions with increased telogen loss, and daily nutritional support for normal hair growth is important. These patients are at greater risk to have poor hair growth without adequate nutritional supplements. Sun protection is important for normal scalp as well as scalps with pattern hair loss. The greater the predisposition for pattern hair loss, the more important is the need for preventive sun protection. Contrary to the myth that wearing hats causes hair to fall out, a hat can help protect the scalp and hair from UV damage that slows down the thinning hair process.

The greater the significance of female pattern hair loss (finer, thinner hair with more exposed scalp), the less natural protection the person has from sun damage. Obviously, the front, top, and vertex of the scalp are the most vulnerable due to their proximity to the sun’s rays.

There are agents that have been shown clinically and histologically to improve the health of the epidermis, dermis, and hair follicle. Generally these agents have been used on non-scalp skin. They include glypoic complex, minoxidil, retinoic acid, and others. On a clinical basis, there is improvement in skin texture, skin color, and skin tone with use of these ingredients, and even improvement in scalp hair growth.

These ingredients also cause a flattening of the stratum corneum, increased thickness of the epidermis, increased cellularity and vascularity of the dermis, an overall thickening of the dermis, and the development of larger hair follicles, which will create thicker and longer hairs. On a physiologic basis, there is increased cell growth of the epidermis, improved epidermal exfoliation, increased glycosaminoglycan production, increased collagen synthesis, and stimulation of the hair follicle matrix stem cells (increasing the hair growth cycle and shortening the resting phase of the telogen cycle), increasing the length, thickness, and volume of the hair.

One would hope that hair care products with the right ingredients, appropriate pH, and proven results will create and maintain a healthy scalp and hair growth. But a person’s overall nutrition and the use of proven follicle stimulators to help maintain and prevent pattern hair loss are extremely important.

The scalp and hair have a pH of 4.5 +/- 0.5. Maintaining the normal pH of the scalp and hair is important for normal structure and function. Shampoos that contain ingredients to promote healthy scalp and hair (Glypoic Complex Volumizing Shampoo, for example) are designed to clean dirt, sebum, oil, and dead skin cells from the scalp and to promote normal scalp skin stratum corneum exfoliation and maintain the normal acidic pH of the scalp. Conditioners that contain ingredients to promote healthy scalp and hair (such as Glypoic Complex Volumizing Conditioner) are designed to restore the normal acid pH of the scalp skin, reduce tangle, and restore the normal moisture content of the hair shaft. The moisture retention of the hair shaft is pH dependent. Acidic pH causes the cuticle cells to flatten and seals the moisture into the hair shaft. Safe chemical treatments to the hair shaft work only on the hair shaft above the scalp skin and do not have a negative impact on the hair follicle, stem cells of the hair follicle, or the dermal papillae.

Minoxidil at a concentration of 2-5% has been documented in numerous scientific studies and clinical trials to stimulate hair follicle growth. It has a direct effect on the hair follicle, although the exact mechanism is not well understood. The hair follicle is one of the few tissues that contain pluripotential cells that can divide and differentiate when influenced by substances produced by cells of the dermal papilla of the hair follicle, matrix stem cells of the hair follicle, or external, applied follicle stimulators. The hair follicle is a small structure, but due to the large number of different cell types involved in its functioning, its complexity is enormous, and there is much to be learned about the function of follicle stimulators. Minoxidil appears to shorten the telogen (resting) phase of the hair growth cycle, returning the hair follicle to the anagen (growing) phase. Male and female pattern hair loss is characterized by a low anagen:telogen ratio on scalp biopsy. Minoxidil follicle stimulators increase the anagen:telogen ratio, creating thicker, fuller scalp hair. Scientific data suggests that topical minoxidil stimulates matrix stem cells of the hair follicle to reactivate, thus producing a thicker, longer hair independent of hormonal influences.

Four distinct effects of follicle stimulator (pure minoxidil) have been elucidated. These effects of pure minoxidil have been clinically proven to increase the size of the hair root and follicle. Minoxidil formulation is critical for penetration (maximize solubility and increase bioavailability, which increases effectiveness). There is an increase in ATP (adenosine triphosphate) and protein synthesis, causing an increase in cellular function in the hair root matrix cells, stimulating cell division independent of hormones. There is improved cell proliferation (growth), making a longer, thicker hair. This is accompanied by an increase in protein synthesis necessary for normal hair growth. There is an increase in blood circulation, providing a supply of nutrients and oxygen to the hair follicle.

Results of My Glypoic Complex Study

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. With the right knowledge and products, positive improvements can be made.

I conducted a prospective open-label study to evaluate the effect of Glypoic Complex Volumizing Shampoo and Glypoic Complex Volumizing Conditioner, along with aminoplex (amino acid supplement containing 19 L-amino acids) and “pure” 2% minoxidil follicle stimulator (in a proprietary formulation) on hair growth and the structural and functional integrity of the scalp epidermis and dermis of women with fine and thinning hair with Ludwig type I or type II female pattern hair loss.

Patients were instructed to use glypoic complex (volumizing) shampoo and glypoic complex (volumizing) conditioner on a daily basis or whenever their hair was cleansed. Topical 2% minoxidil was applied twice daily. They were also instructed on proper scalp sun protection with hats and sunscreen. There were no dietary or nutrition restrictions, but the patients took aminoplex daily. Patients were allowed to use styling products and color their hair but were instructed to avoid harsh chemical treatments to the hair.

The pretreatment biopsy showed a basket weave, hyperkeratotic appearance of the stratum corneum and thinning of the epidermis with some perifollicular and perivascular inflammation. The biopsy 12 months after beginning the glycolic shampoo and conditioner treatments showed a decrease in the perifollicular inflammation and an increase in the thickness of the epidermis. The stratum corneum appeared more compact. This confirms other studies that indicate that inflammation plays a role in female pattern hair loss.

Other Treatments for Female Pattern Hair Loss

Low-level laser light therapy is another treatment option. Biostimulation affects the mitochondria and in turn messenger RNA synthesis, which ultimately leads to enhancement of cell proliferation. Early initiation of therapy may be more effective than late stage treatment, which may just prevent progression.

If a conservative, non-surgical treatment is not effective 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 condition is having on your patient.

Dr. Lawrence Samuels, MD is a board-certified dermatologist, a follicular hair transplant specialist, 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 products called Rx Systems PF® (www.rxsystemspf.com), which are available online and at select spas and salons nationwide.

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