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Androgenetic Alopecia

Author: Robert P Feinstein, MD; Chief Editor: Dirk M Elston, MD more...



Updated: Mar 18, 2013
Practice Essentials
Androgenetic (or pattern) alopecia is a genetically determined disorder characterized by the gradual conversion of
terminal hairs into indeterminate, and finally into vellus, hairs. It is an extremely common disease that affects men
and women.
Essential update: Androgenetic alopecia linked to prostate cancer
In a meta-analysis of 7 case-control studies, an association was found between androgenetic alopecia of the scalps
vertex and a significantly increased risk of prostate cancer (OR 1.25; 95% confidence interval 1.09-1.44; Z = 3.13; P
= .002). In the study, which involved a total of 8994 patients (including 4916 controls), Amoretti et al examined odds
ratios for a link between prostate cancer and individual hair loss patterns. The association was found only for balding
at the vertex.
[1]
Signs and symptoms
Signs of androgenetic alopecia include the following:
Gradual onset
Increased hair shedding
Transition in the involved areas from large, thick, pigmented terminal hairs to thinner, shorter, indeterminate
hairs and finally to short, wispy, nonpigmented vellus hairs
End result can be an area of total denudation; this area varies from patient to patient and is usually most
marked at the vertex
Diffuse alopecia areata may mimic the androgenetic form. The presence of exclamation point hairs, pitted nails, or a
history of periodic regrowth or tapered fractures noted on hair counts suggests the diagnosis of diffuse alopecia
areata.
Males
Men note a gradual recession of the frontal hairline early in the process
Men present with gradual thinning in the temporal areas, producing a reshaping of the anterior part of the
hairline
Females
Hair generally is lost diffusely over the crown; this produces a gradual thinning of the hair rather than an area
of marked baldness; the part is widest anteriorly
The frontal hairline is often preserved in women
Bitemporal recession does occur in women but usually to a lesser degree than in men
See Clinical Presentation for more detail.
Diagnosis
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Laboratory studies
History and the physical examination are the most important aspects of diagnosis in patients with androgenetic
alopecia. The following laboratory tests, however, can play a role in patient assessment:
Dehydroepiandrosterone (DHEA)-sulfate and testosterone analysis: In women, if virilization is evident
Iron, total iron-binding capacity, and transferrin saturation: To test for iron deficiency, if telogen effluvium is
present
Thyrotropin level: If a thyroid disorder is suspected
Biopsy and histology
A biopsy is rarely necessary to make the diagnosis of androgenetic alopecia. If a single biopsy specimen is obtained,
it should generally be sectioned transversely if pattern alopecia is suspected.
In androgenetic alopecia, hairs are miniaturized. Although the condition is considered a noninflammatory form of hair
loss, a superficial, perifollicular, inflammatory infiltrate is noted at times. A mildly increased telogen-to-anagen ratio is
often observed.
See Workup for more detail.
Management
The following drugs have been approved by the FDA for the treatment of androgenetic alopecia:
Minoxidil: Androgen-independent hair-growth stimulator
Finasteride: 5-Alpha reductase type 2 inhibitor
The cosmetic results of surgical treatment for androgenetic alopecia are often satisfactory. Micrografting produces a
more natural appearance than does the old technique of transplanting plugs.
See Treatment and Medication for more detail.
Background
Androgenetic alopecia, or pattern alopecia, is an extremely common disorder affecting both men and women. The
incidence of androgenetic alopecia is generally considered to be greater in males than females, although some
evidence suggests that the apparent differences in incidence may be a reflection of different expression in males and
females.
Pathophysiology
Androgenetic alopecia is a genetically determined disorder and is progressive through the gradual conversion of
terminal hairs into indeterminate hairs and finally to vellus hairs. Patients with androgenetic alopecia have a
reduction in the terminal-to-vellus hair ratio, normally about 4:1. Following miniaturization of the follicles, fibrous
tracts remain. Patients with this disorder usually have a typical patterned distribution of hair loss.
In androgenetic alopecia, studies have indicated a self-renewal of the hair follicle via keratinocyte stem cells located
at the area of the bulge of the hair follicle. In addition, a series of studies using mice has indicated that interfollicular
keratinocyte stem cells could generate de novo hair follicles in adult mouse skin. These regenerated hair follicles
cycled through stages of telogen to anagen. However, these transitions between bulge and epidermal keratinocytes
have not been seen yet in human studies.
[2]
Another report has indicated that mice lacking in functional vitamin D receptors develop a functional first coat of hair,
but lack the cyclic regeneration of hair follicles leading to the development of alopecia.
[3]
Whether these findings will
lead to a new area of exploration into the cause of androgenetic alopecia in humans is unknown at this time.
A lymphocytic microfolliculitis targeting the bulge epithelium, along with deposits of epithelial basement membrane
zone immunoreactants, are frequently seen in androgenetic alopecia in both sexes. Those cases with a positive
immunoreactant profile respond better to combined-modality therapy than do those with a negative result.
[4]
Numerous studies have identified 2 major genetic risk loci for androgenetic alopecia. These are the X-chromosomal
AR/EDA2R locus and the PAX1/FOXA2 locus on chromosome 20. A recent genome-wide association study
compared move than 1100 severely affected cases of androgenetic alopecia and controls to note differences in the 2
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groups. The study indicated that HDAC9 is the third androgenetic alopecia susceptibility gene. The results of this
German study were further analyzed by fine-mapping and then individually replicated in an Australian sample.
[5]
Epidemiology
Frequency
International
Androgenetic alopecia is an extremely common disorder that affects roughly 50% of men and perhaps as many
women older than 40 years. As many as 13% of premenopausal women reportedly have some evidence of
androgenetic alopecia. However, the incidence of androgenetic alopecia increases greatly in women following
menopause, and, according to one author, it may affect 75% of women older than 65 years.
A community-based study of androgenetic alopecia in 6 cities in China indicated that the prevalence of androgenetic
alopecia in both Chinese males and females was lower than that seen in whites but similar to the incidence among
Koreans.
[6]
Mortality/Morbidity
Androgenetic alopecia is essentially a cosmetic disorder. Other than affecting the patient psychologically,
[7]
androgenetic alopecia is significant only in that it allows ultraviolet light to reach the scalp and, thus, increases the
amount of actinic damage. Males with androgenetic alopecia may have an increased incidence of myocardial
infarction.
[8]
An increase in benign prostatic hypertrophy has also been associated with androgenetic alopecia.
[9]
Arias-Santiago
et al measured prostatic volume by transrectal ultrasound and urinary flow by urinary flowmetry in order to study this
hypothesis. Their findings suggest that a relationship exists between early-onset androgenetic alopecia and prostate
growth associated urinary symptoms, most likely owing to their pathophysiological similarity. They suggest that future
studies may clarify whether treatment of patients with androgenetic alopecia might benefit concomitant benign
prostatic hypertrophy.
[10]
If these associations are proven conclusively, androgenetic alopecia will be of greater clinical significance.
Race
The incidence and the severity of androgenetic alopecia tend to be highest in white men, second highest in Asians
and African Americans, and lowest in Native Americans and Eskimos.
Age
Almost all patients with androgenetic alopecia have an onset prior to age 40 years, although many of the patients
(both male and female) show evidence of the disorder by age 30 years.

Contributor Information and Disclosures
Author
Robert P Feinstein, MD Associate Clinical Professor, Department of Dermatology, Columbia University College
of Physicians and Surgeons
Robert P Feinstein, MD is a member of the following medical societies: American Academy of Dermatology,
American Medical Association, Noah Worcester Dermatological Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.
Specialty Editor Board
Leonard Sperling, MD Chair, Professor, Department of Dermatology, Uniformed Services University of the
Health Sciences
Leonard Sperling, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.
Androgenetic Alopecia http://emedicine.medscape.com/article/1070167-overview
3 de 6 12/12/2013 19:55
David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair,
Department of Dermatology, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of
Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for
MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.
Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School
of Medicine
Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology,
American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.
Catherine M Quirk, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American
Academy of Dermatology
Disclosure: Nothing to disclose.
Chief Editor
Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.
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