Female Androgenetic Alopecia: An Update on Diagnosis and Management

Michela Starace; Gloria Orlando; Aurora Alessandrini; Bianca Maria Piraccini

Disclosures

Am J Clin Dermatol. 2020;21(1):69-84. 

In This Article

Abstract and Introduction

Abstract

Female androgenetic alopecia (FAGA) is a common cause of non-scarring alopecia in women. The onset may be at any age following puberty and the frequency increases with age. Clinically, it shows a diffuse hair thinning over the central scalp, while the frontal hairline is usually retained. FAGA can have a significant psychological impact, leading to anxiety and depression. For this reason, early diagnosis is very important to stop the progression of the disease. The sex hormonal milieu is the main pathogenetic mechanism studied in FAGA. The role of androgens is not clearly defined and only one-third of women with FAGA show abnormal androgen levels. Endocrinological diseases with hyperandrogenism associated with FAGA comprise polycystic ovarian syndrome (PCOS), hyperprolactinemia, adrenal hyperplasia and, rarely, ovarian and adrenal tumours. Usually the diagnosis of FAGA is made clinically. A complete clinical examination and a blood examination can reveal other signs of hyperandrogenism. Trichoscopy shows the typical hair miniaturization. A scalp biopsy can be useful when the clinical evaluation does not provide a definitive diagnosis or when cicatricial alopecias with hair loss in the distribution of FAGA or alopecia areata are suspected. FAGA is a slowly progressive disease. The goal of therapy is to stop the progression and to induce a cosmetically acceptable hair regrowth. The most important drugs are topical minoxidil and oral anti-androgens. The purpose of this review is to provide an update on FAGA and to create a guideline on diagnosis and management of this frequent hair disease, not always easily recognizable from cicatricial alopecias with a similar distribution.

Introduction

Female androgenetic alopecia (FAGA) is a common cause of non-scarring alopecia in women.[1] Clinically it shows a diffuse hair thinning over the central scalp, while the frontal hairline is usually retained. It is typified by a progressive follicular miniaturization and an increased telogen phase. Several studies have reported a reduced quality of life in women with FAGA. Indeed it can have a significant psychological impact, leading to anxiety and depression.[2]

'Androgenetic alopecia' (AGA) is used to refer to this form of hair loss both in men and women, where 'andro' signifies a hormonal aetiology and 'genetic' refers to the hereditary contribution. Some years ago, the term 'female pattern hair loss' (FPHL) was introduced for this condition in women.[3] Later it was clarified that FPHL refers to all diseases with hair loss in a typical FAGA distribution.

Recently, cicatricial alopecias with hair loss in the distribution of typical FAGA have been reported. Fibrosing alopecia in pattern distribution (FAPD) presents as a central scarring hair loss with perifollicular erythema and follicular hyperkeratosis and histological features of lichen planopilaris (LPP) and AGA.[4] Cicatricial pattern hair loss (CPHL) is characterized by histological features similar to FAPD and 'pencil–eraser-sized' areas of focal atrichia, lacking the clinical inflammatory signs seen in FAPD.[5] A common form of cicatricial alopecia seen in African American women, central centrifugal cicatricial alopecia (CCCA), appears in the same area of the scalp as FAGA and is also characterized by a perifollicular lymphocytic infiltrate.[5] Frontal fibrosing alopecia (FFA) is histologically similar to FAPD but it is characterized by a permanent progressive recession of the fronto-temporal hairline; not a typical feature of FAGA, but quite common in some forms of male AGA.[5,6]

In this context, FPHL has not been considered a disease but rather a phenotype of clinical presentations of different disorders including some subtypes of cicatricial alopecias.[5]

The purpose of this review is to provide an update on diagnosis and management of FAGA.

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