Female Androgenetic Alopecia: An Update

Clinical Presentation

FAGA is characterized by a progressive hair follicle miniaturization with the conversion of terminal follicles in velluslike follicles, an increased telogen/anagen ratio and a shortened hair cycle. If untreated, it leads to a slow progressive hair thinning of the scalp, though not to complete baldness, as happens in males.^[16]

Three main patterns of FAGA presentation have been described. Most frequently it shows a frontal hair thinning accentuation resulting in the 'Christmas tree' pattern (Olsen pattern)^[25] (Figure 1). The second most common pattern is characterized by central scalp involvement with the sparing of the frontal hairline (Ludwig pattern)^[26] (Figure 2). Finally, in patients with significant androgenization, bitemporal recession can be observed; rarely it could be associated with vertex thinning (Hamilton pattern)^[27] (Figure 3).

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Figure 1.

'Christmas tree' pattern of female androgenetic alopecia (FAGA), with frontal hair thinning accentuation

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Figure 2.

Typical female androgenetic alopecia (FAGA) presentation, with involvement of the central hairline at different degrees of severity (a–c)

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Figure 3.

Hamilton pattern in female androgenetic alopecia (FAGA)

However, severe FAGA often involves parietal and occipital regions with diffuse hair thinning.^[28]

Table 1. Main features of FAGA and cicatricial alopecias with a female pattern distribution
	FAGA	FAPD	CPHL	CCCA	FFA
Clinical features	Onset after puberty	Mostly targets post-menopausal women	Onset after the fourth decade	Targets almost exclusively African American women	Mostly targets post-menopausal women
	Mostly involves the central scalp	Involvement of the central scalp	Involvement of the central scalp	Begins in the central scalp and progresses centrifugally	Progressive recession of the fronto-temporal hairline
	Slowly progressive hair thinning	Cicatricial hair loss	Cicatricial hair loss	Cicatricial hair loss	Cicatricial hair loss
	Widened central part- ing line	Clinically evident erythema	'Pencil–eraser-sized' areas of focal atrichia	Clinically evident inflammation may be present	Itching and trichodynia
Trichoscopic features	Hair diameter variability > 20%	Follicular erythema	Absence of follicular erythema	Peripilar white/grey halos	Follicular erythema
	Yellow dots indicative of empty follicles	Perifollicular hyper-keratosis	Absence of perifollicular hyperkeratosis	Honeycomb pigmented network	Perifollicular hyper-keratosis
	Follicular ostia usually preserved	Loss of follicular ostia	Loss of follicular ostia	Point–point white dots	Loss of follicular ostia
	Peripilar hyperpigmentation	White fibrotic patches	White fibrotic patches	White fibrotic patches	White fibrotic patches
Histological features	T:V reduced (< 3:1)	Lichenoid infiltrate of hair follicles	Lichenoid infiltrate of hair follicles	Perifollicular lympho- cytic infiltrate	Lichenoid infiltrate of hair follicles
	Telogen:anagen increased	Concentric perifollicular lamellar fibrosis	Concentric perifollicular lamellar fibrosis	Concentric perifollicular lamellar fibrosis	Concentric perifollicular lamellar fibrosis
	Increased number of follicular stelae	Lymphocytic interface dermatitis	Lymphocytic interface dermatitis	Sebaceous glands loss	Sebaceous glands loss
	Mild perifollicular inflammation/fibrosis may be present	Sebaceous glands loss	Sebaceous glands loss	Premature disintegration of internal root sheath

Table 1. Main features of FAGA and cicatricial alopecias with a female pattern distribution

FAGA

FAPD

CPHL

CCCA

FFA

Clinical features

Onset after puberty

Mostly targets post-menopausal women

Onset after the fourth decade

Targets almost exclusively African American women

Mostly targets post-menopausal women

Mostly involves the central scalp

Involvement of the central scalp

Begins in the central scalp and progresses centrifugally

Progressive recession of the fronto-temporal hairline

Slowly progressive hair thinning

Cicatricial hair loss

Widened central part- ing line

Clinically evident erythema

'Pencil–eraser-sized' areas of focal atrichia

Clinically evident inflammation may be present

Itching and trichodynia

Trichoscopic features

Hair diameter variability > 20%

Follicular erythema

Absence of follicular erythema

Peripilar white/grey halos

Follicular erythema

Yellow dots indicative of empty follicles

Perifollicular hyper-keratosis

Absence of perifollicular hyperkeratosis

Honeycomb pigmented network

Perifollicular hyper-keratosis

Follicular ostia usually preserved

Loss of follicular ostia

Point–point white dots

Loss of follicular ostia

Peripilar hyperpigmentation

White fibrotic patches

Histological features

T:V reduced (< 3:1)

Lichenoid infiltrate of hair follicles

Perifollicular lympho- cytic infiltrate

Lichenoid infiltrate of hair follicles

Telogen:anagen increased

Concentric perifollicular lamellar fibrosis

Increased number of follicular stelae

Lymphocytic interface dermatitis

Sebaceous glands loss

Mild perifollicular inflammation/fibrosis may be present

Sebaceous glands loss

Premature disintegration of internal root sheath

Female Androgenetic Alopecia: An Update on Diagnosis and Management

Clinical Presentation

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Female Androgenetic Alopecia: An Update on Diagnosis and Management

Clinical Presentation

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