How Should Treating Women Suffering with FPHL be Addressed?
When it comes to diagnosing female pattern hair loss (FPHL), a dermatologist or hair loss specialist is best suited for the job. Using dermoscopy, these medical professionals will note miniaturized hairs upon examination of the scalp, indicative of FPHL. Scalp dermoscopy has developed as a valuable tool that allows physicians to differentiate between the various types of allopecias. At this time, only one FDA approved medication and one FDA approved medical device are available for treating this condition in women. These two products include topical minoxidil and low level light therapy (LLLT). Depending on the degree of hair loss, some women may benefit from using multiple therapy options. Below is a comprehensive list of medications used for treatment of FPHL, including those with carrying an off-label use.
Topical Minoxidil has recently shown to improve the quality of life in those women suffering from FPHL. As previously mentioned, it is the only FDA-approved medication for this condition. Twice daily administration of the 2% topical solution is the recommended dose. A 5% topical foam is also FDA indicated for once daily dosing. One recent study showed the 2% formulation was effective in 60% of FPHL cases. However, the 5% foam has had even better results. The 5% once daily dosing helps patients remain compliant and also limits side effects such as dandruff and itchy scalp associated with this medication. In a small percentage of women, this medication may cause an excessive increase in hair growth on other parts of the body, termed hypertrichosis. The effectiveness of this product is very important to stress, as many women do not believe it can actually work since it can be purchased over the counter (OTC) vs. prescription only. Still other women may wash their hair infrequently and dislike the idea of having to apply the product daily. Others may be fearful of the possible side effect that could occur while using this medicine. For these women, off-label treatments may pose better treatment options.
Spironolactone is one of the off-label treatments available to women with FPHL. This potassium sparing diuretic is an aldosterone antagonist, having anti-androgen properties. For many women suffering with FPHL, they have normal levels of estrogens and androgens; however, they are genetically inclined to be more sensitive to androgens. The androgen sensitivity usually occurs in the frontal 33% to 66% of the scalp and may also affect the sides. Because spironolactone has anti-androgen properties, it blocks the androgen receptors hindering hair follicle miniaturization. Spironolactone can be dosed at 100mg/day to delay hair loss in patients with early thinning, but a dose of 200mg/day is required to initiate hair regrowth. In order to monitor patient tolerance, physicians are encouraged to consider dose titration to achieve the desired dose. Electrolyte levels should be checked regularly for all patients to ensure sodium and potassium levels are within normal limits. Patients treated with this medication should avoid potassium supplements and should be asked about other medications they may be taking. Antidepressants that are classified as selective serotonin reuptake inhibitors (SSRIs) taken concurrently with spironolactone may cause increased potassium wasting. Also, pregnancy should be avoided while taking spironolactone because the anti-androgen effects of the drug could also have an adverse effect for a male fetus. If one becomes pregnant, the treatment should stop immediately. Possible side effects of this drug include light-headedness, breast tenderness, mid-cycle spotting, and lessening or loss of menses altogether.
Some birth controls such as Yaz and Yasmin contain the ingredient drosperinone in addition to estradiol. Drosperinone is very similar to spironolactone and exerts similar anti-androgen effects. Thus, these birth controls may benefit women with hair loss.
Finasteride is a 5-alpha reductase inhibitor and when dosed at 2.5 to 5mg daily has shown to benefit those suffering from FPHL. While this medication is only indicated in men with enlarged prostate, recent studies have been promising. According to one study done in South Korea, 70 of 86 women treated with finasteride 5mg had improvement in global photographs after 12 months of treatment. Statistically significant results were seen in hair density and quality of hair. Use of finasteride in women has been limited due to concerns of breast changes or breast cancer. Due to newer studies published in the Journal of Urology showing no connection exists between this class of drug and the increased risk of breast cancer, prescribers have become more comfortable in treating women with FPHL with this drug. As an effort to screen for breast cancer, annual mammograms are recommended for women taking this medication. Women with a strong family history of breast cancer may choose to avoid this treatment option completely. A pro of finasteride is its lack of drug interactions, making it a safe choice for women on a complex drug regimen. Women treated with finasteride should be told not to donate blood while undergoing treatment. Additionally, this treatment is not for women planning to become pregnant in the near future. Women must have undergone a hysterectomy, had their tubes tied, or be on 1-2 forms of long acting and reliable birth control before even being considered as candidates for finasteride therapy.
Dutasteride is another 5-alpha reductase inhibitor having similar drug properties to finasteride. It that blocks both type I and type II 5 alpha reductase, therefor, making it more effective at blocking DHT. While dutasteride has potential to be a successful treatment option for FPHL, studies in women are limited. It has proven efficacious in treating MPHL, however, it is still has not gained FDA approval for this indication.
Ketoconazole shampoo is a great add-on therapy to the hair loss treatment regimen. Studies have shown that 2% ketoconazole shampoo plus topical minoxidil had greater improvement of hair density compared to topical minoxidil alone.
Topical estrogen cream is being studied as a possible treatment for FPHL. 75 post-menopausal women were treated with topical estrogen cream over 12-24 weeks in a study done in Greece. While the cream improved hair loss in 60-65% of female users, side effects of post uterine bleeding and one report of cancer were reported. Therefore, this treatment should be used on a risk vs. benefit basis only.
While treating FPHL can be a difficult task, it is also a rewarding one. On many occasions, treatment will be trial and error. However, most women are happy to learn several treatment options are available for their condition. Patient satisfaction can be increased through the use of photography. By taking pictures of each patient at the initial visit and then continuing this practice at each follow-up visit once treatment has been initiated, women can note the hair growth success along the way. This can be quite rewarding to the patient, as many individuals do not realize the products are working until after comparing before and after photos. Women in particular benefit from treatment success as it increases their quality of life and overall self esteem.
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