Have a happy healthy hair day!!
ABSTRACT: Female pattern hair loss (FPHL) is a biological process that is genetically mediated. Various medicines are used to treat it, few acting via a hormonal mechanism and few acting peripherally via non hormonal mechanisms. It is a difficult condition to treat due to its associated psychological impact and despite the advent of newer drugs, treatment options with proved efficacy in FPHL, are still minimal. Counselling is of utmost importance in this condition and minoxidil 2 % lotion topically still remains the mainstay in all grades of FPHL. Despite the fact that the role of androgen excess or genetic basis has still not been established, the role of antiandrogens in treatment of FPHL cannot be ignored. However, the treatment approach of FPHL is changing with the recent trends. There are various medical, semi-invasive, surgical and camouflage options also available now. Few of these are under trial; however for better understanding and classification, they have been discussed in this chapter. A newer approach combining all these modalities, will give a better patient compliance and more promising results.
Female pattern hair loss (FPHL) is one of the most challenging hair disorders to treat, due to its multifactorial aetiology and associated psychological impact. The role of genetic basis or androgenic nature has still not been clearly established and the impact of iron deficiency and hypothyroidism is still debatable.1,2,3 Multiple topical and oral medications targeting these aetiologies have been tried; however topical Minoxidil has remained the mainstay in FPHL treatment irrespective of the aetiology. Role of antiandrogens has been proved successful in recent studies, especially in patients with hyperandrogenism4,5and many newer modalities of treatment have also been introduced.
Treatment for FPHL can be widely divided as:
Counseling: Irrespective of the grade of alopecia, all females with hair loss need good counseling. Patients should be explained the nature of the hair loss, the necessity for long term treatment and adequate investigation and given realistic expectations. Stressing on these points helps in increasing the patient compliance too. Keeping the patient aware about options such as surgical modalities and camouflage techniques helps decrease the anxiety and depression, in severely affected women.
As the etiology of FPHL can be hormonal or non-hormonal, the medical management is divided into the following groups-
It is the only FDA approved topical agent for FPHL, and can be used in FPHL in normoandrogenic and hyperandrogenic women.
Mode of action: It has no androgenic action and its active molecule is minoxidil sulphate. This molecule acts on the potassium channels in cell membranes and causes peripheral vasodilatation. The exact mechanism by which minoxidil promotes hair growth is still unclear.
Other possible effects of minoxidil on the hair follicles include:
Due to these effects, minoxidil increases follicular vascularity, prolongs anagen, shortens telogen, and converts miniaturized (intermediate) hair to terminal hairs.
Dosage: 2% minoxidil applied twice daily is the US-FDA approved dosage for FPHL. Although studies have claimed better response to 5% lotion, chances of side-effects are higher with 5% lotion. Study done by Blume-Petyavi et al has shown that once daily application of 5% lotion causes lesser side effects and better compliance than 2% lotion.7
Side-effects:They are minimal with 2% lotion. However, non-virilizing hypertrichosis, irritant contact dermatitis(due to the propylene glycol vehicle), dryness and deposition of drug on the hair shaft mimicking dandruff are more with 5% lotion.8These effects are reversible on treatment break and reduction of concentration (within 4-6 months). The unsightly dandruff appearance can be reduced by using shampoos with salicylic acid and/or ZPTO.
Application: Since minoxidil is an over-the-counter product, it is widely used but patients are unaware about its practical aspects. While prescribing following instructions are of utmost importance:
Newer Formulations: Recently gel and foam form of minoxidil have been made available. Newer combinations, with:
1)Tretinoin 0.05% or 0.01%, increases the absorption by three times,11,12but the chance of irritation is greater with it13,14. Azelaic acid is also added to the combination occasionally.
2)Amnexil 1.5% (reverses perifollicular fibrosis) is known but its superiority over minoxidil alone in not proved.
3) Topical Finasteride (no additional benefit proven) 15
All antiandrogens act by inhibiting binding of 5α DHT to androgen receptor. Due to this central action all drugs in this category cause feminization of male fetus and oral contraceptive pills are necessary to give along with them. Nowadays many of these antiandrogens are synthetic progesterones and are given as combination oral contraceptive pills (OCPs)
I] ANTIANDROGENIC ORAL CONTRACEPTIVE PILLS:
These are the first line therapy for women suffering from hairloss associated with PCOS. PCOS being the most common cause of hormonal imbalance in pre-menopausal women these days, the importance of these drugs cannot be neglected. Additionally OCPs are also given along with antiandrogens, hence selecting the right one is of utmost importance. An OCP contains an estrogen and progesterone. The progesterone component can be proandrogenic or antiandrogenic. The third (Norgestimate and desogestrel) and fourth(drospirinone)generation progesterones are considered least androgenic. Since the 3rd generation ones have higher thromboembolic properties, Drospirinone is considered the safest and most antiandrogenic progesterone in combination OCPs.
The other newer synthetic progesterone with antiandrogenic properties is cyproterone acetate.
CYPROTERONE ACETATE (CPA): CPA is unavailable in USA but approved in Britain as treatment for acne and hirsuitism. There is sufficient evidence to support the use of CYA benefits FPHL in evidence of hyperandrogenism 16,17,18
Dosage Regimes: In Pre-menopausal women, cyclic antiandrogen therapy (CAT) is used globally, i.e. 100mg/day of CYA on day 5-15 and 50µg of ethinyl estradiol on day 16-25 of the cycle.19,20,21In India Diane35®(2mg CPA and 50µg ethinyl estradiol) is available as an OCP. It has been proved effective in FPHL along with additional 20mg CPA on day 5-20.22In post-menopausal women, 50mg/day of CYA daily is used.23 CYA has not been proved superior to spironolactone or topical minoxidil in FPHL but one study has claimed it to be the best treatment option in FPHL.24Side-effects: weight gain, menstrual irregularities, breast tenderness, nausea, depression, decreased libido and depression are few of the adverse effects. It is contraindicated in women with liver abnormalities due to its biliary secretion
DROSPIRINONE: is a 17α spironolactone derivative and has antiandrogenic, progestagenic and anti-aldosteronic activities. It is used as an OCP at 3mg/day with 30µg of ethinyl estradiol. Due to its anti-mineralocorticoid features, it has become the most widely used OCP as its dose does not cause any weight gain or fluid retention. However, theoretically use of drospirinone simultaneously with spironolactone can increase chances of hyperkalemia, though there are no studies to prove this theory.
II] FLUTAMIDE:is a pure non-steroidal antiandrogen and is approved in USA only for prostate cancer. It has been considered as the treatment of choice for hair loss and hirsuitism in PCOS25and results in greater reductionin hair loss than any other antiandrogen or finasteride.16,26
Dosage: one study has proven that 250mg/day for one year gives good results27, however to avoid the side-effects, low doses (125mg/day to 62.5mg/day) along with OCPs also give satisfactory results in women with PCOS.
Side-effects: At higher doses hepatotoxicity is seen in 13%24and monitoring of liver transaminase is essential. Increase in levels to more than twice the normal range, should be an indication to stop the drug.28 Since the hepatotoxicity is so common and very severe, this drug is not used frequently in the Indian scenario. Other common side effects are dry skin,lethargy, mood changes, decrease libido and feminization of male fetus.
III] SPIRONOLACTONE: is approved in USA for hypertension and in Australia for hirsuitism. It is anantagonist of aldosterone with antiandrogen action. Despite a lack of sufficient studies with an adequate cohort size, this drug is widely usedin FPHL. There is no minimally effective dosage proved in case of spironolactone.
Dosage: When used for 6 months at dose of 50-200mg/day it can reduce the total testosterone level substantially29. Improvement is seen after 6 months of treatment30
Side-effects: It is a category C drug for pregnancy. Adverse effect of hyperkalemia is very rare in healthy women but the physician must be aware of the risk and warn patient from consuming excessive amounts of bananas and/or coconut water. Other side-effects such as lethargy, menorrhagia and cutaneous side-effects can occur. It can occasionally precipitate lupus type eruptions and alopecia too.31
There are 2 main drugs in this category that act on 5α reductase enzyme and block the conversion of testosterone to dihydrotestosterone, Finasteride and Dutasteride
Finasteride exclusively acts on 5αreductase type II present in hair follicles and prostate, and reduces systemic as well as peripheral follicular androgenic activity. It is most commonly used oral drug in male androgenic alopecia at a dose of 1mg/day and is US-FDA approved for the same. It can be used in hyperandrogenic and normoandrogenic women too. Normoandrogenic women occasionally have high levels of 5αreductase, hence they tend to benefit with this drug.32
Dosage: In women, the dose requirement is higher. Studies have proved that a 5mg/day dose is required in post-menopausal women with or without hyperandrogenism. In pre-menopausal women it can be used along with an OCP at same dose.33. If the OCP is antiandrogenic, the dose of finasteride can be reduced to 2.5mg/day.34. Recently it is also available as a topical agent; however it did not have any advantage over minoxidil.35
Side-effects: It is a category X drug as it can cause feminization of the male fetus. It is generally well tolerated and the adverse effects such as breast tenderness and increased libido, decrease after first few months of therapy. It can be absorbed via the skin surface however the amount absorbed is too less to cause any effects, never the less it is advisable to inform the patient about this. Blood donations can be done after 1 month of stopping finasteride.
Dutasteride acts on both type I and Type II 5α reductase. There are fewer reports of dutasteride on women as it 3 times more potent inhibitor of type II enzyme than finasteride.36 It can cause serious side effects on the fetus if used in a pre-menopausal female. It is not US-FDA approved for hairloss.
Dosage: due to the lack of studies, the same dose used in men is used in women, i.e., 2.5md/day.
A topical preparation used in mesotherapy has given good results, it contains 0.5mg dutasteride, 20mg biotin, 200mg biotin, 500mg D-panthenol.37Side-effects: related to sexual performance and reproduction are higher in men, in women
MISCELLANEOUS NUTRITIONAL AND ADJUVANT DRUGS: Various new studies have focused on different modalities of approach to hair loss in women and men. Newer target molecules and bioengineering has also been adopted in this field due to the limited treatment options. All these modalities work only as adjuvants and are still being researched. Table 1 gives a brief list of few of them, used in androgenic alopecia in men and women. They surely give us hope for newer more efficient drugs in the near future
|Iron supplements||Extremely important in India, due to high prevalence of iron deficiency anemia and proved association with hair loss.38|
|Vitamin B12, Folic acid and Biotin||OCPs with CPA with ethinyl estradiol can worsen B12 deficiency24, hence supplementation is required along with them|
|Cysteine, histadine, copper and zinc||These amino acids and trace elements have been proved in a few studies to be beneficial. Copper peptides are now-a-days one of the most marketed supplemental therapy.|
|Alfatradiol 0.025% solution||Alfatradiol is a topical estrogens used in FPHL, but due to contrary results of the efficacy the studies are insufficient.40|
|Melatonin 0.1% solution topically||Known to cause hormone alteration in DHT and testosterone, has been tried in one study topically as 0.1% solution, leading to significant increase in anagen hair.41|
|Biomimetic peptides (Trifolium pratense flower extract combined with acetyl tetrapeptide-3) used topically||Its mode of action is by inhibition of 5-α-reductase activity, reduction of inflammatory reactions, and stimulation of ECM protein synthesis in the vicinity of the hair follicle.42|
|Stemoxydine 5% solution||A potent prolyl-4-hydroxylase competitive inhibitor, used topically to mimic hypoxic signally and maintain hair growth and cycling. In a single study stemoxydine was applied 1 time a day (6ml), and at the end of the 3 months of the trial, there was an increase of 4% in hair density. Currently, this molecule is patented by L’Oreal Research and Innovation, Clichy, France.43|
|Valproic acid solution 8.3% topically||Valproic acid (VPA), a widely used anticonvulsant, inhibits glycogen synthase kinase 3β and activates the Wnt/β-catenin pathway, which is associated with hair growth cycle and anagen induction.44|
|Roxithromycin 5% solution used topically||Roxithromycin increases hair elongation and inhibits catagen-like changes induced in vitro with IFN-gamma in murine and human hair follicles by its anti-apoptotic activity to keratinocytes.45|
NON-INVASIVE AND SEMI-INVASIVE MODALITIES:
SURGICAL MANAGEMENT: Now-a-day hair transplantsare being attempted in women with good donor area. Due to the chronicity of FPHL and scarce treatment options, most the patients may already be applying minoxidil 2% lotion for 2-3 years prior to their consult with no significant improvement and treatment failure. In such cases to avoid frustration and depression in patients, surgery can be offered during the first visit along with medical management. The Strip surgery is a better option in women rather than Follicular unit extraction, as the amount of shaving of hair required with strip surgery is less.53 This modality has been discussed in detail in the later chapters.
COSMETIC CAMOFLAGE: In severe cases, hair pieces and wigs aregood camouflaging and concealment options. Mild grades of alopecia can be concealed with hair fibres and micro-pigmentation.
Micro-pigmentation is a new technique involving tattooing of the scalp in pin points giving an illusion of increased hair density. It has been discussed in detail in later chapters.
Female pattern hair loss (FPHL) is a biological process that is genetically mediated. Various medicines are used to treat it, few acting via a biological response to hormonal mechanism and few acting peripherally via non hormonal mechanisms. Minoxidil 2 % lotion topically is the only treatment approved by US-FDA, and it remains the mainstay in all treatment protocols for FPHL. However, the treatment approach of FPHL is changing with the recent trends. There are various medical, semi-invasive, surgical and camouflage options also available now. A newer approach combining all these modalities, will give a better patient compliance and more promising results.
Introduction: Loss of the eyebrows can be due to various diseases, trauma or hereditary. Eyebrows play a major role in our expressions, hence restoration of the eyebrows not only improve the appearance but also the psychological well-being of patients.
Case Reports: We report 4 patients (age between 20-29 years) with loss of eyebrows, who were treated by follicular extraction method (FUE) and implantation by implanters. The grafts were harvested from the occipital area of the scalp in 2 patients and from the nape of the neck in 2patients. Only single hair follicles were selected to match the eyebrow hair. Nerve block was given and anaesthesia was instilled locally. Implantation was done with an implanter that helped to give direction, maintain the curvature and angle of the hair. The number of grafts varied in each eyebrow depending on the existing density.
Additionally topical 5% minoxidil gel was advised twice daily. This helped therapeutically and physically as the gel component helped to shape the occasional unruly hair in the eyebrows. The result achieved in 6 months was extremely satisfying and acceptable to all the patients. No complication was reported in any of the patients.
Conclusion: Nape of the neck is the preferred site as the donor area, due to similar hair diameter as eyebrow hair.Use of FUE and implanters in eyebrow transplants give successful and patient friendly results. They result in minimal scaring in donor site and natural angle of eyebrows in recipient site.
“Ugly is a field without grass, a plant without leaves, or a head without hair.”
-Ovid “The Silent Woman”
· Hair loss may have extreme psychological effects due to the current societal pressure
· Not all hair loss patients are to be operated, since nowadays patients demand surgery but may not need one
· It is important to give time to counselling of the patient to identify any underlying psychological disorder
· If the patient has a psychiatric disorder, it is advisable to counsel the patient and encourage them to take a psychiatrist opinion before going ahead with the surgery, to avoid any unnecessary hassle or legal complications.
Hairloss can be traumatising in a society that perceives hair as a sign of youthfulness, vigour and success. This worsens when loss of hair starts at an early age, resulting in patients feeling physically and socially less attractive, less virile, less likable and having low self-esteem. In search for a remedy and quick fix, this societal pressure leads to an increase in the demand for hair transplant surgeries. This is worsened by excessive advertising of hair transplant and camouflage techniques on television, newspapers and social media sites. Women with acute telogen effluvium or active scarring alopecia approach for surgery as a cure. Similarly patients, who don’t need surgery or are not the right candidates, have started demanding for a hair transplant. Multiple online marketing sites and forums have started rating surgeons and have support groups for hair loss patients. It is not uncommon to get patients with grade 6 alopecia, coming with their past photos or pictures of movie stars and asking for hairlines like them. Frequently, we also get a patient who quotes a study on stem cells under trial and asks, ‘Doctor, can you do this for me?’ Hence with the current scenario, each patient approaches with a different psychology and emotion.
In one third patients these emotions are so over-whelming that they start affecting the patient’s daily lifestyle, such aslimiting their social activities, avoiding family occasions and spending enormous amount of time and money on hair grooming. This behavioural impact is noticed not only in men but in women too. Surveys have shown that around 40% of women with alopecia have had marital problems, and around 63% claimed to have career related problems.1 The same grade of alopecia may initiate a different psychological response in different patients, some are regarded as physiologically normal responses while some are borderline psychosomatic disorders and rarely a typical case of an underlying psychological disorder may be encountered.To prove this further, clinical studies have also shown that 20-48 % of patients presenting for cosmetic surgery may have a psychiatric diagnosis too.2Such patients need to be treated psychologically too along with their hair treatments, to get satisfying results. Hence evaluation of psychology of a patient suffering from hair loss, should play a major part in the training of an hair transplant surgeon to avoid dire consequences. It is the physician’s responsibility to segregate such patients, counsel them, and in most cases refer them or rarely themselves become the psychotherapist.
More than 3 lakh hair restoration surgeries have been done in 2014 itself, as per the International Society of Hair Restoration Surgery 2015 Practice Census Results data.3Since multiple surgeons in our country are not members of ISHRS, hence the actual number of surgeries may be much higher. Several factors have lead to this changing trend and increasing demand in hair transplant surgeries.
Paradoxically, coinciding with the demand for procedures there is an increasing fear of side effects and demand for simpler and safer procedures. Often in the same patient one sees obsessive urge for procedure and also a paranoid fear of side effect- the twin demands of providing “ guaranteed efficacy with absolutely no side effects” is one of the challenges of hair transplant surgery.
DISEASE VS DESIRE:
As a result trichology is changing from disease oriented speciality to a desire satisfyingspeciality, where a patient demands a procedure for a perceived problem. This has led to a debate as to whether such patients are indeed patients or should they be termed as clients.
The difference between a patient and a client is given below:
|Has a disease||Has a desire|
|Mostly needs medical treatment ; occasional surgical treatment||Mostly needs a procedural treatment|
|Fear of consequences of disease, fear of infection, fear of progression of alopecia||Well aware; often has read well; knows often what treatment is needed|
|Accepts treatments willingly||Wants options- safe options|
|Easier to counsel about side effects||Paranoid about side effects|
|Respectful towards doctor; doctor is dominant||Demands an equal relationship|
|Easier to handle if there is a side effect||Demanding; can be aggressive, more likely for a medico legal situation|
Being a successful hair transplant surgeon is always a multifaceted job. It involves being a director, an organizer, a marketing salesman and an entrepreneur. If one patient has a bad experience while undergoing a hair transplant, he not only gives the doctor a bad reputation but also discourages other patients from thinking about a hair restoration surgery. Hence making sure the patient has a pleasant experience and understanding their feelings at every step is a crucial part of this job.
Characteristics of of a good hair transplant surgeon are as follows:
ASSESSMENT OF PSYCHOLOGY OF A HAIR LOSS PATIENT
In 1818, Heinroth described the term ‘Psychosomatic’ referring to the influence, the mind has on the body. The easiest way for a physician of a non-psychiatric background to assess the psychology or thinking of the patient is via a good doctor-patient relationship. This is easier said than done. Despite the best medical education and training, good communication and interpersonal skills come naturally to health-care providers or with great experience and observation. Only a doctor with good communication skills will be able to segregate the cases that need psychotherapy.
Most important thing while evaluating a patient’s psychology is to give the patient time. Minimum 15 minutes per consultation are a must.4 It is often worthwhile to give the patient a questionnaire to fill . A counsellor or a junior doctor can also screen the patient first.
Following points give a stepwise guideline on evaluating a patient’s psychology when he enters an aesthetic clinic.
Being anxious, nervous and self-conscious is a normal feeling while visiting a doctor and hence it is important to make the patient feel comfortable during his visit.
Asking open-ended questions helps in allowing the patient to talk more and open up.
Ask details about the expectations? To understand his expectations, ask, what and how much would satisfy him? Is there any minimum that he expects? Show him photos of what results can achieve and then ask will he be happy if such results are achieved?
TYPES OF EMOTIONS IN ALOPECIA:
The difference between emotions and psychology is that, emotions are what a patient feels or experiences and psychology is how the doctor perceives these emotions. The patient may feel sad and rejected but diagnosing him of depression is the doctor’s job.
UNDERSTANDING THE PSYCHOLOGY BEHIND THE EMOTION:
Not all patients have an underlying psychological issue. However all patients do have an underlying emotion or motive behind getting a hair transplant surgery. A survey done by the ISHRS 2015 practise consensus, showed that apart from having low density of hair, there were multiple reasons why female patients ask for a hair transplant. (Table1)3
Table 1: Aside from “wanting more hair,” what was the main reason women were seeking hair restoration in 2014? (n=233)
65% of the women in the study felt the reason for getting the surgery was psychological. Rarely we encounter patients with psychosomatic causes asking for a surgery. These are the patients that need to be segregated.
Psychosomatic causes: One-third of the patients visiting a dermatologist have associated emotional and psychosomatic factors,only treating the physical aspect in these patients is not going to yield any results, the psychosomatic factor needs to be resolved too.7Most common presentation of these factors seen in a hair transplant centre is in cases of body dysmorphic disorder (BDD) and depression.
BDD is considered a type of obsessive compulsive disorder and has been discussed in detail in another chapter in this textbook.8
The following table gives a list of screening questions to be asked during history taking:
Screening questions in to indentify patients with psychological disorder
If the answer to these five questions is “yes”, it is highly likely that the patient has BDD, and elective aesthetic surgery should not be performed
1.Do you believe that your alopecia is abnormal for your age?
2.Have you ever been very concerned about your appearance?
3.Do you often and carefully view yourself in the mirror? How much time do you spend doing so?
4.Do you attempt to hide your hair loss with your caps, scarfs, or camouflage?
5.Does your preoccupation with appearance have affected your life in the areas of your profession, social contacts, and partnerships? Have you neglected normal activities because of the defect?
After the screening, underlying psychosomatic cause can be confirmed via a simple tool-The Visual Analogue Scale (VAS). The doctor and patient independently rate disfigurement and record severity on the optical VAS using values between 0 and 10 (with 0 meaning “no disfigurement” and 10 meaning “most severe disfigurement”). When a discrepancy of more than 4 points on the VAS occurs, body dysmorphic disorder is highly suspicious.
INTERVENTION AND DECISION TO DO THE PROCEDURE:
An ideal case to perform a procedure is the one with no obvious psychopathology, clearly defined areas of dissatisfaction, realistic expectations and who is self-motivated. Contradictorily, aesthetics procedures should be avoided in patients with major depression, signs of self-mutilation, troubled or agitated on day of surgery or on psychotics.9Depending on the assessment of the patient, if the physician feels there are no psychosomatic factors behind the patient’s demand for the surgery, he should go ahead. Borderline cases or mild cases of obsessive compulsive disorder or BDD also benefit with cosmetic procedures or a combination of psychiatric and cosmetic treatment.4Patients with psychological disorders believe they have a ‘defective appearance’ and despite doing a surgery they will feel it still looks defective, hence are always dissatisfied. They usually have a tendency to get multiple surgeries. Such patients also refuse to get psychiatric help initially. Counselling and communication skills are of utmost importance at stance instances. It is the dermatologist’s responsibility to act like a psychotherapist and explain the complexity of the condition to the patient. Only once the patient has insight, will he be willing to accept change. The doctor should work in a formalized collaboration with a psychiatrist, so it is easier for the patient to open up to psychiatric therapy without much resistance.10Occasionally a dermatologist may also have to prescribe selective serotonin reuptake inhibitors, such as fluoxetine , Sertraline orEscitalopram in case the patient is extremely reluctant to visit a psychiatrist.
Doing a procedure on a patient with BDD may have dire consequences too, as patients may occasionally turn violent. There are 2 cases of murder of surgeons by patients showing symptoms of BDD.11Surveys have shown that 29% of aesthetic surgeons have been threatened legally by BDD patients.12
Warning signs for when not to do procedures
It is important for a dermatologist, not just to know when to do or how to do, but also when not to do. Following tips can be of help in identifying such patients:
Here are some personal examples of patients encountered by the author, to explain such patients in a practical aspect:
Only a psychologically fit patient will be satisfied by a surgery. The doctor should not only be trained in aesthetics but also in psychotherapy and should know basics of pharmacology behind psychology. The judgement of taking a decision in such patients depends purely on the physicians knowledge and experience in dealing with psychological conditions.