Alopecia, or hair loss, is a common condition that many men and women face. There are many factors that can affect proper hair growth, such as genetics, hormones, environmental factors, etc. However, the most prevalent type of hair loss is androgenetic alopecia, which is also known as male or female pattern hair loss. This type of hair loss presents differently in men and women, but both occur due to genetic and hormonal causes. Before discussing male and female pattern hair loss, let’s discuss the normal hair growth cycle.

What is the normal hair growth cycle?

The cycle of normal hair growth is divided into 3 phases:

1. Anagen phase, which is the growth phase, lasts between 2 to 8 years
2. Catagen phase, which is the regression phase, lasts between 2 to 3 weeks
3. Telogen phase, which is the resting phase, lasts between 3 months

At the end of the telogen phase, hair falls out of the follicle and is replaced by a new hair. In a normal scalp, 80-90% of hair exists in the anagen phase, 10-20% in the telogen phase, and 1-2% in the catagen phase.

Types of Hair Loss

There are many classifications of hair loss, each describing the potential causes of hair loss.

1. Androgenetic alopecia: Androgenetic alopecia is the most common type of hair loss. For men, this hair loss can begin after puberty and progress over time, possibly leading to complete baldness. For women, this type causes hair thinning but rarely does it lead to complete baldness.
2. Alopecia areata: Alopecia areata is a type of hair loss occurring due to an autoimmune condition. This means that the body attacks healthy cells, including the hair follicles. This prevents new hair from growing. This condition can affect children and adults, and it may occur without warning. Alopecia areata can progress to complete hair loss.
3. Anagen effluvium: Anagen effluvium is a type of hair loss that is rapid and occurs due to medical treatment, such as chemotherapy. Cancer medications are strong and fast acting against killing cancer cells, but they also stop hair follicle production in the scalp and other body areas. However, once the chemotherapy ends, hair loss will typically be reversed.
4. Telogen effluvium: Telogen effluvium is a type of hair loss where large numbers of follicles enter the resting phase of the growth cycle, but the next growth phase does not occur. This leads to hair falling out from the scalp, but no new hair growth occurring afterward. This type of loss is usually triggered by situations, such as thyroid imbalance, childbirth, fevers, surgery, iron deficiency, etc. Also, use of certain medications, such as isotretinoin and warfarin, may also contribute to this type of hair loss. If the trigger event is temporary, this hair loss is reversible. However, telogen effluvium is considered to be chronic if the hair loss lasts longer than 6 months.
5. Tinea Capitis: Tinea capitis is a type of hair loss that occurs due to a fungal infection on the scalp. This condition, also known as scalp ringworm, causes hair to fall out in patches. These patches can lead to bald spots, which can get bigger over time. The areas affected by the ringworm often have a red scaly appearance, and it may be very itchy as well. Since this type of hair loss has specific symptoms, early treatment will provide great hair regrowth.
6. Cicatricial alopecia: Cicatricial alopecia is a rare type of hair loss and is also known as scarring alopecia. In this condition, inflammation destroys hair follicles, causing scar tissue to form in the place of the follicle. Once the scar tissue forms, hair does not regrow. This type of hair loss may begin very slowly and symptoms may not be noticeable. However, some people may experience hair falling out all at once. Cicatricial alopecia can occur at any age and affects both men and women.
7. Traction alopecia: Traction alopecia or cosmetic hair damage is a type of hair loss that occurs due to excessive hairstyling and use of treatments. People who routinely keep hairstyles that involve pulling the hair tight, such as cornrows or pigtails, can develop this type of alopecia. Also, those who routinely get hair treatments with hot oils or perms may also experience hair loss. If scarring develops from excessive hairstyling or treatments, hair loss may become permanent.

Pricing For Your Custom Hair Loss Product

Why do men lose hair?

Male pattern hair loss, or male androgenetic alopecia, is one of the main causes of hair loss in adult men. Often, men experience this hair loss beginning from their frontal hairline and the crown of the head, causing them to have a U-shaped baldness.

In terms of onset, male pattern hair loss tends to start around ages 20-40, especially for those who have a genetic component to their hair loss. A second peak of cases is commonly seen in men aged 50 to 60 years. In advanced conditions, some might start seeing hair loss at the beginning of puberty.

The key player of male pattern hair loss or androgenetic alopecia is testosterone. This hormone is an androgen, meaning that it contributes to providing male traits and male reproductive activity. Testosterone is converted into 5-DHT (dihydrotesterone), which is a more potent form of the hormone. Although these hormones play a role in the development of male characteristics, too much free DHT may become a problem for some males and even females. DHT can bind to receptors on the hair follicles, causing them to shrink. DHT can also shorten the hair growth cycle, causing hair to become thinner and brittle.

The reason behind male pattern hair loss is multifactorial. Some potential causes are:

1. Genetics: Genetic variations in the hair follicle receptor can cause some men to have smaller hair follicles, which can shrink. This leads to hair growth to become shorter and thinner, until no new hairs grow. Men with more family members that have hair loss are more likely to have hair loss themselves.
2. Hormonal: DHT, a potent form of testosterone, can cause many men to have hair loss, as this hormone can cause the hair follicles to shrink. Men can also have certain medical conditions that affect hormones, such as hypothyroidism, diabetes, etc.
3. Medications, chemotherapy: Some medications might induce hair loss, such as statins (cholesterol medication), amiodarone (arrhythmia medication), colchicine (gout medication), hormones (testosterone) etc. Chemotherapy is meant to kill cancer cells, but other healthy cells may become targeted as well. Thus, many people with chemotherapy tend to have hair loss as their hair follicles are being damaged.
4. Age: As the body gets older, cell growth begins to slow down. Cells in the hair follicles begin to grow slower and slower, causing the rate of cell death to be faster than the rate of cell growth.
5. Stress: Stress can cause hair follicles to be pushed into the resting phase, preventing any new hair growth.
6. Diet: Men who have diets with low nutrients may also experience hair loss. Vitamins and minerals, such iron, biotin, zinc, and vitamin D, play important roles in maintaining hair growth. Deficiencies in these nutrients can lead to hair thinning and eventual hair loss.

Why do women lose hair?

Female pattern hair loss, or female androgenetic alopecia, is one of the main causes of hair loss in adult women. This type of alopecia is considered as a “non scarring diffuse alopecia”, meaning that hair follicles become smaller over time, which further leads to thinning hair. Often, women experience this hair loss in the top and crown of their head, with the front hairline affected in advanced stages.

In terms of onset, female pattern hair loss tends to start during the reproductive years, causing many patients aged 25-40 years to seek treatment. A second peak of cases is commonly seen in menopausal women aged 50 to 60 years. In advanced conditions, some might start seeing hair loss at the beginning of puberty.

In the female pattern hair loss, the growth phase becomes shorter and the thick hairs get replaced by miniaturized hairs. Also, the time between the resting and the next growth phase becomes longer, thus hair loss exceeds hair growth. This extra resting phase is called the kenogen phase, which means that the hair follicle remains empty.

The reason behind female pattern hair loss is multifactorial. Some potential causes are:

1. Genetics: Hereditary hair loss usually starts after age 40 for women, and it typically progresses slowly. Many women might find their hair parting is wider or their frontal hairline is further back than before.
2. Hormonal: Hormones play a huge role in hair growth. Pregnancy and menopause can cause sudden hormone changes, where some may experience hair growth but some may have sudden hair loss. Health conditions, such as PCOS and hypothyroidism, can cause hormone imbalances, which increases the risk of hair loss.
3. Medications, chemotherapy: Some medications might induce hair loss, such as statins (cholesterol medication), amiodarone (arrhythmia medication), colchicine (gout medication), etc. Chemotherapy is meant to kill cancer cells, but other healthy cells may become targeted as well. Thus, many people with chemotherapy tend to have hair loss as their hair follicles are being damaged.
4. Hair styling that could damage the hair follicles: Routine hair styling with heat can damage hair follicles, causing hair to thin and fall out. Also, those who have their hair in braids, weave, twists, and tight ponytails are more likely to have hair loss due to intense pressure on their hair roots. This pressure can damage the follicles, causing scarring and potential permanent hair loss.
5. Age: Hair aging can begin after age 60, in which hair becomes thinner and fewer in number. Also, hair growth begins to slow down, causing the rate of hair loss to be higher than the rate of hair growth.
6. Stress: Stress causes the body to enter “fight mode”, where the body prioritizes it energy for vital functions. Stress can cause hair follicles to move to or remain in the resting state, causing hair to fall out. Stressors, such as illness, death, medication changes, extreme weight loss, etc can cause potential hair loss. However, once the stress is lessened, hair will begin to grow again.
7. Diet: Extreme dieting can cause sudden weight loss, which can put stress on the body, prompting it to focus on survival. Also, dieting can affect nutrient intake, which may cause the hair to not have essential vitamins and minerals needed for healthy growth.

Treatments:

The following medications can be combined into customized hair growth products of your doctor’s choosing. Various formulations are available, such as hair loss shampoos, creams, foams, gels, etc.

1. Minoxidil
   Minoxidil is one of the most commonly used medications for hair loss in men and women. It works by prolonging the growth or anagen phase of hair growth cycle. This medication is androgen or hormone independent, thus making it safe to use for pregnant women as well. Some common side effects include scalp dryness, itching, and irritation. The irritation is commonly associated with inactive ingredients, such as propylene glycol, which are present in commercially available formulations.
2. Finasteride/Dutasteride
   Finasteride and Dutasteride are hormone or androgen dependent medications commonly used for hair loss in both men and women. They both work by inhibiting the 5 alpha reductase enzyme, which prevents the conversion of testosterone to the more potent 5-DHT. This medication should not be used by pregnant women. Some common side effects include breast tenderness and decreased libido.
3. Spironolactone
   Spironolactone is a hormone or androgen dependent medication used to treat hair loss in both men and women. This medication has an anti-androgen effect, as it decreases testosterone levels and blocks androgen receptors in target areas. Some common side effects include breast tenderness and high potassium levels. It should not be used with pregnant women.
4. Cetirizine
   Cetirizine is histamine-1 receptor blocker, commonly used for allergies. However, it also shows activity against prostaglandin D2 production, which is known to inhibit hair growth. By inhibiting prostaglandin D2, cetirizine can promote hair growth.
5. Tretinoin
   Tretinoin is a vitamin A derivative, commonly used for acne. However, studies have shown that Tretinoin enhances the response of Minoxidil, one of the most common medications used for hair loss.
6. Latanoprost/Bimatoprost
   Latanoprost and Bimatoprost are prostaglandin analogs used to treat hair loss in both men and women. They work by prolonging the hair growth phase, allowing hair to grow for a longer period of time. These medications are used commonly for glaucoma, but a side effect of eyelash hair growth was seen, prompting its use for hair growth.
7. Ketoconazole
   Ketoconazole is an antifungal medication that is used to treat hair loss in both men and women. It works by having anti-androgenic activity and decreases hair follicle DHT levels. It is commonly available as a hair loss shampoo.
8. Corticosteroids
   Corticosteroids can be used for patients who have hair loss due to an autoimmune condition. These medications can suppress the immune system, preventing the body from killing healthy hair cells. Steroids are available in topical form, with common side effects of scalp irritation and redness.
9. Progesterone
   Progesterone is heavily involved in hormone regulation. Systemically, progesterone can decrease androgen synthesis, causing lower levels of testosterone in the body. Locally at the hair follicle itself, progesterone can decrease the conversion of testosterone to the more potent DHT, preventing damage to the follicle.
10. Azelaic Acid
    Azelaic acid is an acid that is produced naturally by yeast on the skin. It plays a role in hair growth as it has been found to inhibit 5-alpha reductase, which prevents the formation of DHT.
11. Biotin
    Biotin is a type of B vitamin. It is often used for hair growth, as some people have hair loss related to nutrient deficiencies. However, biotin is effective if these deficiencies exist, as it has no effect on DHT and the hormonal process of hair growth.

Availability

All of these medications may be available at your regular pharmacy. However, you may need a specialized combination of different medications to treat your hair loss. At CareFirst Specialty Pharmacy, we have the capability to specially compound unique combinations that you may need for optimal treatment. We work to provide you medications that are specific to your treatment needs. Reach out to your dermatologist to obtain a prescription today!

References:

1. Ramos PM, Miot HA. Female pattern hair loss: a clinical and pathophysiological review. An Bras Dermatol. 2015; 90(4):529-543. doi: 10.1590/abd1806-4841.20153370.
2. Dinh QQ, Sinclair R. Female pattern hair loss: current treatment concepts. Clin Interv Aging. 2007; 2(2): 189-199. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684510/.
3. Kelly Y, Blanco A, Tosti A. Androgenetic alopecia: an update of treatment options. Drugs. 2016; 76: 134901364. https://link.springer.com/article/10.1007/s40265-016-0629-5.
4. Hair Loss in Women. Clevelandclinic.org. https://my.clevelandclinic.org/health/diseases/16921-hair-loss-in-women. Updated February 10 2021.
5. Hair loss-symptoms and causes. Mayoclinic.org. https://www.mayoclinic.org/diseases-conditions/hair-loss/symptoms-causes/syc-20372926. Updated May 22, 2020.
6. Wilson DR. Hair Loss and Testosterone. Healthline.com. https://www.healthline.com/health/hair-loss-and-testosterone. Updated August 22 2018.
7. Carter A. What you need to know about DHT and hair loss. Healthline.com. https://www.healthline.com/health/dht. Updated January 10 2019.
8. Rossi A, Campo D, Fortuna MC, et al. A preliminary study on topical cetirizine in the therapeutic management of androgenetic alopecia. Journal of Dermatological Treatment. 2018; 29(2):149-151. DOI: 10.1080/09546634.2017.1341610
9. Sharma A, Goren A, Dhurat R, et al. Tretinoin enhances minoxidil response in androgenetic alopecia patients by upregulating follicular sulfotransferase enzymes. Dermatologic Therapy. 2019; 32: e12915. doi: https://doi.org/10.1111/dth.12915
10. Types of hair loss. Nyulangone.org. https://nyulangone.org/conditions/hair-loss/types. Accessed March 24, 2021.
11. Mikhail M. Hair loss in women-most common causes by age. Goodrx.com. https://www.goodrx.com/blog/most-common-causes-of-hair-loss-in-women-by-age/. Updated February 27, 2020. Accessed March 24, 2021.
12. Grymowicz M, Rudnicka E, Podfigurna A, et al. Hormonal effects on hair follicles. Int J Mol Sci. 2020; 21(15): 5342. doi: 10.3390/ijms21155342.
13. Image 1: male vs female pattern baldness. Retrieved from: https://www.merckmanuals.com/-/media/manual/professional/images/skn_losing_hair.gif?mw=704&thn=0&sc_lang=en-ca
14. Image 2: hair growth cycle. Retrieved from: 599660-What-Are-the-Four-Stages-of-Hair-Growth_-1296x927-Body.png.