Dr. Natalia Spiering's Masterclass: Hair loss in women

In this monthly masterclass, Dr. Natalia discusses hair loss in women.
-The first step when dealing with hair loss in women is getting the diagnosis right.
-Diagnosing the type of hair loss is almost always based on taking a thorough history from the patient (listening and asking the right questions) and examining the scalp.
-In my opinion, a scalp biopsy is rarely necessary and is only helpful in very specific individual circumstances.
-There are two types of hair loss - scarring and non-scarring.
-Each type of hair loss requires a diagnosis and then appropriate treatment.
-The three most common forms of hair loss I see in my clinic are Androgenetic Alopecia (age-related hair loss), telogen effluvium (acute onset stress-related hair loss) and alopecia areata.
-Telogen effluvium:
occurs when there is a marked increase in the number of hairs shed each day.
There is an increased proportion of hairs shift from the growing phase (anagen) to the shedding phase (telogen).
Normally only 10% of the scalp hair is in the telogen phase, but in telogen effluvium this increases to 30% or more.
This usually happens suddenly and can occur approximately 3 months after a trigger.
It can last for 3-6 months and then spontaneously resolves.
-Androgenetic alopecia in women is also known as Female Pattern Hair Loss: Hair loss affects the crown (the parting widens) but spares the frontal hairline.
Incidence is 29-38% in women over 70 and only 3% in 20-29 year old women.
Androgen-responsive hair follicles gradually shorten their anagen (growth) phase resulting in more follicles in the shedding phase (telogen).
Circulating free testosterone (comes from the adrenal glands or ovaries) enters cells and converts to dihydrotestosterone (DHT) which then acts on androgen receptors in susceptible scalp hair follicles.
There is usually no increased levels of androgens (except in patients with PCOS).
Oestrogens may play a role by stimulating hair growth, which is why we see more FPHL in post-menopausal women.
Minoxidil is the only treatment approved by the FDA - we don’t know how it works but it causes increased growth rate, thicker diameter of the hair follicle and lengthened anagen phase.
5% has demonstrated superiority over 2% in clinical trials with no systemic side effects though 5% caused more local side effects of scalp itch and irritation.
There has only been one large scale placebo controlled trial of oral finasteride 1 mg daily for 12 months in post-menopausal women and it did not show any improvement over placebo.
Spironolactone up to 200 mg a day is off-license but has been shown in case reports and open label trials to be effective at reducing hair loss