A Cross-Sectional, Observational Study of the Clinico-Epidemiological Profile of Female Pattern Hair Loss in Western India and its Association with Metabolic Syndrome

Abstract

Background:

The increasing prevalence of female pattern hair loss (FPHL) is an alarming concern. There are many studies on FPHL in the world literature but there is a dearth of Indian data on the same.

Aims and objectives:

The present study aims to ascertain the demographic variables and clinical features of FPHL in Western India and its association with metabolic syndrome (MetS) to add over and above the existing data.

Materials and Methods:

Ninety females who were diagnosed with FPHL were included after approval of the institutional ethics committee. Demographic details, detailed history, and clinical features were noted, following which a few blood investigations for diagnosis of MetS were advised and evaluated.

Results:

Our study population’s age ranged from 17 to 65 years, with the mean age of 34.7 ± 1.3 years. According to the Basic and Specific (BASP) classification, The basic pattern prevalence as found in our study was 46.7% for M type, 35.6% for L type, and 17.7% for C type. The FPHL severity score revealed that 82 (91.1%) had advanced disease at presentation. Prevalence of MetS was found to be 34.4% and had a significant correlation with age of onset in years (p=0.041) and severity score (p=0.013) implying that it leads to an early onset and greater severity of FPHL.

Conclusion:

FPHL is increasingly common among Indian women, who frequently present with a bitemporal recession of the hairline. Calculation of the female pattern hair loss severity index (FPHL-SI) can help in the categorization of patients and assessment of prognosis. MetS should be actively looked for in patients of FPHL and managed accordingly.

Introduction

Female pattern hair loss (FPHL) is a hormonally orchestrated non-cicatricial alopecia in genetically susceptible females resulting from a progressive decrease in the ratio of the terminal to vellus hairs, a process known as follicular miniaturization.[1] It has a characteristic patterned distribution with the frontal and parietal scalp having the greatest thinning, and the occipital scalp is relatively spared. FPHL accounts for 15.3% of diffuse hair loss among Indian women.[2] Multifarious etiologies have also been implicated in pathogenesis [Figure 1].[3]

Figure 1.

Pathogenesis of female pattern hair loss. (APM: Arector pili muscle, DKK: Dickkopf WNT signaling pathway inhibitor, DHT: Dihydrotestosterone, DPC: dermal papilla cells, GSK: Glycogen synthase kinase, IL: Interleukin, MMP: Matrix metalloproteinase, NO: Nitric oxide, ORS: Outer root sheath, PG: Prostaglandin, TGF: Transforming growth factor, TNF: Tumor necrosis factor, WNT: Wingless-related integration site)

Population differences in the prevalence and types of androgenetic alopecia (AGA) are known to exist; hence, our study, from Western India, aims to fill this lacuna in the literature.

Materials and Methods

A cross-sectional, descriptive study was carried out in the outpatient dermatology department at a tertiary care center after acquiring the permission of the institutional ethics committee. Ninety females presenting with hair loss who were diagnosed as FPHL on trichoscopy (hair diameter diversity >20% and presence of peripilar sign) and confirmed by histopathology were enrolled after taking documented consent. Patients who had received treatment for hair loss in the last 6 months were excluded from the study.

Basic details including age (in years), height (in cm), weight (in kg), and waist circumference (in cm) were noted, and the body mass index (BMI) was calculated. The participants were asked in detail about the age of onset, duration, and progression of hair loss. The presence of a family history of AGA or any other medical disorders was recorded. Other causes of hair loss such as telogen effluvium due to iron deficiency, acute infections, thyroid dysfunction, or chronic deficient diet were excluded. Menstrual history, drug history, addictions, and dietary habits were enquired about.

The general examination included an assessment of pallor, blood pressure, lymphadenopathy, and signs of hyperandrogenism. Local examination comprised of examining the extent of widening of the mid-part, the pattern of hair loss (patchy or diffuse), the degree of recession of the frontal hairline, signs of scalp inflammation (erythema or scaling), and hair pull test.

The pattern of hair loss was ascertained by the basic and specific (BASP) which is a universal gender-neutral classification system for patterned hair loss. The basic (BA) type denotes the shape of the anterior hairline, and the specific type (SP) refers to the density of hair on the frontal scalp or vertex). There are four basic types (L, M, C, and U) and two specific types (F and V).[4] The disease severity was calculated based on the FPHL severity index (FPHL-SI).[5]

To make the diagnosis of metabolic syndrome (MetS), participants were required to have three or more of the following: abdominal circumference ≥80 cm, triglycerides ≥150 mg/dl, HDL <50 mg/dl, blood pressure ≥130/85 mmHg, fasting blood sugar ≥100 mg/dl.

After the data collection, the statistical software used was IBM SPSS version 21.0 and Microsoft Office Excel 2007; p values < 0.05 were accepted as indicative of statistical significance.

Results

Profile of participants

The youngest patient was 17 years old while the oldest was 65 years, the mean age at presentation being 34.7 ± 1.3 years.

As many as 35 (38.8%) were overweight with a BMI of more than or equal to 25, while 11 (12.2%) were obese with a BMI of more than or equal to 30.

Findings on history and examination

The mean age of onset was 31.3 ± 1.3 years [Figure 2] and the mean total duration of symptoms was 3.4 ± 0.5 years. The hair shedding was continuous throughout the year in 40 (44.4%) and periodic in 26 (28.9%).

Figure 2.

A column chart depicting the distribution of participants based on the age group of onset of FPHL

The mean blood pressure was 119.9 ± 0.9 mmHg systolic and 78.0 ± 0.6 mmHg diastolic. Signs of hyperandrogenism like refractory acne, obesity, acanthosis nigricans, hirsutism, galactorrhea, and seborrhea were positive in 75 (83.3%) patients.

Findings on clinical examination of the scalp

Widening of the mid-partition of the scalp was found in 86 (95.6%). Twenty-seven patients (30%) were found to have recession of the frontal hairline. Signs of inflammation like scaling or erythema were found in 31 (34.4%) patients. The hair pull test was positive only in 9 (10%) patients.

The FPHL-SI was calculated and out of 90, only 8 (8.9%) were found to have early FPHL (score: 5–9) whereas 82 (91.1%) had established/advanced FPHL (score: ≥10). No significant association was found between the difference in the age of onset and severity score between participants with or without a family history of hair loss. The mean (SD) of the severity score between menopausal [12.1 (1.8)] and menstruating [11.4 (1.9)] participants was not different statistically (p = 0.161, unpaired t-test).

The pattern of hair loss was classified according to the BASP scale. The basic pattern prevalence as found in our study was 46.7% for the M type, 35.6% for the L type, and 17.7% for the C type. We did not record any U pattern in our study [Figure 3]. The different basic patterns of hair loss according to the BASP classification did not affect the severity score.

Figure 3.

A bar chart comparing the patterns of hair loss observed (based on the BASP scale)

Association with MetS

MetS was found in 31 (34.4%) of the participants and correlated with the onset, duration, and severity of FPHL [Table 1]. We did not find any significant correlation between the different parameters of MetS and the basic pattern or duration of hair loss. However, central obesity (a waist circumference of >80 cm) had a significant association (p = 0.047) with the severity score [Table 2].

Table 1.

Difference in the onset, duration, and severity of female pattern hair loss based on the presence of metabolic syndrome in the participants

Variable	Metabolic syndrome		P
	Present	Absent
Mean (SD) of the age of onset in years	30.2 (11.4)	37.5 (12.9)	0.041*
Mean (SD) of duration in years	5.4 (3.8)	3 (4.3)	0.068
Mean (SD) of severity score	12.7 (2)	11.3 (1.8)	0.013*

*Significant at 0.05 level. Unpaired t-test used

Table 2.

Association between different variables of metabolic syndrome (each of the 5 components) with severity score

	Severity Score
	<10	≥10	Pearson chi2	P**
Metabolic Syndrome
Absent	07 (87.50%)	62 (75.61%)	0.5760 (1)	0.675
Present	01 (12.50%)	20 (24.39%)
Waist circumference
≤80	07 (87.50%)	42 (51.22%)	3.868 (1)	0.047*
>80	01 (12.50%)	40 (48.78%)
Triglycerides
<150	05 (62.50%)	57 (69.51%)	0.1672 (1)	0.7
≥150	03 (37.50%)	25 (30.49%)
HDL
≥50	04 (50.0%)	51 (62.20%)	0.4561 (1)	0.706
<50	04 (50.0%)	31 (37.80%)
BP
<130/85	08 (100%)	74 (90.24%)	0.8566 (1)	1
≥130/85	0	08 (9.76%)
FBS
<100	07 (87.50%)	55 (67.07%)	1.4191 (1)	0.427
≥100	01 (12.50%)	27 (32.93%)

*Significant at 0.05 level. **Fisher’s exact test used. HDL: high density lipoprotein; BP: blood pressure; FBS: fasting blood sugar

Findings on histopathological examination of the scalp

The number of hair follicles in a 4 mm diameter biopsy punch was found to be 0–10 in 14.4%, 11–20 in 54.4%, 21–30 in 30%, and >30 in 1.1% of the subjects with mean being 17.1 ± 6.4 (p < 0.0005) versus 40 in the normal scalp.[6] A single hair per follicular unit was seen in 76.7% of the patients in the affected areas of the scalp. The terminal to vellus hair ratio of <4:1 which is considered diagnostic of follicular miniaturization in FPHL was a universal finding (normal >7:1, telogen effluvium >8:1). Fibrous streamers were observed below the miniaturized hair follicles in vertical sections. Other findings were a mixed perifollicular inflammatory infiltrate and perifollicular fibrosis in a significant number of cases.

Discussion

FPHL is becoming an increasingly prevalent condition in the present times due to a shift in the patient’s profile concerning lifestyle modifications, cosmetic habits, hormonal disorders, increase in psychological stress levels as well as due to recent advances in diagnostic tools. Therefore, we decided to take up this study to find out the clinico-epidemiological profile of this condition in Western India to gain information over and above the existing literature.

Periodicity of hair loss was described by 26 (28.9%) patients as excessive hair shedding during menstruation which was characterized by low estrogen levels. This supports the hypothesis that estrogen has a stimulatory role in hair growth.[7]

Mental stress can be the cause or consequence of hair loss.[8] We found positive symptoms of stress (depression/insomnia/anxiety) in 21 (23.3%) of our patients. This number is significantly higher than the 9% that was reported by Siah et al.[9] in Canadian women in the year 2016.

We did not find any association between positive family history and the age of onset or the severity of the disease. There was no significant difference (p = 0.343) in the age of onset and severity score between participants with or without a family history of hair loss. This validates the polygenic pattern of inheritance with incomplete penetrance and highlights the contributory role of other external factors in pathogenesis.

The fact that 82 (91.1%) patients had established/advanced FPHL (score: ≥10) reflects that by the time patients consult a doctor, their hair loss has already progressed, which calls for immediate measures to halt the progression of miniaturization.

The prevalence of MetS in our study was 34.4% which is similar to the studies from Egypt and Korea [Table 3].[10-13] The presence of MetS had a significant correlation with the age of onset in years (p = 0.041) and the severity score (p = 0.013) implying that it leads to an early onset and greater severity of FPHL. The parameter of waist circumference >80 cm also significantly correlated with the severity score implying that central obesity can be considered an individual risk factor for developing severe FPHL.

Table 3.

Tabulation of the prevalence of metabolic syndrome found in female pattern hair loss patients and its association with disease severity

Author	Year	Place	Sample size	Classification used	Prevalence	Association with disease severity	P-value for significance
S.M. Yi et al.[11]	2012	Korea	3408 (1701 Males and 1707 Females)	Norwood (Male) Ludwig (Female)	29.3%	Significant	<0.01
Marwa S. Zaki[12]	2012	Egypt	66	Ludwig	39.4%	Significant	<0.01
El Sayed et al.[10]	2016	Egypt	90	Ludwig	68.9%	Significant	<0.0001
Gaber MA[13]	2021	Egypt	60	Ludwig	30%	Significant	<0.001
Our study	2022	India	90 cases (no controls)	BASP	34.4%	Significant	<0.05

So, based on the above data, we can conclude that FPHL is an increasingly common cause of diffuse hair loss in adult Indian women, especially in the fourth decade. Increased hair shedding during menstruation can be correlated to decreased estrogen levels during this period. FPHL can be associated with symptoms like itching due to the underlying inflammation. A significant number of patients were found to be suffering from psychological stress which could either be the cause or consequence of this condition. Therefore, efforts should be made to deal with this issue by thorough counseling or in conjunction with a psychiatrist, if indicated. Calculation of the FPHL-SI can help in the categorization of patients and assessment of prognosis. MetS should be actively looked for in patients of FPHL and managed accordingly. Limitations of this study include a lack of controls to interpret the laboratory findings, not taking dietary history with respect to high glycemic food especially because metabolic syndrome was being evaluated as a co-association, and a biased representation of the population as most of them belonged to the lower socioeconomic strata. Epidemiological studies provide an arsenal to assess the magnitude of any disease in our population which will enable clinicians to diagnose it at an early stage. As a result, either the pathological changes can be reversed, or progression halted with aggressive intervention, leading to better treatment outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.