Female pattern hair loss (FPHL) is a common, nonscarring hair-loss disorder
Prevalence of FPHL increases with age; 12% of females will have symptoms by age 29 years, 25% by age 50 years, and 41% to 50% at age 70 years and older.1 Risk factors include genetics and endocrinological diseases (e.g., polycystic ovarian syndrome, adrenal hyperplasia, ovarian or adrenal tumours).1,2
The diagnosis of FPHL is clinical
Patients initially present with central scalp or diffuse hair loss, with progressive miniaturization of hair follicles; this differs from male pattern hair loss, which typically starts in the temples or crown.1,2 The differential diagnosis includes telogen effluvium (TE), a diffuse shedding often triggered by psychological stress, weight loss, or iron deficiency.2,3
Further testing and referral may clarify the diagnosis
A hair-pull test can help to rule out TE. When a small bundle of scalp hair is pulled and 6 or more hairs easily come loose, the test is positive, but in FPHL, it is usually negative or localized to the central scalp.2,3 Further investigations (e.g., ferritin, thyroid-stimulating hormone) should be reserved for when alternative diagnoses are suspected.2 Androgen levels are usually normal and not helpful.2 Dermatology referral is recommended if the diagnosis is unclear, to exclude other conditions (e.g., scarring alopecias), or when pruritus, burning, or pain accompany the hair loss.2 Scalp biopsy is not usually indicated.1
Treatment aims to slow progression
First-line treatments include topical minoxidil (2% solution twice daily or 5% foam once daily) and oral spironolactone (up to 100 mg twice daily).1,2 Second-line options include oral minoxidil, finasteride, low-level laser (light) therapy, platelet-rich plasma, and oral contraceptives. 1,2 Response typically takes 6 to 12 months, and may be accompanied by transient initial shedding.2 In a randomized controlled trial, the mean benefit of 5% topical minoxidil was 42/100 on a visual analogue scale, as rated by investigators, indicating moderate improvement.4 A systematic review of spironolactone monotherapy showed increased hair density in 43% of users.5 Combining treatments can improve efficacy. Hair transplants can be considered for nondiffuse hair loss. Most pharmacologic treatments are contraindicated in pregnancy.1
Female pattern hair loss has psychological impacts
Screening for anxiety and depression is warranted since FPHL is associated with psychological stress.6
Footnotes
Competing interests: Cathryn Sibbald reports receiving consulting fees from AbbVie, Leo Pharma, Incyte, Sanofi, UCB Pharma, and Arcutis, and holds a leadership role with Camp Liberté. Jeffrey Donovan reports receiving royalties from UpToDate, consulting fees from Pfizer and Vichy, and honoraria from Vichy. Dr. Donovan also participates on the board of directors for the Scarring Alopecia Foundation and is the active director of the Evidence-Based Hair Fellowship Training Program. No other competing interests were declared.
This article has been peer reviewed.
References
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