female hair loss , androgenetic female alopecia

Androgenetic alopecia in women.
A problem without solution?

_Introducción
Despite the severe impact of  androgenetic female alopecia  (hair loss ) can have on health
psychic women, few studies
address the importance of these effects (1). Even the
therapeutic research is much more oriented
to male baldness. Few clinical trials
led to new advances in androgenetic alopecia
of women. A search of articles devoted to
common baldness of men in recent years,
gave poor centenarians. However, if the same
search focuses on common baldness of women,
the figure is reduced to several dozen.
According recognized epidemiological data, 50%
of men over age 50 are bald. Perhaps,
the high frequency of male baldness could justify
the extraordinary attention he has received and still
receives. But, contrary to what may seem,
the incidence and prevalence of baldness in women
no less than in men.
Tosti et al (2) found that 40% of women
FAGA have 50 years. Vera Price (3) states that
common baldness in women is as common as in
man, although differences in the clinical aspect,
and cosmetic tools at their disposal,
higher than in the case of man, allow less
appearance of the problem.
In both sexes, common baldness or androgenetic alopecia
is due to inherited predisposition, on which
acting androgens. In women, the lowest level of 5
alpha reductase and increased cytochrome P450 aromatase
and fewer androgen receptors in
hair follicles of the scalp, allowing the
alopecia is less aggressive and less apparent.
However, the accompanying anxiety may be
much higher than the male. In fact, one in
FAGA three women referred pain sensation
in the scalp, "as if his hair was inclined
in a wrong direction. "In most
cases, tricodinia or painful hair is a manifestation
latent depression, framed in a syndrome
psychosomatic (4).
However therapeutic solutions women
are rare and often considered a problem
unresolved, which is minimized.
Then try to review the current situation
treatment of FAGA.
_Tratamiento
Promoters of the anagen phase
Minoxidil: In recent decades, the observation
an increase in hair growth in patients
taking minoxidil, a vasodilator of
smooth muscle to control your blood pressure, took
to try local use successfully. In 1991 it was approved
FDA (Food and Drug Administration) in
form of 2% solution for topical use for alopecia
androgenetic. Its effectiveness in women had
shown in a clinical double
blind placebo, about 550 women from 18 to
45 years and for 32 weeks. The average
weight gain hair was 42.5%
in the minoxidil group compared to 1.9% in group
placebo (5).
Minoxidil is an activator of prostaglandin
synthetase I found in the dermal papilla
normal hair follicles in anagen or
catagen, which is involved in hair growth.
Therefore has a nonspecific activating action
hair follicles, extending the
growth period and achieved an improvement
alopecia between 30 and 60% of patients,
with few side effects. Among these is
irritation and contact allergy and hypertrichosis
lateral face of the cheeks on a 3 to
5% of the women who use it. The absorption is less
5% of the applied dose.
The positive response to treatment is more intense
the shorter the time evolution of the
baldness. Requires continuous use, twice
day on dry hair for a minimum of
six months. By suspending the treatment is lost
their beneficial effects upon returning to the situation
in about six months.
Recent clinical studies with minoxidil 5%
have not demonstrated superior efficacy. The comparison
of this concentration with 2% solution in a total
of 493 women in two controlled studies compared
placebo, 32 and 48 weeks respectively and
500 women for 52 weeks, has shown
Significant differences (3).
Antiandrogens
Finasteride: This molecule was approved by the
FDA on 19 December 1997 and has been put
available to patients in Spain in February
1999. Finasteride is a specific inhibitor of
5-alpha reductase type II, shown in alopecia
Androgenetic male with good results (6).
However, the only clinical trials
in 136 postmenopausal women with FAGA, treated
with 1 mg versus placebo, have not shown
the expected efficacy (7). Moreover, its use is
contraindicated in women of childbearing age, because
can cause abnormalities in the genital tract
the male fetus during pregnancy.
Cyproterone acetate: cyproterone acetate
antiandrogen is a derivative of hydroxyprogesterone
it has progestational activity, antigonadotrópica
and anti-androgen (8). The mechanism of action
the antiandrogen cyproterone acetate as seems
be by competitive inhibition of the binding of
Androgen receptors for these bodies
effectors, preventing receptor binding
with dihydrotestosterone, which are interrupted
the effects on the target organ. This improves
acne, hirsutism and androgenetic alopecia in
women (9,10).
Clinical studies on women with FAGA, treated
cyproterone acetate in doses of 20 mg / day,
5 to 20 day menstrual cycle, more ethinylestradiol
0.05 mg / day for 21, showed significant differences
versus placebo group. Women
treated increased the number of hairs in anagen
and decreased telogen and dystrophic hairs
(11).
For its feminizing action is indicated only
women at doses of 25 to 100 mg / day, from 5 to 15 day
menstrual cycle. Should be used associated with estrogen
(inverted sequential therapy) and ethinylestradiol
at doses of 0.03 mg and 0.05 mg / day for 21 days,
with an interval of 7 days off medication, for
minimize side effects on the menstrual cycle
due to hypoestrogenism (amenorrhea, bleeding
intermenstrual and osteoporosis), and to ensure action
contraceptive. Cyproterone acetate is teratogenic,
acting on genital differentiation, feminized
male fetus. Intersex malformations
of the external genitalia are possible only during
the sensitive phase, ie between weeks 8 and 14 of
pregnancy. However, as the case of pregnancy,
is detected quickly, is extremely
rarely eat cyproterone acetate during
this phase. In post-menopausal women can use
uninterruptedly.
Besides the competition with androgens for
their receptors, the combination of cyproterone acetate
and ethinyl estradiol has other antiandrogenic,
as it increases in serum globulin
conveyor of sex hormones,
thus decreasing the level of free androgens,
thus presents less substrate to the target organ.
There are prepared with low doses of acetate
cyproterone (2 mg) combined with ethinylestradiol
(0.035 mg) with contraceptive action, which are administered
for 21 days with 7 rest. It is advisable
avoid prescribing preparations that decrease
contraceptive efficacy either by
decreased intestinal absorption (cholesterol lowering,
antibiotics such as tetracycline and
above) or by liver enzyme induction
(anticonvulsants, rifampicin). Another possible
treatment regimen consists of administration
300 mg at the beginning of the cycle in a single dose, but
is often poorly tolerated.
Cyproterone acetate is contraindicated in
pregnancy and breastfeeding, hepatic disease, depression,
history of thromboembolic processes, diabetes
severe sickle cell anemia. Acetate
Cyproterone is a safe drug (12). The
therapeutic effects and long-term side have
been assessed in recent work (13). The authors
present a study of the safety of therapy with
cyproterone acetate retrospective and prospective, reaching
to assess side effects in patients
with treatment of up to 17 years. Were collected
adverse effects in 23% of cases. Most
were mild and transient and were only because of
discontinuation of therapy in 9% of patients.
Of this population representative of all cases
processed and analyzed retrospectively, was selected
a subset of patients for research
prospectively. Thirty-five patients with good response
cyproterone acetate and prolonged therapy
included in this study were monitored during
two years. Of these, 24 had received five
or more years, 9 for more than 10 years, and 2 for
over 15 years. The treatment consisted of five
different regimes with varying doses of acetate
cyproterone combined with ethinyl estradiol, and acetate
cyproterone alone. Biochemical parameters were determined,
Metabolic and endocrine at the beginning and
3, No. 7. October 2000
472
end of the study. Hematological and biochemical data
were within normal limits. There was a
mild decrease in glucose tolerance and a moderate
increased insulin and C-peptide after
of oral glucose. The effects of acetate
cyproterone and ethinyl estradiol on the metabolism
lipid were mild, and apparently dependent
dose and regimen. Not Found
suppression of adrenal function or the relationship
with ACTH. Prolactin levels in
and fasting serum concentrations of prolactin,
after challenge with metoclopramide, not
showed large deviations. Scans of
breast and liver were normal, except for existence
of adenofibrosis or mastopathy in 2 patients. The
Side effects most often mentioned were
breast tenderness, decreased libido and headache.
Spironolactone: Its indication is the FAGA
recognized by the Ministry of Health and Consumption.
It is an aldosterone antagonist that behaves
as a competitive inhibitor of the binding of androgens
their receptors. It has demonstrated its effectiveness
in hirsutism, but no reliable data on
the FAGA (14). Camacho prefers acetate
cyproterone, when there is impaired adrenal
(15). The dose ranges from 50 to 200 mg / day as tolerated,
for at least six months. It can cause
hyperkaliemia, breast tenderness, menstrual disorders
and other side effects such as urticaria, vasculitis,
lichenoid eruptions and eczema.
Flutamide: Its indication in FAGA not recognized
by the Ministry of Health and Consumption. Decreases
serum levels of dehydroepiandrosterone
sulfate. It has demonstrated its effectiveness in hirsutism,
but there are no reliable data regarding the FAGA
(16). The dose ranges from 125 to 375 mg / day for 9
to 12 months, as tolerated. Produces hepatotoxicity
which can lead to the death in 1% of patients
by an unknown mechanism.
58,841 UK: An androgen receptor antagonist
topical, that has not yet been marketed.
Effectiveness studies in the macaque
with androgenetic alopecia showed promising results
(17).
Estrogens
The role of estrogens in growth
human hair is unclear (18). It is known that
systemically, increase the numbers of the globulin
sex hormone-binding, thereby
decrease in free testosterone, and therefore less
impact of this on the pilosebaceous follicle.
Although estrogen therapy has been used as
the FAGA, both orally and topically,
there are few clinical trials to determine in
precisely its potential effectiveness. One of them (19) double
blind placebo, treated 51 women with FAGA
with local application of a lotion containing
17 alpha-estradiol at 0.025% for a minimum
6 months. The percentage of hairs in telogen
was reduced by 63% in patients treated
compared to 37% in placebo patients. Equally
worsened by 50% of them, compared to 11%
of patients with treatment. In no case dropped
seborrhea or new hair appeared.
For general way, are used to supplement
other treatments, combined with non-androgenic progestins,
and that to achieve therapeutic efficacy
alone need huge doses that increase
the risk of side effects.
Surgical
Hair Transplant: Although the model is FAGA
clinically diffuse and therefore not very suitable for the
transplantation, there are some cases with male pattern
that can be treated like men, with
transplant surgery (20). Of course, proper
patient selection is the basis for therapeutic success.
Care and hygiene Cosmetics
Fortunately, there is no restriction on the
Time camouflage hair problem: frequent washing,
dies, molds, lacquer, hair gel, mousse,
hairpieces or hair can be used with discretion,
without adversely affecting the evolution of the
alopecia.
_Conclusión
Androgenetic alopecia is the most common
of alopecia in humans, both men and
women. While the peculiarities of the pathogenesis
FAGA in the women and their hormonal status
hinder their treatment, one can achieve a high
how effectively a combination of different therapies:
stimulators of hair follicle growth
(minoxidil), antiandrogens (cyproterone acetate) and
cosmetic resources. All these treatments must
be continued for at least one year to assess
the overall response, although improvement can begin
at 4 or 6 months. It is essential to explain the
effects and limitations of treatment for better
the patient's mental adjustment to the problem you have.
The psychological care to avoid a major
impact on quality of life, should be taken very
into account.

1. Girman CJ, et al. Patient-perceived importance
of negative effects of alopecia
androgenetic in women. J Womens Healt
Gend Based Med 1999; 8 :1091-1095.
2. Tosti A, Camacho F, Dawber R. Management
of androgenetic alopecia. J
Eur Acad Dermatol Venereol
1999;12:205-214.
3. Price VH. Treatment of hair loss. N
Engl J Med 1999;341:964-973.
4. Grimalt R, Ferrando J, Grimalt F. Trichodynia.
Dermatology 1988;196:374.
5. Price VH, Menefee E. Quantitarive
estimation of hair growth. I. Androgenetic
alopecia in women: effect of minoxidil.
J Invest Dermatol 1990;95:
683-687.
6. Rittmaster RS. Finasteride. N Engl J
Med 1994;330:120-125.
7. Roberts J, Hordinsky MK, Olsen EA
et al. The effects of finasteride on
post-menopausal womwn with androgenetic
alopecia. In: Programme and
abstracts of the Hair Workshop. Brullels,
Belgium, May 2-3 1998;16-7.
8. Lucky, A W. Hormonal correlates of
acne and hirsutism. Am J Med 1995;
16(98):89S-94S
9. Guerra Tapia A. La androgenización y
su tratamiento. El acetato de ciproterona
30 años después. Piel 1999; 14:532-538.
10. Beylot C, Doutre MS, Beylot-Barry
M. Oral contraceptives and cyproterone
acetate in female treatment. Dermatology
1998;196(1):148-152.
11. Peereboom-Wynia JD, van der
Willigen AH, van Joost T, Stolz E. The
effect of cyproterone acetate on hair
roots and hair shaft diameter in androgenetic
alopecia in females. Acta
Derm Venereol 1989;69:395-398.
12. Van Hooff MH, Hirasing MB,
Koppenaal C, Voorhorst FJ, Schoemaker
J. The use of oral contraceptives
by adolescents for contraception,
menstrual cycle problems or acne.
Acta Obstet Gynecol Scand 1998;
77(9):898-904.
13. Van Wayjen RG, Van der Ende A.
Experience in the long-term treatment
of patiens with hirsutism and /or acne
with cyproterone acetat-containing
preparations: efficacy, metabolic and
endocrine effets. Exp Clin Endocrinol
Diabetes 1995; 103(4):241-251.
14. Lobo RA, Shoupe D, Serafini P,
Brinton D, Horton R. The effects of
two doses of spironolactone on serum
androgens and anagen hair in
hirsute women. Fertil Steril 1985;
43:200-205.
15. Camacho FM. Alopecias e hirsutismo.
Etiología, diagnóstico y tratamiento.
Medicine 1999;7(136):6413-
6424.
16. Camacho FM y Montagna W. Tricología.
Ed. Grupo Aula Médica SA. Madrid
1996:372.
17. Uno H, Obana N, Cappas A, et
al. Stimulation of follicular regrowth
by androgen receptor blocker
(Ru58841) in macaque androgenetic
alopecia. In: Randall VA, VanNeste
DJJ, eds. Hair research for the nest
Millenium. Amsterdam: Esevier
1996;349-353.
18. Saphiro J, Price V. Hair Regrowth.
Therapeutic agents. Dermatol Clin
1998;16:341-356.
19. Orfanos CE, Vogels L. Local therapy
of androgenetic alopecia with
17 alpha-estradiol. A controlled, randomized
double-blind study. Dermatologica
1980;161:124-132.
20. Avram MR. Hair transplantation in
women. Semin Cutan Med Surg