Miniaturization: The Clue to the Early Diagnosis of Androgenetic Alopecia

One of the most common causes of hair thinning is androgenetic alopecia.  Men with androgenetic alopecia may notice hair loss at the top of the scalp as well progressive receding in the temples. Women with androgenetic alopecia notice thinning in the middle of the scalp.  The central hair part may become wider over time.  As hair thinning occurs the scalp becomes progressively more visible.   

I treat androgenetic alopecia with either 1) topical medications such minoxidil, 2) oral hormone blocking medications or 3) with hair transplantation. For some patients, I may recommend all three treatments. I encourage patients to consider using medical treatments in the early stages in order help maintain or improve the present hair density and prevent further loss over time.

Patients considering treatment for the very early stages of androgenetic alopecia often ask how I can absolutely sure they have androgenetic alopecia. Some of the doctors I teach ask the same question. How do you tell androgenetic alopecia is present if the patient does not actually have hair loss yet?What are the clues to the early diagnosis of androgenetic alopecia?

Androgenetic alopecia can be diagnosed based on the pattern of hair loss and by observing a process known as hair follicle “miniaturization.” When I lecture about androgenetic alopecia, I refer to miniaturization as the process by which hair follicles get skinnier over time.   It takes time for doctors to learn to identify hair follicle miniaturization, but I teach the following analogy to help others master this skill. 

Pretend that hair follicles are like tree trunks in the forest.  This analogy is kept in mind as the scalp is examined. If the size of the tree trunks is all the same – the patient does not have androgenetic alopecia.  If some of the tree trunks are fat and some of the tree trunks are skinny, the phenomenon of miniaturization is being observed. This is shown in the picture above. The most likely cause, by far, is androgenetic alopecia.

There are rarely other conditions that can be associated with miniaturized hairs besides androgenetic alopecia.  But this analogy is extremely important.  Many patients with concerns about hair loss end up receiving a diagnosis of androgenetic alopecia.  If there is no miniaturization, the diagnosis is wrong, and there is another reason for hair loss.