Spironolactone for Hair Loss: Can it be prescribed for patients with prior breast cancer?

Is Spironolactone Safe to Use in Patients with a Prior Diagnosis of Breast Cancer? Does it affect the chance of Cancer Recurrence ?

A new study examined whether the anti androgen pill spironolactone is safe to use if someone had a previous diagnosis of breast cancer.

About three studies to date have suggested that spironolactone does not increase the risk of breast cancer. However studies to date have not examined if using spironolactone once a patient is diagnosed with breast cancer confers any increased risk.

Estrogen levels are slightly increased in about one quarter of breast cancer patients using spironolactone which raised the question whether use of this medication might have other effects - such as increase the risk of breast cancer coming back in a patient who was previously diagnosed and treated for breast cancer. Breast cancer coming back is known as a recurrence and can be local recurrence (breast cancer coming back in the breast), regional recurrence (breast cancer coming back in the lymph nodes) or distant recurrence (breast cancer coming back in another part of the body such as the bone).

Preliminary Study Suggests Good Safety in First 2 Years

A new study by Wei and colleagues examined whether spironolactone increases the risk of recurrence within 2 years after a diagnosis of breast cancer. 746 breast cancer patients who had been prescribed spironolactone were matched to 746 breast cancer patients in a large database who had never used spironolactone

Breast cancer recurrence occurred in 16.5% of those who received spironolactone compared with 15.8% of those who did not receive spironolactone; the difference was deemed not statistically significant. The authors concluded that spironolactone was an option for treating hair loss in patients with breast cancer.

This study is valuable as it provides a start to understanding the use of these medications in women with breast cancer. I was surprised to see such a high rate of recurrence in this study (15 % at year 2). Most studies in the breast cancer literature do not have such high rates of recurrence by year 2. For example, stage 1 breast cancer is the most common type of breast cancer and only a very small proportion of women have recurrences by year 2 (well under 5 %).

More Studies Needed To Evaluate Safety in Years 2-20

More studies are needed especially longer studies that take us to five years (and beyond). Although recurrence risk is highest at 2 years (which was the cut off the authors of this study chose) well over 50 % of patients who are going to actually have a recurrence will have their recurrence beyond year two. For example, in some studies the median time is about 3 years meaning that one half of patients who are going to have a recurrence will have a recurrence after year 3 and one half will have a recurrence before year 3. We know the risk of recurrence is greatest in the first two years but most women are carefully followed for five years to evaluate for early recurrence. Five years is traditionally used in oncology as the benchmark not two years. 

The chance of recurrence between years 2 and 5 is not insignificant and 20 % of recurrences occur between year 5 and 20. So longer term studies are absolutely needed. In addition, factors such as size of the tumor, pathology of the cancer, and the presence or absence of lymph node involvement all affect recurrence risk. Therefore detailed studies of high risk vs low risk patients is needed. We know that women with younger age, advanced stages, negative hormone receptor status, and poorly differentiated tumor cells experienced the greatest hazard for recurrence. Hopefully, larger and longer term studies will build on the important initial observations by these authors.

Reference

Wei C, et al. Published online May 21, 2020. J Am Acad Dermatol.

Bicalutamide for Female Pattern Hair Loss: Should we add it to the list of anti androgens ?

Bicalutamide (Casodex) is pure anti-androgen with Potential Benefit in Treating Female Androgenetic Alopecia

Bicalutamide is a non-steroidal pure anti androgen that was FDA approved for treating prostate cancer at a dose of 50 mg daily back in 1995. Recent studies have investigated its use in treating female androgenetic alopecia.

STUDY 1: Ismail and colleagues, 2020

Dr. Rodney Sinclair’s group from Australia (Ismail and colleagues, 2020) performed a retrospective review of 316 women treated with bicalutamide. The standard starting dose was 10 mg daily although starting doses ranged from 5 mg to 50 mg in the study. The average age of patients was 49 years with a range of 15-85 years. In the study bicalutamide was usually prescribed together with some other medication including oral minoxidil in 308 patients and spironolactone in 172 patients. Six patients received bicalutamide alone (i.e. monotherapy). The most common adverse effect was mild elevation of liver transaminases in 9 (2.85%) patients. This elevation was mild in all cases (less than twice the upper limit of normal) and asymptomatic in all cases as well.. Furthermore, the liver enzyme elevation resolved without needing to adjust the dose in 4 out of 9 patients. In 2 patients, the transaminitis resolved with further dose reduction. Other side effects bicalutamide in the study included peripheral edema in 2.5 % of patients and gastrointestinal complaints in 1.9 %. Use of bicalutamide provided benefit in the treatment of AGA in women.

STUDY 2: Fernandez-Nieto and colleagues, 2020

Dr. Sergio Vano Galvan’s group from Spain (Fernandez-Nieto et al. 2020) recently published their data of 44 women receiving bicalutamide at doses of 25-50 mg daily. The ages of patients in this study were 20-59 with an average age of 34.8 years. The authors chose higher doses than Sinclair’s group for the simple reason that higher doses of bicalutamide are already commonly used in treating hirsutism. Side effects in this particular study included transient elevation in liver enzymes with 5 of 44 (11.4%) patients having a mild increase liver enzymes - all of which self resolved without a need to stop the drug. In addition to elevated liver enzymes, other reported side effects including were shedding, amenorrhea, headaches and endometrial hyperplasia. None of the patients needed to stop treatment. Similar to the Ismail et al study mentioned above, use of bicalutamide in this study also provided benefit in the treatment of AGA in women.

COMMENTS

These are interesting studies and I suspect we’ll be hearing a lot more about bicalutamide in the years to come. I’ve been using it for a few years now and was encouraged to see some good data here with regard to side effect profile and generally good safety. Bicalutamide has fewer side effects than flutamide, another non stereoidal anti androgen (NSAA) and in general the side effects profile is acceptable when compared to the 2 other commonly used antiandrogens we use for treating androgenetic alopecia - spironolactone and finasteride. Further studies are needed to understand how bicalutamide compares to finasteride and spironolactone and what of side effects we might need to counsel our female patients.

Reference

Ismail et al. Safety of oral bicalutamide in female pattern hair loss: a retrospective review of 316 patients. Journal of the American Academy of Dermatology. Available online 19 April 2020

Fernadez-Nieto Et al. BICALUTAMIDE: A POTENTIAL NEW ORAL ANTIANDROGENIC DRUG FOR FEMALE PATTERN HAIR LOSS.J Am Acad Dermatol. 2020 Apr 19:S0190-9622(20)30667-8. doi: 10.1016/j.jaad.2020.04.054. Online ahead of print.

Zinc Supplements: The Potential to Lower Iron (Ferritin) Levels Must Not Be Forgotten

Zinc supplements lower serum ferritin in some patients

Patients who use zinc supplements need to be aware of the delicate balance that exists between how the body absorbs iron and zinc. Long term use of zinc supplements without measuring zinc and iron and copper levels is not advisable. This is because chronic zinc consumption has the potential to lower iron and copper levels.  Zinc and iron complete with each other for intestinal absorption. In addition, increased zinc absorption has the potential to lead to increased exertion of copper. The net result is that chronic zinc use has the potential to lead to both low iron levels and low copper levels. 

In 2002, Carmen Donangelo and colleagues published a nice study in the Journal of Nutrition. The authors studied the effect of 6 weeks of zinc supplementation compared to 6 weeks of iron supplementation in young women with low ferritin levels (less than 20). The women were divided in two groups - 11 took zinc supplements and 12 took iron supplements.  In the iron-supplemented group, blood hemoglobin, plasma ferritin and the percentage of transferrin saturation increased but zinc indices did not change. In the zinc-supplemented group, plasma ferritin and the percentage of transferrin saturation decreased, whereas the plasma transferrin receptor and erythrocyte zinc protoprophyrin levels increased.  The authors concluded that the use of iron supplements in women with low ferritin levels improves iron indices with no effect on zinc status but that the use of zinc supplement improves zinc indices, but has the potential to reduce worsen iron deficiency.

This was a very nice study and serves as a helpful reminder that supplements should always be used in a rationale manner. If zinc supplements are going to be used in an ongoing manner, one should consider periodically measuring zinc, iron (and copper) levels. 

Reference

Donangelo C et al. Supplemental Zinc Lowers Measures of Iron Status in Young Women with Low Iron Reserves. The Journal of Nutrition, Volume 132, Issue 7, July 2002, Pages 1860–1864. 

Hair loss in the Frontal Hairline.

Cause of Frontal Hairline Loss

I enjoyed giving a lecture yesterday to our brilliant University of British Columbia dermatology resident physicians. We discussed the common and uncommon scarring and non-scarring hair loss conditions that affect the frontal hairline of males and females.

Managing Hair Loss During and After Pregnancy: Facts vs False Reassurance

Hair Loss During and After Pregnancy

Individuals with hair loss often ask what steps they should be taking to best help their hair during pregnancy and what steps they should take after delivery.

I have written on certain aspects of this topic before. Please consider reviewing my past articles on Hair Loss, Pregnancy & Breastfeeding:

July 23, 2019 - Stopping Medications in Pregnancy

May 6, 2018 - Pregnancy and Female Pattern Hair Loss

Mar 1, 2017 The Safety of Hair Loss medications in Pregnancy

May 19, 2012 - Which medications are safe during breastfeeding?

For many women who ask this question and are currently pregnant, I often say that there are two ways to help the hair while pregnant. The first is make sure that the individuals does not truly have any deficiencies by getting some basic blood tests if the individual or her doctor are worried about some type of deficiency. The second way to potentially help the hair is to consider reviewing the benefits of low level laser therapy (LLLT). Besides correcting a vitamin deficiency, administration of low level laser treatments is really the only treatment that can be safely used during pregnancy.

For women who were using minoxidil before pregnancy but needed to stop during the pregnancy, I strongly encourage them to see an expert to determine when minoxidil might best be restarted after delivery. Both the American Academy of Pediatrics and the American Academy of Dermatology have stated that Rogaine is reasonably safe for breastfeeding women (yes, despite the fact that all warning labels say otherwise). I can’t emphasize enough the importance of speaking to the dermatologist about this. in my opinion, we need to let years and years of medical research and years of observation help guide how we make tough decisions not simply outdated warning labels that protect companies from legal ramifications. These decisions are of course taken on a case by case basis.

False resurgence has no place in the management of any type of hair loss - and this is particularly true in managing hair loss around the time of pregnancy. It would be wonderful if I could reassure women that hair always grows back “fully” after delivery (i.e. to the same density as before pregnancy) - but this is not accurate. For most women who shed hair post partum, the shedding eventually slows down around month 6-9 post partum and shedding returns to normal and hair regrowth happens. However, hair density does not always grow back as full as it was before pregnancy if a woman has the genes for genetic hair loss instructing the hairs what to do.  For many women it does - but not all. This is far more than my professional medical opinion - it’s fact. For this reason, I encourage patients to have a solid treatment plan in place.

False reassurance that hair “always” grows back and not to worry leaves many women confused and disappointed. I sometimes advise a conservative approach and sometimes an aggressive approach to treatment after delivery. It all depends on the stage of the patient’s androgenetic alopecia, her current age and health and her family history of hair loss and other conditions. We don’t yet have tests available to set the known genes for genetic hair loss - so this is not part of the evaluation. The decision on what to use during pregnancy is easy as only laser is safe (and supplementing any deficiencies that are uncovered in the blood tests).  

Lecture on Hair Loss

55th Annual Post Graduate Review in Family Medicine

I was invited to speak this morning at the 55th Annual Post Graduate Review in Family Medicine at the Vancouver Marriott Pinnacle Downtown Hotel in Vancouver, BC. I spoke on “An Approach to Hair Loss in Women.”

What Combination Locks Teach us About Managing Hair Loss

Getting all the Numbers Right Opens the Lock

There are many ways people can physically lock up their personal belongings. Key locks and combination locks are popular ways of securing one’s belongings. With a key lock, one simply needs to have the right key and the lock can be unlocked. With a combination lock, one needs the right digits and enter them in the right order.

Combination Locks and Hair Loss

Combination locks remind me a lot about how we treat hair loss. Nobody ever expects to be able to open a three digit combination lock if only remember 1 or 2 of the required combination numbers can be remembered. Unless they can all be entered, the lock is simply not going to open.

Every day, I see patients with hair loss who tell me they their treatments just aren’t working. For example, they might have lichen planopilaris and tell me their topical steroids aren’t working. They might have androgenetic alopecia and tell me their minoxidil is not working. They might have alopecia areata and tell me their steroid injections aren’t working. In many cases, the patient is absolutely right - the current treatments just aren’t the right treatments and we need to change them. Sometimes, however, the treatments are actually just fine, it’s just we have not addressed the other hair loss conditions that are present. The patient and his or her physician was expecting success but several other hair loss conditions are present and have not been addressed. We can’t successfully open the lock unless we enter all the numbers and we can’t successfully treat hair loss unless all the conditions that are present are treated.

Consider the 46 year old female patient with lichen planopilaris who is using topical steroids (clobetasol). She feels the hair shedding is a bit better but she’s still losing hair and it’s still quite itchy. What I soon realize is that the patient also has seborrheic dermatitis and has low vitamin D, and low zinc. I also suspect an allergic contact dermatitis from a shampoo ingredient. After examining the patient, I recommended that she continue the topical steroids, supplement with oral vitamin D and oral zinc, add a low allergen anti dandruff shampoo (such as Free and Clear Antidandruff) and avoid her regular shampoo until patch testing is arranged by a dermatologist. Within a few weeks the patient finds her scalp feels better and looks better and hair shedding is reduced further. She’s glad she does not need stronger immunosuppressants for her particular case… and so am I.

Conclusion

With many hair loss treatments, we often expect the treatments to work. But too often we forget to ask ourselves if any other conditions are present. Many patients are surprised to leave the office with 2, 3 or 4 hair and scalp diagnoses but they should not be really too surprised. We can’t open a four number combination lock by entering just 1 number. Similarly, we can’t successfully and completely treat a scalp disorder whereby four conditions are contributing if we are just trying to deal with only one of the conditions.

Serum Magnesium Levels in Women with Diffuse Hair Loss

Should we be checking blood levels of magnesium ?

There are many causes of hair shedding or telogen effluvium. Common causes include intense stress, thyroid problems, crash diets with sudden weight loss, and medications. However, a wide variety of other ‘triggers’ have the potential to cause hair loss. Deficiencies in various minerals are also potential causes of telogen effluvium. Deficiencies in zinc, iron, magnesium, selenium, for example, all have the potential to trigger hair loss.

A 2004 study reminded us that testing for magnesium deficiency (“or hypomagnesemia”) may be reasonable in women presenting with concerns about diffuse hair loss and diffuse hair shedding. The normal adult value for magnesium is 1.6-2.5 mEq/L and hypomagnesemia is generally defined as a level of serum magnesium under 1.6  mEq/L or 1.5 mEq/L.

Tataru and Nicoara studied three groups of women age 16 to 40. Group A was made up of 26 women with diffuse hair loss for which the cause was unknown. Group B consisted of 14 women with diffuse hair loss for which the cause was known (seborrhoea, hormonal issues, thyroid disease). Group C consisted of 24 women without hair loss.

The authors found in the first group (group A), there were 12 cases (46.1%) with hypomagnesemia and the average magnesium level was 1.80 mEq/L. In the second group (group B), there were 3 cases (21.4%) and the average magnesium level was 1.99 mEq/L. Finally, in the control group (group C) the authors found 2 cases (8.3%) hypomagnesemia and the average level was 2.23 mEq/L These data suggested that low magnesium levels were indeed more likely to be found in women with diffuse shedding.

Check serum magnesium levels may be important to consider for some women with diffuse hair loss according to a 2004 study. Supplementation with magnesium may help some women with diffuse hair loss if levels are found to be low.

Magnesium supplementation may reduce hair shedding in some women

In the second part of the study, the authors evaluated the effect of providing magnesium supplementation to women in Group A and Group B. The dose was equivalent to 96 mg  (8 mEq or 4 mmol) daily for 2 months. The authors observed a noticeable decrease of hair loss in 69.1% of the patients from group A (18 from 24 cases) in comparison with 35.7% (5 from 14 cases) in the group B.

Conclusion

This study was among the first large scale studies to document the incidence of low magnesium in women with diffuse hair loss and to show that women with diffuse loss are more likely to have low magnesium levels than women without diffuse loss. Moreover, these studies showed that supplementation magnesium may help some women reduce hair loss and shedding.

Finding the precise cause of hair loss in women with diffuse loss and hair shedding can be challenging. Ordering every single blood test is not practical and not cost effective. Sometimes the medical history can guide us, but not always.

Supplementing with magnesium is reasonable if blood tests prove that there is low magnesium. Supplements with 100-250 mg of elemental magnesium are quite reasonable for 2-3 months but I often start with every other day for 2 weeks to ensure that the patient does not experience diarrhea. Supplements with higher levels of magnesium are not typically recommended. After 3 months, I typically reduce the dose quite significant and recheck levels. Depending on the patient, the old magnesium levels, the new magnesium levels at the end of month 3 and the original suspected reason for the low magnesium, I might either continue at low doses or stop the magnesium altogether.

I have always found this to be an interesting study. I have not found a high proportion of women with hair shedding to have magnesium deficiency but am always on the look out.

Women with high intake of vitamin D may have low magnesium levels as well as other medication users. Low magnesium can give symptoms of muscle pain, fatigue, high blood pressure, irregular heart beats, osteoporosis and mood disorders so certainly we need to be particularly thinking about the possibility of low magnesium levels when this issues are present.

Im general, basic tests for women with hair shedding include:

CBC, TSH, ferritin, 25 hydroxy vitamin D, DHEAS testosterone, AM cortisol, ESR

zinc, magnesium, ANA, creatinine, AST, AST.

Consideration can given to ordering a variety of other tests depending on the exact patient history including syphilis screening, HIV, selenium, mercury and others.

Reference

A Tataru and E Nicoara. Idiopathic diffuse alopecias in young women correlated with hypomagnesemia. J Eur Acad Dermatol Venereol. 2004 May;18(3):393-4.

Hair Loss in Women: Irregular periods = Blood tests

Irregular periods = Blood tests

When speaking with patients about their hair loss, there are many pieces of information that a patient may share that should trigger the clinician to look deeper into the particular issue.

Irregular menstrual cycles in women are one such example especially when they occur in females age 16 to 43. Of course, there are many reasons for irregular periods and some of these reasons may have nothing to do with hair loss.

However, a variety of medical issues associated with hair loss may cause irregular periods. These include polycystic ovarian syndrome, congenital adrenal hyperplasia, hyperprolactinemia, Cushings, adrenal and ovarian tumors and cysts, stress, excessive dieting, thyroid disease.

The evaluation of women with irregular periods is best done on a case by case basis after review of all the facts. Blood tests shown here are frequently helpful especially in the third to fifth day of the menstrual cycle and especially in the morning. Patients with abnormalities may sometimes undergo further testing or referral, depending on the suspected cause.

Biotin Deficiency in Pregnancy

Biotin Deficiency in Pregnancy

Most people are not deficient in biotin. However, that said, biotin deficiency is difficult to measure. Deficiencies known to exist in a variety of situations including pregnancy, inflammatory bowel disease, Advanced age, oral antibiotics, alcoholism and certain medications (like isotretinoin, valproic acid and carbamazepine). Unlike many blood tests for testing “deficiencies”, there is no simple “biotin” blood test.

One way to determine if someone is biotin deficient or not is to evaluate for increased urinary excretion of 3-hydroxyisovaleric acid (3HIA), which likely reflects decreased activity of the biotin-dependent enzyme beta-methylcrotonyl-CoA carboxylase. A second way is to search for decreased activity of the biotin-dependent enzyme propionyl-CoA carboxylase (PCC) in peripheral blood lymphocytes.

A 2009 study by Mock and colleagues provided evidence that biotin deficiency may actually be quite common during pregnancy. In their pilot study, activity of PCC in peripheral blood lymphocytes (as a measure of biotin deficiency) was decreased in 18 of 22 (81%) pregnant women.

These studies are interesting. While they draw attention to the issue of biotin deficiency in pregnancy, it also draws attention to whether such deficiency impacts the hair during or after pregnancy. This is not known at present but deserves further study. Biotin deficiency may be more common during pregnancy than most realize.
 

Reference

Marginal biotin deficiency is common in normal human pregnancy and is highly teratogenic in mice. Mock DM. J Nutr. 2009.

Preparing for Pregnancy: Considerations for Women with Androgenetic Alopecia

Planning a Pregnancy with Female Pattern Hair Loss

Many women with genetic hair loss are worried about getting pregnant and how the pregnancy and delivery will affect their hair. It's an area that really isn't talked about very much. Some women feel it's difficult to talk opening with their partner or family about their hair when all the focus is on the pregnancy, the baby and the new or expanding family.  But these issues are important and issues that I help patients with on frequent basis. 

 

Preparing for the Pregnancy

For women who are planning when to become pregnant, there are a number of considerations that are related to the hair. I encourage all patients with hair loss who are considering pregnancy to have a good discussion with the dermatologist and of course the physician caring for the pregnancy as well.  

Most of the time, hair improves in pregnancy.  However, some women do experience hair loss during the pregnancy. A significant proportion of women experience some degree of hair shedding after delivery. Hair regrowth occurs 6-7 months later but may or may not return to pre-pregnancy densities.  

1. Deciding to Stop Medications

Many of the medication used for treating female pattern hair loss (androgenetic alopecia) can't be used during pregnancy. This includes minoxidil, Rogaine, platelet rich plasma, anti-androgens. The only treatment that can be used are vitamins and low level laser therapies. 

Minoxidil should ideally be stopped two weeks before the time that a women decides to start trying. However, there are many women world-wide who become pregnant while using minoxidil and simply stop minoxidil once they miss their period. There is no evidence that this method has any harm for the pregnancy or the baby.  However, minoxidil must not be used during the pregnancy and anytime after the first period is missed. Many physicians will strictly recommend that their patients stop minoxidil if they are trying to conceive. However, there is no good evidence to support this recommendation. 

Anti androgens, however, need to be stopped several months before the pregnancy. The most common anti-androgen used in women of child bearing age is Spironolactone (Aldactone) and this must be stopped ideally 2 months before any planned pregnancy. Spironolactone can not be used during pregnancy as it could cause harm to a developing baby. Other anti-androgens, including saw palmetto, and finasteride need to be stopped long before as well. Dutasteride is not typically be used in women of child bearing ages. However due to it's very long half life, any woman who is using dutasteride and considering pregnancy should speak to their physician and dermatologist about how long they need to be off the medication before trying to get pregnant. 

 

2. Blood tests

For some women, pregnancy can lead to changes in the levels of many key mineral and vitamins relevant to hair growth. Blood tests can help identify these deficiencies. Deficiencies of vitamin D and iron are among the most common during pregnancy and levels may need to be followed during the pregnancy. Other deficiencies are less common but can include biotin and zinc. If there are concerns about thyroid stratus or diabetes these will also need to be monitored.

3. Supplements

All women considering pregnancy should speak to their physicians about appropriate supplements. These will generally include appropriate folic acid. However, other supplements may be very relevant depending on the patient's history. As mentioned above, these may include vitamin D, iron, biotin and zinc.

4. Scalp Inflammation

I am a strong believer that scalp inflammation needs to be addressed at any time during the course of hair loss. This is also true during pregnancy. Prolonged scalp inflammation from various sources has the potential to accelerate androgenetic alopecia (AGA). Inflammation can come from many potential sources including seborrheic dermatitis, psoriasis and various eczemas. 

We don't have much information on the safety of anti-dandruff shampoos in pregnancy. The data would suggest that periodic use of zinc pyrithione and ciclospirox have reasonable safety and these are frequently my top choices for many of my own patients.  If dandruff (or seborrheic dermatitis) is troublesome, I generally advise use once every 2 weeks and to be left on the scalp for 60 seconds before rinsing off. Small amounts of betamethasone valerate scalp lotion can be used once weekly if itching persists.  

Ketoconazole shampoos don't have much in the way of data. Patients interested in using should check with their OB or the physician caring for the pregnancy. There is no good data to really suggest a problem with periodic use of topical shampoos containing ketoconazole. It's not the top choice for my practice as they have the potential to affect testosterone synthesis.  Oral ketoconaole is certainly not advised. It increased the risk of cardiovascular, skeletal, craniofacial and neurological problems in many studies.  I don't recommend coal tar shampoos during pregnancy. Animal studies show that high doses are associated with perinatal mortality, cleft palate, small lungs and other developmental issues. I avoid them in my practice. 

Conclusion

Patients with androgenetic alopecia (female pattern hair loss) who are considering pregnancy should review their general health and scalp heath with their physicians. Blood tests may be recommended and periodic monitoring of the scalp may be appropriate during the pregnancy.

 

Children of Women with Polycystic Ovarian Syndrome:

What is the latest research ?

Polycystic ovarian syndrome (PCOS) is a hormonal disorder in women. It is not one condition but a constellation of symptoms. Patients with PCOS typically have evidence of hyperandrogegism (excess male type hormones and irregular periods. Women with PCOS typically have cysts present in the ovaries but some do not.  The exact cause of PCOS remains unknown although a genetic component is likely for many women. The ovaries of women with PCOS are known to secrete higher levels of male hormones which contributes to irregular periods and infertility. Women with PCOS may seek medical attention for a variety of reasons including insulin resistance, diabetes, high blood pressure, acne, increased hair growth on the face, irregular periods, infertility.  Women with PCOS may also present to a hair clinic with concerns about androgenetic alopecia. It is therefore extremely important that hair specialists understand this condition. 

New Research on Children born to Mothers with PCOS

A great deal of research is currently being conducted into the cause of PCOS and how it affects women. Research is also being conducted into the health of babies born to mothers with PCOS. Research has suggested that the hormonal changes in utero influence the development of the fetus. 

One issue that has been studied is the risk of attention-deficit/hyperactivity disorder (ADHD) in babies born to mothers with PCOS. ADHD is the most common childhood neurodevelopment disorder. Male hormones may play a role as boys are two to three times more likely to develop ADHD.

A study by Berni and colleagues of over 16,000 women showed that women with PCOS have a slight risk of giving birth to children with attention deficity hyperactivity disorder (ADHD) and Asperger syndrome. 

Kosidou and colleagues performed a matched case-control study using health and population data registers for all children born in Sweden from 1984 to 2008.  In their study, a total of 58,912 ADHD cases (68.8% male) were identified and matched to 499,998 unaffected controls by sex and birth month and year. The results indicated that Maternal PCOS increased the odds of offspring ADHD by 42% after adjustment for confounders (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.26-1.58). The risk for ADHD was even higher among obese mothers with PCOS and was highest among obese mothers with PCOS and other features of metabolic syndrome.

Conclusion

Recent research suggests that differences in maternal hormones during pregnancy in women with PCOS affect the chances of having children with ADHD and possible other neurodevelopmental issues. Overall the risk is low. 

REFERENCES

Berni TR, et al. Polycystic ovary syndrome is associated with adverse mental health and neurodevelopmental outcomes. J Clin Endocrinol Metab. 2018.

Kosidou K, et al. Maternal Polycystic Ovary Syndrome and Risk for Attention-Deficit/Hyperactivity Disorder in the Offspring.  Biol Psychiatry. 2017.

Finasteride Use in Women: Yes or No?

Finasteride & Women

Finasteride is FDA and Health Canada approved for men with hair loss. Although it's not formally FDA approved for use in women, the medication has been prescribed to women with androgenetic alopecia for nearly two decades.  When a physician prescribes finasteride for androgenetic alopecia in women, they are said to be using these medications in an 'off label' manner.  The following is the key point about using finasterde for women : it's only prescribed on a case by case basis. 

Polar Views on Finasteride Use

The public needs to understand there are many views among physicians  on finasteride. There are some physicians that will never prescribe this medication to women -  period.  There are some physicians who will prescribe it only to post-menopausal women. There are some who will prescribe to some pre-menopausal and some post-menopausal women - but only on a case by case basis - and only with full counselling of risks and benefits.   

Much of the concern around use of finasteride in pre-menopausal women stems from the significant harm that would come to any fetus that was born to to a mother who used finasteride during pregnancy. These risks and real - and serious. Finasteride is given the highest category of risk during pregnancy - so called "category X." Women who are pregnant or who could become pregnant must never use finasteride.

The other concern that some physicians have pertains to cancer risk. To date, we actually don't have any good evidence to suggest that finasteride increases a woman's risk of cancer. In fact, reasonably well conducted studies in men would suggest that breast cancer risk is not increased. Good studies have not been done in women. However, women with strong histories of estrogen dependent cancers (breast, ovarian, gynaecological cancers) should also review use of finasteride with their doctors.  In some cases, use may not be appropriate.  I'll discuss other side effects below. 

 

Does Finasteride Help Genetic Hair Loss in Women?

So does it help women with genetic hair loss? Studies from nearly two decades ago said no. A study by Dr vera Price and colleagues in 2000 suggested a 1 mg dose in post menopausal women did not help androgenetic alopecia.  But just 2 years later, in 2002, Shum and colleagues presented 4 women (2 pre and 2 post menopausal) who did respond to a higher dose of finasteride - this time 2.5 mg finasteride. All 4 women had hyperandrogenism (one or more of elevated hormones, hair on the face, infertility issues). This refueled interest in the role of finasteride for women. 

In 2006, Dr Iorizzo and colleagues from Bologna, Italy published a study which further renewed interest in the use of finasteride for the treatment of female pattern hair loss. Iorizzo and colleagues looked at the benefit of finasteride at a dose of 2.5 mg in 37 women diagnosed with female pattern hair loss. All women in the study were also using a birth control pill to prevent pregnancy.  After 12 months of follow up, 62 % of women using finasteride had an improvement in hair density. 13 patients (30 %) hair loss had stabilized -   it did not get worse but  did not improve. Only 1 of 37 patients experienced a worsening of their hair density.
 

What are the side effects of finasteride in women?

I'm often asked about the range of side effects that are possible for women who use finasteride. Side effects of finasteride in women include, but are not limited to: harm to a fetus (finasteride can not be used in pregnancy), fatigue, weight gain, depression, anxiety, decreased libido, sexual dysfunction, hair shedding, breast tenderness, breast enlargement.  Other side effects can occur but are less common. These include changes in platelet counts and muscle injury (myopathy).

Reference

Iorizzo M1, Vincenzi C, Voudouris S, Piraccini BM, Tosti A. Finasteride treatment of female pattern hair loss. Arch Dermatol. 2006.

Shum et al. Hair loss in women with hyperandrogenism: Four cases responding to finasteride. Journal of the American Academy of Dermatology 2002; 47: 733-9

Bird ST et al. Male breast cancer and 5 alpha reductase inhibitors finasteride and dustasteride. J Urology; 190:1811-4

Preventing Androgenetic Alopecia: Is it possible?

Preventing AGA in Men and Women

I'm often asked if one can prevent genetic hair loss. The typical scenario is a patient whose parent or sibling is bald or balding and wants to know if they can reduce their chances of developing a similar pattern of hair loss. Can one prevent balding outright? In the present day, that answer is no. However, there are things that can be done to reduce the magnitude and speed of progression of the hair loss.

Genetic Hair Loss is strongly ... genetic. It's the genes inside the hair follicles that influence how the hair loss will or will not unfold. We'll take a look at factors that can affect genetic hair loss to a slight degree in a moment, but first let's turn our attention to studies of identical twins. 

Studies of identical twins are very important in answering questions like "does what I eat affect my rate of balding?" or ,,,, "does being stressed affect how fast I bald?"

Identical twins carry the same genetic profile. By studying the appearance of identical twins at various points throughout their lives, we can get a better sense of how important factors like genetics and the environment actually are. If genes are the "key factor" in how balding progresses then, identical twins should look ‘identical’ in terms of their hair density at various points in their lives. In contrast, if environmental factors like smoking, drinking, stress, weight loss and ultraviolet radiation are important, identical twins might not have the same hair density because their environment is different. 

The 1992 Hayakawa Study

Interesting research studies in 1992 showed that genetics is by far the most important factor and the environment only has a minor role. 92 % of identical twins were found to have "no significant" differences in their hair density at later points in their lives. However,  8% of identical twins had a slight difference. Interestingly, no twin had a striking difference! In other words, there was never a situation where one identical twin was bald and another had full hair. These studies support the notion that one’s genetics is by far the most important factor in the balding process - but there is a slight role for how outside 'environmental factors' shape genetic hair loss.

Limiting Genetic Hair Loss: Optimizing Environmental Factors  

The Hayakawa studies taught us that there is a bit of room to optimize how fast genetic hair loss occurs. Overall, these factors have a minor role but still have some role. These factors include the following.

1) Be a non smoker.

It's clear that smoking can influence genetic hair loss by speeding up how fast it progresses. An important study examing the relationship between smoking and hair loss was a 2007 study by the Taiwanese group of Dr. Su and Dr Chen.  These researchers examined 740 patients between the ages of 40 and 91 over a 2 month period.  They found that smokers generally had worse androgenetic alopecia compared to non-smokers. In fact, smokers had nearly a two-fold increased risk of having moderate or severe genetic hair loss compared to non-smokers. In addition, the early development of male balding was more likely in smokers. The exact reasons is not clear but it has been proposed that smoking is damaging to the tiny blood vessels and the there are toxic substances in cigarette smoke that damage the cells in the hair follicles. It's also possible that smoking causes inflammation which speeds up the process of genetic hair loss. 

2) Keep a healthy weight. 

It does appear that obesity increases one's risk of developing worsening androgenetic alopecia. A 2011 study looked at the risk factors for male balding in policeman in Taiwan. Interestingly, young male policemen who were obese had much higher rates of male balding than thinner policemen. In 2014, researchers from Taiwan explored whether there was a relationship between obesity the severity of male balding. They studied 142 men (average at 31 years) with male balding who were not using hair loss medications.   The study showed that men with more severe  hair loss tended to be more overweight than men with less severe hair loss.  In fact, men who were overweight or obese had an approximately 3.5 fold greater risk for severe hair loss than men with more normal weights. In addition, young overweight or obese men had a nearly 5 fold increased risk of severe hair loss. The exact reasons are unclear. However, obesity leads to altered metabolism, insulin resistance and worsening inflammation that could affect balding. 

 

3) Limit anabolic steroid use.

Anabolic steroids can worsen genetic hair loss in those that are predisposed. These steroids increase the pool of androgens that all act to facilitate miniaturization.

4) Reduce ultraviolet radiation to the scalp.

An interesting study from researchers in Taiwan offers further clues that sunlight just 'might' contribute in some way to male balding.  The researchers compared balding patterns in 758 policemen  and 740 men in the general polulation.  Interestingly, policemen aged 40 to 59 had a two fold increased risk of having male balding. In addition, there was a statistically significant association between male balding and sunlight exposure. More research is needed understand if and how ultraviolet radiation affects the process of male balding. Reference

 

Conclusion

It's not always possible to prevent genetic hair loss. However, it may be possible to reduce the speed of its progression by limiting hair shedding and limiting toxic (i.e. smoking, obesity, UV radiation) and hormonal effects (i.e. anabolic steroids) on the hair follicle.

Reference

Hayakawa K, et al. Intrapair differences of physical aging and longevity in identical twins. Acta Genet Med Gemellol (Roma). 1992.

Su LH and Chen T H-H. Association of Androgenetic Alopecia with Smoking and Its Prevalance Among Asian Men. Archives of Dermatology 2007 143; 1401-1406.

Mosley JG and Gibbs AC. Premature grey hair and hair loss among smokers: a new opportunity for heatlh education? British Medical Journal 1996; 313: 1616.

Severi G et al Androgenetic alopecia in men 40-69 years: prevalence and risk factors.British Journal of Dermatology 2003; 149: 1207-1213

Chao-Chun Y et al. Higher body mass index is associated with greater severity of alopecia in men with male-pattern androgenetic alopecia in Taiwan: A cross-sectional study.  J Am Acad Dermatol 2014; 70; 297-302.

Su LH et al. Androgenetic alopecia in policemen: higher prevalence and different risk factors relative to the general population (KCIS no. 23). Arch Dermatol Res. 2011 Dec;303(10):753-61

Late onset Congenital adrenal hyperplasia (CAH)

Late onset CAH: A mimicker of PCOS and early balding in women

 

What is late onset CAH?

Late onset on non-classic congenital adrenal hyperplasia is an uncommon genetic disorder that is frequently due to mutations in 21-hydroxylase gene leading to reduced levels of the 21 hydroxyls enzyme.  Late onset CAH from deficiencies or mutations in other genes such as  11β-hydroxylase (CYP11B1) and 3β-hydroxysteroid dehydrogenase (HSD3B2) are extremely rare.

Late onset CAH should not be confused with the more serious and early onset condition of newborns called congenital adrenal hyperplasia (CAH). Women with late onset CAH develop signs and symptoms of the condition later in life as opposed to the first few weeks and months of life. 

What is the cause of Late onset CAH?

One of the most common causes of late onset CAH is so called 21-hydroxylase deficiency. This is caused by mutations in the CYP21A2 gene. To date, 127 mutations have been reported in CYP21A2. This particular gene provides instructions for making an enzyme called 21-hydroxylase (located in the hormone producing adrenal glands). Mutations in CYP21A2 lead to reduced or low levels of 21-hydroxylase enzyme activity (about 50-80% of normal) which then result in low levels of hormones such as cortisol and/or aldosterone and high levels of androgens (male hormones such as testosterone and androstenedione).

As a result of low cortisol, patients may experience changes in energy levels, blood pressure, blood sugar levels, as well as impaired ability of the body to respond to stress, illness, and injury. Aldosterone plays a key role in helping the body maintain the proper level of sodium and water and helps maintain blood pressure.  The amount of functional 21-hydroxylase enzyme determines the severity of the disorder. Patients with late onset CAH have CYP21A2 mutations that lead to reduce levels on the enzyme but not a complete absence. 

How is late onset CAH inherited?

Late onset CAH is usually inherited in an autosomal recessive (AR) manner. What this essentially means is that for a patient to be affected by the condition they need to have both copies of the affected gene - one gene  from mom and one gene from dad.  The parents of a person with late onset CAH are said to be 'carriers' and typically have only one mutated copy of the gene. The parents usually don't have any symptoms or signs of the disease themselves.   

How is late onset CAH diagnosed?

The patient's signs and symptoms may point to a possible diagnosis.  Generally speaking, the clinical features of late onset CAH reflect an excess of male hormones (androgens) rather than adrenal insufficiency.

Children with late onset CAH may present with premature pubarche (i.e. the development of pubic hair, axillary hair, and/or increased apocrine odor prior to age 8 years in girls and age 9 years in boys). Affected children may be tall and have accelerated linear growth velocity, and advanced skeletal maturation.

About 2-9 % of all women with hyperandrogenism may have late onset CAH. Women with  late onset CAH may develop a variety of symptoms including frontal baldness, hirsutism, acne,  irregular periods, a delay in the timing of the very first period, early onset of pubic hair, accelerated growth, reduced final height and infertility.  

In a multicenter study by Moran and colleagues, the most common symptoms among adolescent and adult women were hirsutism (59%), oligomenorrhea (54%), and acne (33%). Studies by Bidet and colleagues suggested that the initial presenting symptoms in 161 women with late onset CAH were hirsutism (78%), menstrual dysfunction (54.7%), and decreased fertility (12%). Therefore, presentation to a hair specialist regarding hair loss may not occur until later. 

Generally, additional testing is ordered to help confirm the diagnosis.  These tests may include a blood test to measure the concentration of 17-hydroxyprogesterone (17-OHP) on day 3-5 of the menstrual cycle. Levels of 170–300 ng/dL have been found to be useful as a screening tool. These should be obtained in the morning and during the follicular (preovulatory) phase of the menstrual cycle.

The clinical features of  late onset CAH in postpubertal adults may be difficult to differentiate from those of the polycystic ovary syndrome (PCOS). Even 17 OHP concentrations may be within the normal range for individuals with late onset CAH.  An adrenocorticotropic hormone (ACTH) stimulation test may also be ordered which involves measuring the concentration of 17-OHP in the blood before ACTH is administered and 60 min after ACTH is given. This test is typically conducted through an endocrinologist.  The acute ACTH stimulation test remains the gold standard to confirm decreased 21-hydroxylase activity.  

To perform the ACTH stimulation test, a blood sample is first collected to measure baseline hormone concentrations. Then, synthetic ACTH (Cortrosyn, 0.25 mg) is administered. A second blood sample is collected 30–60 minutes later.  When the ACTH-stimulated 17-OHP value exceeds 1500 ng/dL a mutation is likely. In few late onset CAH patients ACTH-stimulated 17-OHP levels will be between between 1000 and 1500 ng/dL.

A common error in investigating CAH is having the patient perform the blood test on any day of the menstrual cycle. 17-OHP levels normally rise in the second part of the menstruate cycle and if the test is done during this phase of the menstrual cycle falsely high levels will be recorded. the 17OHP test must be done on day 3-5. 

Other tests

In addition to 17 OHP, other tests may be recommended by the physician caring for the patient. These  are normally done in the MORNING and on day 3-5 of the menstrual cycle. They include cortisol, androstenedione, testosterone, free testosterone, DHEAS, progesterone, sodium, potassium, creatinine, glucose, hemoglobin A1C. LH and FSH may also be measured. Aldosterone may be tested. Blood pressure measurements will also be obtained. 

What is the treatment for late onset CAH?

For some patients affected with late onset CAH, treatment is not needed. Most endocrinologists agree that treatment is geared towards treating symptoms rather than simply helping bring lab tests into more normal ranges. 

Symptoms of late onset CAH may develop at various points in life, including puberty, after puberty, post part and during times of illness or increased stress.  If symptoms are present, a physician may prescribe a glucocorticoid, often dexamethasone. Dexamethasone is commonly used to treat irregular menstruation, acne, and excess body hair (hirsutism). Anti-androgens are also frequently used, especially by the hair specialist. Oral contraceptives are sometimes used as treatment for adult women or adolescents with irregular periods, acne or hirsutism who are not seeking to become pregnant

If identified early, treatment of children is geared towards helping with a normal linear growth velocity and a normal timing and progression of puberty. For adolescent and adult women, the goals of treatment goals are to help regulate menstrual periods, prevent excess hair growth on the face, and help with fertility. 

REFERENCE

Witchel et al. Nonclassic Congenital Adrenal Hyperplasia Int J Pediatr Endocrinol. 2010; 2010: 625105. 

Moran C, Azziz R, Carmina E, et al. 21-hydroxylase-deficient nonclassic adrenal hyperplasia is a progressive disorder: a multicenter study. American Journal of Obstetrics and Gynecology. 2000;183(6):1468–1474.

Bidet M, Bellanné-Chantelot C, Galand-Portier M-B, et al. Clinical and molecular characterization of a cohort of 161 unrelated women with nonclassical congenital adrenal hyperplasia due to 21-hydroxylase deficiency and 330 family members. Journal of Clinical Endocrinology and Metabolism. 2009;94(5):1570–1578.  

 

Spironolactone for Female Androgenetic Alopecia (AGA)

Spironolactone for Female Genetic Hair Loss

Spironolactone has been used off label in the treatment of androgenetic alopecia (also known as female pattern hair loss, FPHL) for approximately two decades.  The medication acts to reduce the effects of androgens in several ways.   It reduces adrenal androgen production and exerts competitive blockade on androgen receptors. 

Although there are yet to be any randomized placebo controlled trials examining the benefits of Spironolactone in FPHL,  case reports, series, and an open-label trial support its benefit. In a small case study, 200 mg spironolactone reduced hair loss by 50%–62.9% and also increased the total number of anagen hairs.  Perhaps the most important study to date was an an open-label study of 80 women with biopsy-proven FPHL who either received spironolactone (200 mg daily) or cyproterone acetate (either 50 mg daily or 100 mg for 10 days per month if premeno- pausal) for at least 12 months. This study showed that 44% of patients experienced visible hair growth (improvement), 44 % had their hair loss stopped. Only 12 % had reduced hair density. Another key finding of this particular study was that benefits did not depend on whether women had high androgens or normal androgens.  Other studies have shown that adding minoxidil to a spironolactone based treatment plan can be additive and some patients will achieve even further benefits. 

Readers may find these links helpful. The pertain to other articles written by Dr. Donovan on Spironolactone:

Spironolactone for FPHL - A UCLA Study

Irregular Periods from Spironolactone

Spironolactone for FPHL

Hormone Levels and Spironolactone Use: Does it matter?

Should one start Spironolactone with Minoxidil?

 REFERENCE

Sinclair R et al. Treatment of female pattern hair loss with oral anti androgens. Br J Dermatol 2005

Birth Control Pills, Hormones and Hair Loss: Important Considerations

Birth Control Pills affect Androgens

Oral contraceptives have many effects on the hair.  For some  women, oral contraceptives can cause hair shedding when started or stopped by triggering a telogen effluvium. Fortunately for most, this shedding is temporary.  Oral contraceptives can also benefit the hair in many women with androgenetic alopecia by reducing the levels of androgens (male type hormones) in the blood.

Where do androgens come from? 

There are three important sources of androgens in women.  About 50 % of testosterone in the blood comes from the conversion of hormones such as androstenedione and dehydroepiandrosterone (DHEA) and its sulphate dehydroepiandrosterone sulphate (DHEA-S). About 25 % of testosterone comes form the adrenal gland and 25 % from the ovary. 

About 65 % of testosterone that circulates in the blood stream gets bound and inactivated by sex-hormone-binding globulin (SHBG). Most of the remaining 30–35% is bound by albumin. Only 0.5–3% represents freely circulating T ("free T"). Despite the low amount, free T is important as it is active and able to cause a range of clinical phenomena such as hair loss acne and increased hair growth on the face (hirsutism).

Effects of Oral Contraceptives Pills on Androgens

Oral contraceptives (birth control pills), particular the combined oral contraceptives (COCs) are known the levels of androgens in the blood including testosterone, androstenedione and DHEAS. For example, blood levels of testosterone decrease by as much as 50 %. This occurs from the ability of oral contraceptive pills to a) reduce androgen synthesis in the ovary b) reduce androgen synthesis in the adrenal gland and c) increase sex hormone binding globulin in the liver. 

Because of their effects on androgens, birth control pills are options for women with certain types of hair loss, including androgenetic alopecia associated with normal hormone levels, and androgenetic alopecia associated with polycystic ovarian syndrome (PCOS).  Birth control pills are not appropriate for everyone with these hair loss conditions and anyone considering these medications should carefully review risks and benefits with a physician.

Female Pattern Hair Loss

Major and Minor Criteria

Female androgenetic alopecia is common. By the age of 50, well over 1/3 of women will have androgenetic alopecia (AGA)- also known as female pattern hair loss (FPHL). This type of hair loss causes thinning in the frontal and mid scalp. The sides and back may also be affected but generally to lesser degrees than the front for most women. Traditionally, the diagnosis of androgenetic alopecia has been made based on the finding of reduced density in the frontal scalp compared to the back of the scalp and the clear demonstration via dermoscopy that there is a variation in the diameter if more than 20% of hair follicles. This is known as anisotrichosis.

In 2009, Dr Rudnicka and colleagues proposed a series of major and minor criteria for diagnosing FPHL.

FPHL MAJOR CRITERIA

(1) ratio of more than four empty follicles in four images (at 70-fold magnification) in the frontal area

(2) lower average thickness in the frontal area compared to the occiput

(3) more than 10% of thin hairs (<0.03 mm in diameter) in the frontal area.

 

FPHL MINOR CRITERIA

(1) increased frontal to occipital ratio of single-hair pilosebaceous units

(2) vellus hairs

(3) peripilar signs.

Remarkably, the presence of two major criteria or of one major and two minor criteria allow diagnosis FPHL with 98% specificity.

 

Reference

Rakowska A et al. Int J Trichol. 2009;1:123–30.

Treatment of Androgenetic Alopecia During Pregnancy

Treating AGA in Pregnancy:

Most treatments for AGA are either not safe or not recommended during pregnancy. This includes minoxidil, anti androgens, various supplements, over the counter products and topical agents. The cardinal rule of treating any conditions during pregnancy or using any treatment during pregnancy is simple: ask a physician. 

Low Level Laser: Generally Safe for Most

 Low level laser treatments (LLLT) are the only safe treatments during pregnancy for women with AGA. This applies to most of the standard at home devices. Everything else needs stopping and some treatments need stopping well in advance. For some women, treatments during pregnancy are not necessary because it is possible due to hormonal surges during pregnancy stopping treatment may potentially not have a huge effect while pregnant and one can start many treatment again after giving birth. However, it should be noted that some women do experience hair loss during pregnancy as well.

WHICH HAIR LOSS MEDICATIONS ARE SAFE TO USE WHILE BREASTFEEDING?

Although I often ask my patients to discontinue most hair loss medications during pregnancy, the question frequently arises as to whether some medications can be restarted while moms are breastfeeding.  Breastfeeding has many benefits for babies.  For some drugs, the answer is yes. For others, the answer is no.

In 2001, the American Academy of Pediatrics published a helpful guide as to the safety of medications during breastfeeding. It's important to always check with your physician before starting any medication during breastfeeding. However, the following medications (used in hair loss) are felt to be safe for women who are breastfeeding.  For a full list of medications which are safe during breastfeeding, click here.

I generally do not recommend restarting treatments until month 1 after delivery if the baby is breastfed although many studies and reports show no harm in use if minoxidil and antiandrogens by women who are breastfeeding.

Does Finasteride Help All Causes of Hair Loss?

Finasteride: FDA approved for Male Balding

Finasteride is FDA approved for androgenetic alopecia in males but may also help hair loss from other conditions.

Finasteride for Male Balding

Finasteride was approved in 1997 for male balding at a dose of 1 mg. This approval came 5 years after finasteride was approved for treating prostate enlargement at a dose of 5 mg. Although generics are now available, the finasteride pills was initially marketed only as Propecia. For males with balding, it helps all areas that are thinning with the crown helped somewhat more than the front. Young males under 40 seems to get more benefit in the frontal areas of hair loss than men over 40.  Side effects of finasteride should always be reviewed before starting. 

Finasteride Side Effects - Donovan Hair Clinic

What conditions does finasteride help?

Finasteride is approve for male balding but may help several other conditions. These conditions include frontal fibrosing alopecia, some types of female patterned hair loss and very rare cases of lichen planopilaris including fibrosing alopecia in a pattern distribution (FAPD). Such uses are "off-label" and prescribed only in select cases.

What conditions does finasteride not help?

Finasteride does not help other types of hair loss. It does not appear to have benefit in alopecia areata, trichotillomania, telogen effluvium,  infectious causes of hair loss, and scarring alopecias such as folliculitis decalvans.