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.

Focal Atrichia in AGA

Focal atrichia: What does it mean? 

Focal atrichia refers to small circular areas on the scalp that are devoid of hair. These areas are typically slightly larger than a pencil eraser. 

Focal atrichia is seen in both male and female androgenetic alopecia and more common in more advanced stages. They may contain a few tiny vellus hairs if one looks closely but eventually these tiny hairs disappear over time. Hair regrowth does not occur in these areas.

Studies by Olsen and Whiting (see references below) showed that focal atrichia was present in 44% of women with female pattern hair loss, including 67% of late onset vs 15% of early onset, compared to 3/146 (2%) of those with other hair disorders. Hu and colleagues showed that focal atrichia in men with balding was associated with more advanced stages.
 

Reference

Olsen EA, et al. Focal Atrichia: A Diagnostic Clue in Female Pattern Hair Loss. J Am Acad Dermatol. 2017.

Hu R, et al. Trichoscopic findings of androgenetic alopecia and their association with disease severity. J Dermatol. 2015.

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.  

Hair loss is not a guessing game.

Guessing is easiest for men's hair loss

If you had to "guess" the reason for someone's hair loss, you'd likely guess correctly if the patient was male and you chose male balding (androgenetic alopecia). By far that's the most common cause of balding in men.  Dozens of other causes are possible, but they are not common. 

Hair loss in women is more complex.

For women, there's a very good chance you'd be wrong if you guessed androgenetic alopecia as the sole cause. Female hair loss is far more complex - and hair shedding issues and even scarring conditions are not uncommon. Hair loss of course, is not a guessing game and a diagnosis can usually be made by the patient's history, examining the scalp and sometimes examining blood test results or (rarely) performing a scalp biopsy.

HOW ARE HAIR FOLLICLES ARRANGED?

Follicle arrangements

Hair follicles normally emerge from the scalp in groups of 1, 2 or 3 haired "bundles." They don't all emerge as single strands.

During the process of genetic hair loss as well as during the process of scarring alopecias, the bundles of 2 and 3 haired follicular units start disappearing from the scalp and what is left is 1 and 2 haired follicular units.

DHT LEVELS AND FINASTERIDE

How do DHT levels change with one dose of finasteride?

Understanding how DHT levels change with finasteride is important in order to best counsel patients - especially those experiencing side effects. 

After taking 1 pills of finasteride, the drug itself is largely eliminated from the body in 1-2 days given that the half life of finasteride is about 4-6 hours (after five half lives a drug is significantly reduced in the body). However the same is not true of DHT levels. After a single dose of finasteride, DHT levels are reduced by 60 % (ie from 65 ng/dL to 25 ng/dL). However, the DHT levels don't rise back up quickly even though the drug is out of the body. Rather, DHT levels rise slowly increasingly just 15-20 % after the second day (ie from 25-30 ng/dL up to 30-35 ng/dL). Now back to the original question.

Of the two lines in the diagram, red or yellow, which best depicts how finasteride levels change with a single pill?

The answer is the yellow line! This concept is important since patients who are experiencing finasteride related side effects may still benefit from dosing every second or third day. It may not be quite as effective but as we can see from the graph, DHT levels are still being suppressed by this dosing schedule.
 

Reference

Vermeulen et al. Eur Urol 1991.

Is it okay to use more minoxidil?

Using more minoxidil is not advised

The dosings of medications have been carefully worked out to balance efficacy with safety. If a patient feels he or she needs more, they should speak to their physician or pharmacist regarding how to apply minoxidil efficiently. If one feels this dose does not work, they might consider a variety of off label means... but only under supervision. This could include using a bit more than 1 mL, or using oral minoxidil at low doses.

Side effects of using too much minoxidil

The side effects of overdosing on minoxidil include worsening headaches, dizzininess, low blood pressure, heart palpitations, heart rhythm disturbances, ankle swelling, hair growth on the body. Rarely patients end up in the emergency department every year because they feel so unwell after using too much minoxidil. 

Minoxidil is a drug and use must be respected.

Minoxidil: Does age really matter?

Minoxidil and age-related hair loss

Minoxidil is a topical medication used to treat many forms of hair loss including androgenetic alopecia (for which it is FDA approved). Minoxidil can be helpful for treating androgenetic alopecia at any age but becomes even more important to consider with advancing age. 

Senescent alopecia: A type of hair loss often forgotten

Hair thinning as one approaches the 60s and 70s is often less truly androgen driven. The diagnosis of senescent alopecia (SA) needs to be considered in these particular age groups and it can often respond to minoxidil. Senescent or age related alopecia is often forgotten by physicians. It mimics genetic hair loss almost perfectly so is easily misdiagnosed as genetic hair loss. The genes driving it are very different. The key point is that if one recognizes senescent alopecia could be a possibility - the use of treatments like minoxidil become more important rather than other traditional AGA-type treatments like finasteride.

Androgenetic alopecia tends to start somewhere between age 8 and age 50. Hair thinning that occurs later has a high likelihood of representing senescent alopecia. (Of course other types of hair loss may also occur after age 60 and genetic hair loss and senescent alopecia can overlap). A study by Karnik and colleagues in 2013 confirmed that these two conditions (AGA and SA) are truly unique. The authors studies 1200 genes in AGA and 1360 in SA and compared these to controls. Of these, 442 genes were unique to AGA, 602 genes were unique to SA and 758 genes were common to both AGA and SA. The genes that were unique to AGA included those that contribute to hair follicle development, morphology and cycling. In contrast to androgenetic alopecia, many of the genes expressed in senescent alopecia have a role in skin and epidermal development, keratinocyte proliferation, differentiation and cell cycle regulation. In addition, the authors showed that a number of transcription factors and growth factors are significantly decreased in SA. The concept of senescent alopecia is still open to some debate amongst experts. The studies by Karnik give credence to the unique position of these two conditions. But studies by Whiting suggested that it is not so simple as to say anyone with new thinning after age 60 has SA - many of these are also more in keeping with androgenetic alopecia. As one ages into the 70's, 80's and 90's - hair loss in the form of true senescent alopecia becomes more likely.

Reference

Karnik et al. Microarray analysis of androgenetic and senescent alopecia: comparison of gene expression shows two distinct profiles. J Dermatol Sci. 2013.

Differentiating DUPA from CTE

How do we distinguish DUPA from CTE?

Diffuse unpatterned alopecia (DUPA) can generally be differentiated from chronic telogen effluvium (CTE) by careful review of the patient's history, and examination of the scalp using dermoscopy. Rarely a biopsy can be confirmatory but usually this is not needed.

DUPA

On history, patients with DUPA report diffuse thinning. They usually don't have all that much in terms of increased shedding. Typically, the hair loss is first noticed between age 15-24. Examination of the scalp shows variation in the sizes of follicles. We call this 'anisotrichosis'. Some hairs are thick and some are thin. The miniaturization occurs all over the scalp. A biopsy shows a terminal to vellus ratio of much less than 4:1.

CTE

In contrast to DUPA, patients with true CTE are usually a bit older when they first notice hair loss, often 35-60. Their stories are markes by concerns about massive shedding that comes and goes, some weeks good and some weeks bad. Patients with CTE don't usually look like they have hair loss to others whereas patients with DUPA often do look like they have hair loss. In CTE, examination shows terminal thick hairs. The temples may or may not show recession but often do in the setting of CTE. A biopsy shows T: V ratios that are high - and ratios 8:1 or higher are suggestive of CTE (compared to less than 4:1 for DUPA).

In summary, DUPA and CTE can usually be easily differentiated with careful examination and review of the patient's story.

Androgenetic Alopecia and Height

Height, AGA and Genetics

Recent research has shown that many of these genes that control balding also affect how tall an individual may become. 

Heilman-Heimbach and colleagues from the University of Bonn recently performed an extensive study of over 20,000 men (10,000 with hair loss compared to 10,000 without hair loss). The researchers uncovered 63 genetic changes that increase a man's risk of developing early onset balding. These same genetic changes were associated with an increased likelihood of being shorter. They concluded that many of the genes controlling male balding are also linked to being shorter in height.

A second study from the UK by Hagenaars and colleagues identified 287 genetic regions linked to male pattern baldness. This large study examined data from over 52,000 men. This study confirmed a similar finding as the Heilman-Heimbach et al. study above namely that many of the genes regulating hair loss in men also give an increased chance for shorter height.

Reference

Heilman-Heimbach et al. Meta-analysis identifies novel risk loci and yields systematic insights into the biology of male-pattern baldness. Nature Communications, 2017.

Hagenaars SP et al.  Genetic prediction of male pattern baldness. PLoS Genet 13(2): e1006594. 2017.

The Modified Hair Wash Test (MHWT)

A closer look at the MHWT for Differentiating CTE and AGA

The modified hair wash test (MHWT) is an extremely helpful non-invasive test. It is underutilized by dermatologist mainly because of lack of familiarity and exposure. It is an extremely powerful technique to differentiate challenging cases of CTE from AGA. The patient may perform this test at home. 

Performing the MHWT

To perform the MHWT, a patient is instructed to avoid shampooing the hair for 5 days before the date of set test date. On the day of the test, the sink is covered with a gauze. The hair is then shampooed thoroughly and rinsed. The hairs trapped in the gauze are collected counted and divided into hairs less than 3 cm and more than 5 cm.

Interpreting the MHWT

Patients with 10% or more of hairs 3 cm or shorter and who shed fewer than 100 hairs are diagnosed as having AGA; Patients with fewer than 10% of hairs that were 3 cm or shorter and who shed at least 100 hairs were diagnosed as having CTE; Patients with 10% or more of hairs that were 3 cm or shorter and who shed at least 100 hairs were diagnosed as having AGA + CTE; Finally patients with fewer than 10% of hairs that were 3 cm or shorter and who shed fewer than 100 hairs were diagnosed as having CTE in remission.

Can I eliminate the possibility of side effects from finasteride?

Eliminating a Drug is the only way to Eliminate the Possibility of Side Effects

I'm often asked how one can eliminate the side effects of a medication. "I want to take it doctor if it weren't for the side effects."  The reality is that it is possibility to eliminate the chances of side effects from any drug - and that is by not taking the drug.

Reducing Side Effects from Finasteride

The only way to really eliminate side effects from finasteride is not to take the drug. The chances of side effects with oral finasteride are low and in the order of 1-2 %. Nevertheless, all men need to be aware of the possibility of sexual dysfunction, mood changes, gynecomastia and other potential side effects as well.  The chances of side effects tend to be depenent on the amount of finasteride absorbed into the blood stream which in turn affects the degree of reduction in DHT.

1. Reducing the dose

Reducing the dose to 0.5 mg or 0.25 mg may be associated with reduced chances of side effects. DHT is still inhibited at these doses, albeit not as effectively as a 1 mg dose. Studies have suggested that DHT inhibition at 0.2 mg is about 80 % the level of 1 mg pill.

2. Reducing how often it is taken

Even though the drug half life is 6-8 hours, one needs to consider how long 5 alpha reductase inhibition in the scalp is actually occurring. Studies have suggested that 1 mg finasteride daily and 1 mg finasteride every other day are fairly similar in effectiveness although good studies still have yet to be done to really back this up definitely. Taking every other day can reduce side effects but may potentially alter effectiveness as well.

3. Using topical compounded finasteride

The other way to minimize finasteride side effects is to consider topical finasteride applied to the scalp. Absorption into the blood stream may still occur with topical finasteride (as systemic DHT levels are still reduced) but side effects are much less.

4. Taking time to understand the risk and benefits, long term studies

Studies also show that a broad and objective understanding of finasteride, its proper use also reduces side effects. Men who are alarmed about the drug and proceed into taking the drug without a full and balanced view of the risks and benefits also have a higher incidence of side effects. Studies have shown that risks increase in this situation from 2-5 % to above 60 % (i.e. nocebo effects).

Conclusion

Anyone wishing to minimize side effects of finasteride should have a thorough discussion with their physician. For more information on finasteride, download our handout. 

FINASTERIDE - HANDOUT

Differentiating between Short 1 cm Hairs by Dermoscopy: Many Possibilities !

How can we tell apart the various causes of short hairs?

I'm frequently asked by patients and physicians how to determine the identify of a short 1 cm or so hair that is seen on the scalp. Looking at the scalp with dermoscopy, one often want to know "Is this a vellus hair I'm seeing or is it an upright regrowing hair as part of a telogen effluvium? ... or is it simply a normal regrowing hair ?"

This chart below helps summarize the main things I think about when I see a short hair. The answer does not necessarily come immediately but rather it comes by asking 4 questions:

1) Is the hair reasonably thick (i.e. 40-50 um or more) or is it very thin (less than 30 um)?

2) Are the ends pointy or blunt?

3) Are these short hairs found all over the scalp or just one area?

4) Are there just a few of these short hairs or lots and lots of them?

By working through these 4 questions, I can generally determine the cause of the short hair I'm seeing on the scalp. 

Topical Finasteride: Are side effects possible?

Topical Finasteride: Don't forget the placebo studies!

If one is going to use topical finasteride,  they must be 'prepared' for the possibility of side effects. For patients to use topical finastseride (or physicians to prescribe topical finasteride) with the complete expectation that it comes with zero chance of side effects is simply incorrect. The "chances" of side effects in my experience are certainly very, very, very low (probably well under 1 in 1000) and much, much lower than oral finasteride. But they are likely not zero especially if one considers that even placebo pills have side effects! Side effects with topical finasteride have not been reported to date.

 

Topical finasteride: What is the risk of side effects?

Common sense dictates that someone will have a side effect to topical finasteride. Whether it's 1: 1000 men or 1 in 10,000 or 1: 1,000,000 is unknown but there is little doubt in my mind that side effects are possible. We know that DHT is still inhibited in the blood by up to 25 % with some topical finasteride formulations and about one tenth of the amount of finasteride is still absorbed. In other words, a lot less gets into the blood, but it's far from zero. 

 

Analogies I use in my clinic

I completely understand that many physicians and many patients assume that topical finasteride is 100 % free of side effects (or at least close to it). But let's use a few analogies which help us all understand that a 25 % reduction in DHT is going to be a bit much for a small proportion of men.

Humans have a delicate physiology. There are some individuals that are sensitive to small changes in blood levels of anything. There are some individuals that are sensitive to small amounts of alcohol in the blood. Some individuals are sensitive to small amounts of caffeine.

Sexual physiology is likely even more complex. There is no doubt that some will be sensitive to small reductions in DHT. We see similar "DHT" related side effects even with saw palmetto - which is not supposed to even effects DHT at all! We even see DHT related side effects (erectile dysfunction, decreased libido) in 0.7 % of men using "placebo pills" in clinical studies - which inhibit DHT 0 %!! By age 30, about 30 % of men have some degree of sexual dysfunction. By age 50, it's 50 % , and by age 80, it's well over 80 % of men.  Factor this into the 0.7 % chance of sexual-related side effects with placebo pills and it's easy to understand that at least someone is going to present with concerns about side effects from topical finasteride. 

Consider now the following table. We know that oral finasteride inhibits DHT by 70 % based one studied done in the 1990s. The chances of side effects with oral finasteride are around 2 %. This includes sexual dysfunction and mood changes. A drug that inhibits DHT to no degree at all (i.e. 0%) would likely have lower chances of "DHT-related" side effects. But clinical studies using placebo pills in clinical trials of finasteride have suggested this could be as high as 0.7 %. Of course, other side effects could be possible.  We are then left with considering the chances of side effects in a drug that inhibitors DHT levels in the blood by 25 %. Are the chances of side effects zero? Probably not given that not even the placebo has a 0 % chance of side effects.. But fortunately, they are likely very low. We don't yet know that number. In my experience using topical finasteride, I have formed the opinion that it is likely very low and probably well under 1:000. But what is the real number? Is is 1:1000 men?  1:10,000 men?

 

.Many different Topical Finasteride Formulations

If a male is very sensitive to a reduction in DHT then side effects may occur. If a formulation can be created with zero penetration into the blood then systemic DHT will not be affected. That does not exist yet. One must keep in mind that there is no "one" topical finasteride formula - there are dozens of different formulations. Some pharmacies just make it up however, they like. Polychem is studying a specific formulation. MorrF is available in India already through Intas Pharmaceuticals and consists of topical minoxidil and topical finasteride together. .

Topical finasteride is clearly safer than oral finasteride and we have used for several years in our clinic. To say it has zero possible side effects would be incorrect. In my opinion, it is just a matter of time before we hear of possible side effects.  There are side effects even with placebo (and it's as high as 0.7 %!).But overall, topical finasteride is much much safer than oral finasteride. But anyone who uses it must be aware that it is off label and long term effects are not known. There have been millions of prescriptions for oral finasteride to date and well over 1 million men use it every year for treating hair loss. This does not include finasteride use in prostate issues. Compare this to the fact that there are probably under 200,000 men worldwide (maybe quite a bit less) that have used topical finasteride. 

Physicians and patients need to be aware of the 'unknowns' of topical finasteride use and  counsel patients on the reduced chances of side effects but the possibility that a very small proportion of men will report side effects. Overall, the drug appears to have a very good safety profile in the topical formulation.

REFERENCES

M Caserini, et. al.  A novel finasteride 0.25% topical solution for androgenetic alopecia: pharmacokinetics and effects on plasma androgen levels. Int J Clin Pharm Th July 30, 2014 (1-8).

BS Chandrashekar, et. al. Topical minoxidil fortified with finasteride: An account of maintenance of hair density after replacing oral finasteride. Indian Dermatol Online J 2015 Jan-Feb; 6(1): 17-20.

S Sheikh, et. al.  A new topical formulation of minoxidil and finasteride improves hair growth in men with androgenetic alopecia. J Clin Exp Dermatol Res 2015, 6:1.

Hair Loss in Androgenetic Alopecia: Why can't anyone notice my hair loss?

On the Three Stages of Hair Loss in Androgenetic Alopecia

Hair loss in patients with androgenetic alopecia (AGA) starts well before the affected individual actual becomes "aware" that his or her hair is thinning. I often think of AGA in three "stages" - labelled 1, 2 and 3 in the following diagram. These are not to be confused with the 3 Ludwig stages of hair loss.

Another way that I think about the 3 stages of hair loss is shown here.

Stage 1

In stage 1, hair density is slowly reducing but the patient is unaware. There may be a slight increase in hair being shed in the shower or coming out daily in the brush. However, this generally goes by unnoticed by the patient. A biopsy can sometimes (but not always) capture a T:V ratio below 4:1 and some degree of miniaturization (and anisotrichosis) may be present. Much of the time it's challenging to confidently diagnose AGA in this stage. Some stay in stage 1 for a very long time; others just a matter of months.

Stage 2

In stage 2, the patient first becomes aware that something is not quite right. They may see a bit more scalp showing when they look in the mirror. They may feel the hair does not feels as thick when they run their fingers through the hair. Under bright lights they may feel a bit more aware of these changes. When the hair is wet, the thinning is evident.

Nevertheless, in this second stage everyone else tells the patient they look fine. Some patients are told they are "crazy". Even some physicians will tell the patient they "look fine" and need not worry. Patients often feel isolated in this stage because nobody believes them when they say they are losing hair! A biopsy definitely shows a T:V ratio less than 4:1 and miniaturization is clearly seen in more than 20 % of hairs. Many never progress to stage 3 especially those with onset of AGA later in life.

Stage 3

In stage 3, the hair loss has progressed to a stage where hair loss may become evident not only to the patient but also to others. Of course with use of various hairstyles, products, camouflaging agents it may still be possible to hide one's hair loss from others. As stage 3 progresses it becomes more and more difficult to hide hair loss.

Comment

As a physician, I try to understand the goal of my patients. Some patients in stage 2 want help to simply stop their hair loss so that they can "stay" in stage 2 and not move on to stage 3. Other patients want treatment advice to get them back into stage 1 (if possible). Some patients in stage 3 want to improve their density such that they can get a bit more hair back to hide their hair thinning more easily. The patient in such an example may not be looking to move from stage 3 to stage 2 but may be looking to improve their density.

Consider the 31 year old female with early thinning who is worried about her hair. Her friends and family think she's crazy worrying about her hair. After listening to the patients story and examining her scalp, I can reassure her that even without treatment she will stay in stage 2 for 5-10 years (and her friends and family will likely keep telling her she's crazy for many more years to come). However, my concern for her is that if nothing is done she will move on to stage 3 in her 40s, 50s and 60s. The goal of treatment is to prevent this.

I find this chart helpful for many of my patients and when teaching physicians about hair loss. 

"Miniaturization" and "Anisotrichosis" in Androgenetic Alopecia

Terms in AGA: Miniaturization and Anisotrichosis

Androgenetic alopecia is common in men and women. By 50 years, about 50 % of men and 30 % of women have some evidence of androgenetic alopecia. The early features of AGA include hair shedding in some and hair loss in specific areas (temples and crown in men and central scalp in women).

When examined up close as in this photo, one can see "miniaturization" of hairs whereby some thicker hairs undergo a change to thinner hairs. Most hairs we have on our scalp as teenagers range in around 70-90 micrometers in diameter. During the process of androgenetic alopecia, the follicles become thinner and thinner and over time reduce slowly to 50 micrometers then 20 then 10 etc. Finally the fibers are so thin and short that they fail to reemerge from the scalp.

Not all hairs become thin and not all hairs thin at the same speed (rate). There is great variation in the thickness of hairs. We call this variation in hair shaft thickness "anisotrichosis." Two finding of miniaturization and anisotrichosis is a typical feature of androgenetic alopecia in both men and women. 

Minoxidil Dread Shed: What is meant by this?

Shedding from Minoxidil

Minoxidil lotion and foam are FDA approved for treating androgenetic alopecia (AGA) in men and women. This type of hair loss is also called male pattern balding and female pattern hair loss. A common concern among individuals who are deciding whether or not to use minoxidil is the potential for them to develop an increased amount of daily hair shedding in the first 6-8 weeks of starting minoxidil. This is known in the public as the "dread shed." Medically, the term is "immediate telogen release." This type of shedding is not to be confused with the shedding that happens when people with androgenetic alopecia incorrectly stop using minoxidil. (One must never stop treatment if they have androgenetic alopecia or else new hair growth will be shed and all benefits will be lost).

The 'dread shed' can be frightening when it occurs but is generally mild for most. Understanding why this occurs is important to help individuals decide whether this treatment is right for them to start or not.

Immediate telogen release: Understanding shedding with minoxidil

The increased shedding that accompanies starting minoxidil needs to occur for most people. It's not something that is really all that abnormal - it just looks abnormal. When you look closely at the scalps of men and  women with androgenetic alopecia (especially early stages of AGA), one will notice that a higher than normal proportion of cells are in the shedding phase. These hairs are waiting their turn to shed. Hairs generally need to wait in line 2-3 months before they are shed. That's just the rule of the nature. That's what it means to be human.

When minoxidil is applied to the scalp, a signal is sent to all hairs that are waiting in line to be shed. The message that is relayed is that the hairs no longer need to wait 2-3 months in that line. Rather any hair that is waiting in line to be shed is welcome to shed now.  The mandatory 2-3 month waiting period has been temporarily waived. And so what the patient then experiences is an increased amount of hairs coming out on a daily basis once they start minoxidil. What is being shed is hairs that were destined to come out anyways:

Instead of coming out tomorrow, a hair comes out today

Instead of coming out in 2 weeks, a hair comes out in tomorrow

Instead of coming out in 4 weeks, a hair comes out in 1 week

Instead of coming out in 6 weeks, a hair comes out in 2 weeks

This is what the 'dread shed' or 'immediate telogen release is all about.

For more information on the dread shed, readers might consider reviewing other articles. 

Immediate shedding from minoxidil: An analogy

Single Hairs in Androgenetic Alopecia (AGA)

Isolated 'single' hairs in Androgenetic Alopecia

Androgenetic alopecia is often referred to as "thinning" and certainly the progessive miniaturization of hairs is a feature of AGA.

However, another important feature is the disruption of the normal architecture of how follicles are grouped. Instead of finding follicles in groups of 1, 2 or 3 hair units hairs are often seen all by themselves in more advanced stages of AGA.

The accompanying photos shows numerous single hairs in a patient with moderately advanced AGA.

Do I have TE or androgenetic alopecia?

TE and AGA: Commonly Confused.

Many individuals with hair loss attempt to self diagnose their hair loss. This is not generally a good means to get to the bottom of why one is losing hair. Nevertheless, it is common. A frequent scenario crops up in the early stages of androgenetic hair loss where one first sees an increase in the daily shedding of hair. The patient then wonders "Is this a telogen effluvium I am experiencing or is this genetic hair loss?"

TE or AGA: Three ways to figure it out

Understanding the answer to this question really takes into account a full review of many of the hair cycle changes during telogen effluvium as well as androgenetic alopecia. In short there's three ways that one can determine if they have a TE or AGA.

1) Time. A TE will improve with enough time.

First, time is the most definitive way albeit the slowest.  If a patient's hair loss is from a resolving telogen effluvium, there should be a significant improvement in hair density over 6 to 9 months. For most with resolving TE, the hair density should be completely back to normal at that time. If this is actually androgenetic alopecia a worsening of hair density will likely occur over a 12 month period. At best, the hair density would probably be the same but it would be very unlikely for it to improve unless there was some components of seborrhoeic dermatitis that was adequately treated that led to a minor improvement of the overall appearance of the  androgenetic alopecia.  

2) Self diagnosis. A TE causes hair loss all over in a 'diffuse manner'

Another way to determine if this is a result of telogen effluvium or androgenetic alopecia is to perform self diagnosis. This is of course the most dangerous of all the options but nevertheless it's a common way. True androgenetic alopecia has less density on the top middle and front of the scalp compared to the back of the scalp. At least for males, true balding is a patterned hair loss. In telogen effluvium, the density is reduced equally all over the scalp.  I would encourage anyone with hair loss to see his or her dermatologist to review whether a resolving TE or genetic hair loss is in fact what is going on.  

3) Clinical Examination by a Dermatologist

A clinical examination by a physician is often a very good option to help an individual sort out if they have TE or AGA. One needs to consider the timing of the hair loss, when it occurred, factors leading up to the hair loss. But the most important is the scalp examination looking at exactly where the hair is being lost from and whether or not miniaturization of follicles is occurring. Miniaturization is a process whereby hairs get thinner and thinner in their diameter over time. This is frequently a features of androgenetic alopecia. It may be challenging to determine if miniaturization is present in the earliest stages of AGA. Nevertheless, it will become present over time in AGA whereas it will not in a true isolated telogen effluvium. If one has any concern about the diagnosis, then blood tests and a biopsy will complement the work up. Patients with a TE may have normal blood tests, so the presence of normal blood tests does not rule out TE. A biopsy performed with horizontal sections can give valuable information about the percentage of telogen hairs and the ratio of terminal to vellus hairs. A T:V ratio less than 4:1 is a feature of genetic hair loss. It is not a feature of TE. An increase in the proportion of telogen hairs above 15 % is often seen in a TE. This is not typically a feature of AGA.

Comment

Deciphering whether an individual has a TE or AGA can be challenging not only for patients but many clinicians as well. I would like to point out that the vast majority of males who are wondering about telogen effluvium or androgenetic alopecia generally turn out to have androgenetic alopecia.  Exceptions exist of course. The early stages of androgenetic alopecia are associated with shedding which give a confusing clinical picture.  The same is true with women as well although true effluviums are much more common in women than in men. Overall. I would encourage anyone to see a physician to review the accurate diagnosis. 

Advanced AGA: Often a Scarring alopecia

Androgenetic Alopecia: Advanced Stages

 

Advanced androgenetic alopecia (AGA) is sometimes associated with the presence of scar tissue beneath the scalp. This can sometimes cause an uneven and asymmetrical appearance of hair loss and even cause the physician to consider other diagnoses. Chronic sun damage (which is shown here in the photo) accelerates the development of this type of scar tissue in many men with male balding. Therefore advanced androgenetic alopecia can be thought of as a type of "scarring alopecia."