Androgenetic Hair Loss in Cushing Syndrome

Androgenetic Alopecia in Patients with Cushing Syndrome

Androgenetic alopecia, also called male and female balding, is common in the general population. About 30 % of men by age 30 and 50 % by age 50 have androgenetic alopecia. About 20 % of women by age 45 have androgenetic alopecia but this rises to 40-50 % by the 60s.

Cushing syndrome in contrast is a rare condition. About 5-7 cases per million people are diagnosed with Cushing syndrome each year. I have reviewed Cushing syndrome is detail in a prior article “Cushing Syndrome: A Short Primer”. It is known that patients with Cushing syndrome may have an increased risk of androgenetic alopecia as well as other signs of androgenism (like acne and hirsutism). Hirsutism, which refers to the growth of terminal hairs on the body in androgen dependent (male pattern) areas like the beard area, is more common in Cushing syndrome than found in the general population. In fact, 60-85 % of women with Cushing disease may have hirsutism. The ACTH hormone stimulates adrenal androgen production.

Let’s look at some important studies of hair loss in Cushing Syndrome.

In 2006, Kang reported a 27-year-old female who came to clinic with a 3-year history of diffuse hair loss on the scalp. Her past medical history included newly developed high blood pressure and a 10 year history of increased weight gain and oligomenorrhea. Central obesity, hirsutism, acne, violet striae on the abdomen, lower and upper extremities, and androgenetic alopecia on the scalp were observed upon physical examination. She was diagnosed ultimately with Cushing syndrome after further testing.

In 2017, Lefkowitz and colleagues report a case of a woman with presented to clinic with the chief complaint of hair loss. She had multiple dermatological findings, including facial plethora, easy bruising, violaceous striae, hirsutism, and acne. She was diagnosed ultimately with Cushing syndrome after further testing. The case reminds us that hair specialists can sometimes be the first specialist to recognize Cushing syndrome.

Many studies on Cushing syndrome have reported on the prevalence of hair loss. Estimates suggest between 13-51 % of patients have hair loss. A 2011 European Registry of Cushing syndrome by Valassi and colleagues reported that hair loss occurs in 31 % of those with Cushing syndrome based on a study of 351 patients. In those with pituitary Cushing (Cushing disease), the frequency was stated as 34 % based on a review of 224 patients.

A 2016 case control study by Broder and colleagues reported that female pattern hair loss was 5 times more common in those with Cushing syndrome than matched controls

Summary

It’s easy to miss a diagnosis of Cushing syndrome, especially in mild cases. Symptoms can be extremely varied. We use a Cushing syndrome Checklist to guide our questioning when we think there is a chance a patient may have Cushing syndrome.

Symptoms and signs like weight gain, central obesity, striae, bruising, proximal muscle weakness, osteoporosis at young ages, facial plethora, acne, hirsutism, high cholesterol, high blood pressure and diabetes must trigger one to at least think about Cushing syndrome.

Androgenetic alopecia is present in a significant proportion of those with Cushing syndrome but may not be the presenting issue. Features of Cushing may overlap with polycystic ovarian syndrome. In fact, many women with Cushing syndrome have a polycystic ovarian syndrome like morphology on ultrasound. In women with hyperandrogenism the incidence of Cushing syndrome has been estimated to be around 1-2 %.

One needs to have a high index of suspicion for Cushing syndrome. A 24 hour urine for free cortisol, bedtime salivary cortisol test or 1 mg overnight dexamethasone suppression test may be appropriate to order in those suspected of possibly having Cushing syndrome. These are outlined in the prior article, “Cushing Syndrome: A Short Primer”

REFERENCES

Broder MS et al. Identification of potential markers for Cushing disease. Endocr Pract. 2016;22:567–574.

Cunningham SK, McKenna TJ. Dissociation of adrenal androgen and cortisol secretion in Cushing’s syndrome. Clin Endocrinol (Oxf) 1994;41:795–800. 18.

Jabbour SA. Cutaneous manifestations of endocrine disorders: a guide for dermatologists. Am J Clin Dermatol. 2003;4:315–331.

Kang, I. J., Cho, H. R., & Sim, W. Y. (2006). A case of androgenetic alopecia associated with Cushing's disease. Korean Journal of Dermatology, 44(11), 1383-1386.

Lefkowitz E et al. A Case Report of Cushing's Disease Presenting as Hair Loss. Case Rep Dermatol. 2017 Feb 21;9(1):45-50

Newell-Price J et al. The diagnosis and differential diagnosis of Cushing's syndrome and pseudo-Cushing's states. Endocr Rev. 1998;19:647–672. Valassi E et al. The European Registry on Cushing's syndrome: 2-year experience. Baseline demographic and clinical characteristics. Eur J Endocrinol. 2011;165:383–392.