AGA in men

Vellus Hairs in AGA

This week, we'll start a five day look at androgenetic alopecia in men (also called male pattern balding). The identification of so called "vellus" hairs is important in understanding male balding. Vellus hairs are tiny hairs less than 30 micrometers in diameter. They are present on the normal nonbalding scalp but only in low proportions. In male balding, the proportion of vellus hairs rises considerably as large "terminal" hairs are converted to tiny "vellus" hairs. In advanced balding, the vellus hairs disappear leaving a completely bald scalp in the affected areas. 
 

Spironolactone Shortages in US and Canada: Update

Spironolactone Back Order Mainly Affects Canada

There is currently a shortage of spironolactone (Aldactone) in Canada. I have spoken with representatives from Pfizer Canada and USA this morning again and the following are updates.

1. Spironolactone in Canada (1 866 532 8608)

There is a shortage of both 25 mg and 100 mg supplies Canada due to a backorder. The pills are not being discontinued according to the company. These are currently being preferentially released to hospitals as the drugs are used at low doses in heart failure and other medical issues.

By the end of October 2017, the 25 mg pills should be available for shipment to pharmacies in Canada. By early November, the 100 mg pills should again be available as well. For now, it is somewhat hit and miss. Some pharmacies have abundant supplies and others have none. Trial and error can often lead one to find a pharmacy with supply. 

2. Spironolactone in the United States (1 800 438 1985)

According to Pfizer USA, the generic spironolactone is being discontinued but the trade name Aldactone pills are still being produced and are currently widely available. 

My team or I will update as any further updates become available. 

Hair Weights with Finasteride

One of the most carefully conducted studies investigating the benefits of finasteride in treating male pattern balding was in 2002. It was a 96 week study by Vera Price and colleagues. This study not only looked at changes in hair numbers before and after starting finasteride but also hair weights- the actual mass of hairs in a square centimetre area before and after treatment. These studies showed that after using finasteride, hair weights were greater than placebo (25.6% +/- 3.6% [18.5, 32.7] and 35.8% +/- 4.6% [26.7, 44.8] at 48 and 96 weeks, respectively; P <.001 for both time points). This data is important because it showed that finasteride helped men with hair loss by thickening many hairs - which we know now to represent a conversion of some of the vellus-like and miniaturized hairs to thicker terminal hairs. 

Reference

Price VH, et al. Changes in hair weight and hair count in men with androgenetic alopecia after treatment with finasteride, 1 mg, daily. Randomized controlled trial J Am Acad Dermatol. 2002.

Vellus Hairs on the Scalp

Does One Find Vellus Hairs Normally?

Vellus hairs are tiny, short non-pigmented hairs. They are fine hairs with a caliber less than 30 micrometers by definition. It is not common to find vellus hairs on the scalp in an individual without hair loss. On a normal scalp only about 1 of every 25 hairs are vellus hairs. Most hairs on the scalp are large pigmented terminal hairs. During the course of male and female androgenetic alopecia, vellus hairs become more prevalent and may even become the dominant hair type (outnumbering terminal hairs) in advanced balding cases.

Reference

Ko JH et al. Hair counts from normal scalp biopsy in Taiwan. Dermatol Surg. 2012

Should I Use Finasteride for Hairline Maturation?

There are two common changes to the frontal hairline that young men can observe. One is known as hairline maturation and the second is male pattern hair loss (also known as androgenetic alopecia). Both are a cause of worry to patients and both are commonly misdiagnosed.

Hairline maturation

Hairline maturation is a normal process that occurs between age 15-27 whereby a small amount of hair recession occurs in the very frontal hairline and a slight amount of recession of the temple is observed. This is generally 1 cm above the highest forehead wrinkle in the centre and 1.5 inches in the temples. In male balding recession occurs to greater degrees.

Treatment of hairline maturation and male balding

The distinction between the two conditions (hairline maturation vs balding) is important as there are no medical treatments for hairline maturation. Male balding can be addressed with treatments such as finasteride or minoxidil as well as others too.

Finasteride (Propecia and generics) and minoxidil (Rogaine and generics) are FDA approved for male pattern balding. These treatments do not have any effect on normal male hairline maturation. One may want to check with a physician of concerns exist about signs of early male balding. The best thing that can be done in early stages of hair loss is frequent scalp photography every 4-6 months. This is extremely helpful to track changes in the hairline and get a sense of the degree of hairline maturation and balding a person might have.

Androgenetic alopecia in women: Can I still have it if my hormones are low?

AGA in Women with Low Androgens

I'm often asked on various blogs and posts how it's possible to have androgenetic alopecia if a woman's androgen levels are normal or low. Many individuals have received a diagnosis of androgenetic alopecia and once their blood tests return normal, then have questions:

Is the diagnosis wrong?

How could I possibly have AGA if my androgens (testosterone, DHEAS, etc) is normal?

AGA in Women is best called FPHL

One must always keep in mind that androgenetic hair loss in women has much less to do with male hormones than it does in men. MOST women with AGA have normal hormone levels. In fact, about 90 % have normal hormone (androgen) levels. Treatments for AGA in women can still be helpful in many despite normal or low - normal levels. For this reason, many dermatologists choose to call female androgenetic alopecia "female pattern hair loss (FPHL)" rather than ANDROgenetic alopecia to de-emphasize the role of androgens.  

Summary

There are many complex mechanisms that lead to the development of AGA in women. For many women, androgenetic alopecia has little to do with androgens. For some it has a lot to do with androgens and for some it probably has nothing to do with androgens.  

Androgenetic Alopecia and Height

Baldness Associated with Shorter Height

Is there a link between the height of a man and his chances of developing androgenetic hair loss (male pattern balding)? 

Recent studies have suggested that answer is yes. Researchers at the University of Bonn performed an extensive study of over 20,000 men (10,000 with hair loss compared to 10,000 without hair loss) and concluded that many of the genes controlling male balding are also linked to being shorter in height.

The researchers discovered 63 genetic changes that increase a man’s risk of developing early onset balding. These same genetic changes were linked with a greater likelihood of being shorter.

This study confirms that hair loss is not an isolated phenomenon but rather controlled by genes that also determine one’s height and various aspects of health.

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; 8: 14694 DOI

Creatine and Hair Loss

There are many potential reasons for hair loss in individuals who use training supplements. Creatine is frequently used as an 'ergogenic' training aid to enhance performance. Although there is no definitive proof, I'd like to outline why it certainly might cause hair loss in those with a 'genetic susceptibility' to balding.

In a study from South Africa 20 college-aged rugby players participated in a double blind study. Subjects loaded with creatine (25 g/day) or placebo (50 g/day glucose) for 7 days followed by 14 days of maintenance (5 g/day creatine). The researchers looked at serum testosterone and DHT levels at baseline and then at 7 and 21 days. After 7 days of creatine loading, or a further 14 days of creatine maintenance dose, levels of DHT increased by 56% after 7 days of creatine loading and remained 40% above baseline after 2 weeks maintenance. Testosterone levels were unchanged.

While this data does not prove anything about hair loss, it does suggest that the higher DHT could provide a negative impact on hair loss for individuals who are predisposed to androgenetic alopecia (male balding and female thinning). Not all studies have suggested a negative impact on hormone parameters. A study completed in 2004 suggested that creatine supplementation actually decreased the free androgen index after 3 weeks of use. A 2001 study of 11 men did not find differences in serum testosterone in men receiving 10 g of creatine. However, serum cortisol levels were higher after creatine use during the resting period. 

Conclusion

We don't know if creatine supplementation promotes hair loss. One must at least consider the possibility that changes in DHT and even cortisol could have a negative impact on hair loss. 

Reference

van der Merwe J, et al. Clin J Sport Med. 2009.

Volek JS, et al. Eur J Appl Physiol. 2004.

Eijnde BO, et al. Med Sci Sports Exerc. 2001.

Rogaine Foam for AGA

1/2 cap Twice Daily for Men; Once for Women

Minoxidil is the only FDA approved topical solution for treating androgenetic alopecia (AGA). In 1988 it was first approved for men and in 1992 for women. The early formulations contained propylene glycol which had a tendency to cause irritation. Although the propylene glycol based formulations are still widely available, the introduction of minoxidil foam as "Rogaine foam" in 2006 had many advantages as it was less irritating. Rogaine foam was approved for men in 2006 as a twice daily application of 1/2 cap each time. The FDA approved Rogaine foam in 2014 for women at a dose of 1/2 cap once daily.

Valproate and Hair Loss: Does valproate cause hair loss through an androgen mediated mechanism?

There are many different types of drugs used as mood stabilizers is women with bipolar disorder. Many of these drugs can cause hair loss, albeit with different mechanisms. Common medications used in treating bipolar disorder include lithium, valproate, lamotrigine, topiramate, gabapentin, carbamazepine, oxcarbazepine.

Vaproate and Hyperandrogenism

There is increasing evidence suggests that valproate is associated with isolated features of polycystic ovarian syndrome (PCOS). To study this further, researchers studied three hundred women 18 to 45 years old with bipolar disorder. A comparison was made between the incidence of hyperandrogenism (including hirsutism, acne, male-pattern alopecia, elevated androgens) with oligoamenorrhea that developed while taking valproate versus other types of anticonvulsants drugs (like lamotrigine, topiramate, gabapentin, carbamazepine, oxcarbazepine) and lithium. 

What were the results?

It was interesting that among 230 women who could be evaluated, oligoamenorrhea with hyperandrogenism developed in 9 (10.5%) of 86 women on valproate compared to just 2 (1.4%) of 144 women on nonvalproate anticonvulsants or lithium. This translated into a nearly 8 fold risk of these hyperandrogenism and menstrual cycle changes with valproate. Oligomenorrhea happened within 12 months with valproic acid users.

Conclusion

Once needs to be aware of a possible PCOS like clinical phenomenon and for hair specialists - the development of hyperandrogenism and accelerated AGA in women using valproate for bipolar disorder. More studies are needed to confirm these findings.

Reference

Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism in women with bipolar disorder.

Joffe H, et al. Biol Psychiatry. 2006.

Can drugs accelerate androgenetic alopecia (AGA)?

Medications can potentially accelerate androgenetic alopecia. Common examples are anabolic steroids, the use of testosterone injections and topical androgen gels (commonly used for men with "low testosterone"), androgenic progestins in birth control pills, danazol as well as many other medications.

This individual whose scalp is shown in the picture has been using anabolic steroids for body building and has experienced rapid hair loss mainly due to a conversion of his large terminal hairs (some labelled by green dot) to thinner miniaturized hairs (labelled by yellow dot). Treatment of drug accelerated AGA involves either stopping the androgen or blocking the effects of the androgen on the hair follicle using 5 alpha reductase inhibitors... or both. Less specific treatments like minoxidil may provide some benefit. Many individuals can improve with this plan but full regrowth is unlikely.

AGA or LPP: Who is right?

In many fields of medicine, the pathology report provides the final answer as to a patient's diagnosis. We're most familiar with this for example with cancer diagnoses. It comes as a surprise for many patients that scalp biopsy reports are sometimes not so definitive.

Differentiating AGA and LPP

A great example is the diagnosis of early androgenetic alopecia (AGA and early lichen planopilaris (LPP). Sometimes it is pretty clear cut - but not always. Sometimes a diagnosis of LPP is made and the patient really has AGA. Sometimes (although much less commonly) a diagnosis of AGA is made and the patient really has LPP.

LPP: Brief Overview

Lichen planopilaris (LPP) is a scarring alopecia that typically starts with scalp symptoms such as itching and burning. Sometimes the scalp is quite tender in areas. Shedding is often present as well. LPP affects similar areas to androgenetic alopecia (female pattern thinning) so it is a close mimicker. In the early stages, some scalp redness may be present and inflammation may be seen around the hairs clinically. 

AGA: Brief Overview

Androgenetic alopecia (AGA) also starts with shedding. There can be a hint of itching/tingling but not too often. Usually the front of the scalp is more affected by hair loss than the back. 

Biopsies: Helpful or not?

A biopsy can be very helpful provided it is read by an experienced dermatopathologist. Traditionally we have thought of AGA as "non inflammatory" and "non scarring" so one might not think that inflammation and scarring should be present on the biopsy. We know now that's not completely true.  Inflammatory infiltrates are present in AGA in the upper hair follicle and so is loose perifollicular fibrosis. In LPP biopsies, inflammation is also present in the upper hair follicle but it specifically appears to be attacking the hair follicle outer root sheath. (We call this "lichenoid" change). To differentiate AGA and LPP one needs to direct their attention to this specific change in the actual hair follicle. When this specific immune attack is seen, one needs to consider LPP over AGA. Also the amount of perifollicular fibrosis is usually greater as LPP advances. LPP may have other changes in the skin as well that help differentiate it from AGA.

So by biopsy,  androgenetic alopecia and LPP can be confused as both can have inflammation (perifollicular inflammation in the isthmus) and both can have scarring (perifollicular fibrosis).  An experienced dermatopathologist can sort this out. 

So how does one resolve this? Does the patient have AGA or LPP?

One needs to take into account the patient's entire story. If a physician just biopsies every patient that comes into the office, I can guarantee one will make a whole lot more diagnoses of LPP than truly are present. I'm a big believer in this - even though LPP is under diagnosed in the world!  But by listening to the patient's entire story, and examining the scalp and reviewing what the biopsy shows (not just the final read out on the bottom line), one can usually get a fairly good sense. However in rare cases - time is the best judge as a missed case of LPP will likely declare itself over time.

Elevated testosterone Levels in Women with Hair Loss

Testosterone Levels in Women with Hair Loss

There are many causes of elevated testosterone levels in women. Slightly elevated levels can sometimes be considered 'normal' with no underlying issues to be concerned about. Many patients with increased androgen levels have polycystic ovarian syndrome (PCOS) or underlying endocrine issues such as Cushing syndrome. However, elevated but can sometimes be associated with serious underlying conditions, including cancer. Patients with rapid onset of symptoms and signs along with hormone levels that are well above normal need rapid medical attention for proper diagnosis.

What is the 'cut off' for normal?

There are no hard and fast rules when it comes to cut off numbers. A full story is needed from the patient including how fast the symptoms appeared and how many symptoms are present. Is it hair loss? Is acne present? How about increased hair growth on the face (i.e. hirsutism)? Is the patient menopausal or post menopausal? Are menstrual cycles regular? Has there been weight loss or gain? Does the patient have increasing pain anywhere ? How about fatigue levels?

Causes of elevated testosterone levels in women

There are many causes of elevated testosterone levels in women. Patients with high testosterone levels should be sure to make an appointment with their doctor to review causes. A full history and full examination will be needed and more blood tests may be needed as well. Repeating the testosterone is often advisable too given that it can vary quite a bit day to day. A measurement in the morning is advised.

The top 10 causes of elevated testosterone include

1. Just a normal level for the patient

2. Polycystic ovarian syndrome (one of most common causes)

3. Ovarian hyperthecosis

4. medication induced (androgen replacement, anabolic steroids)

5. Cushing syndrome

6. Congenital adrenal hyperplasia

7. Ovarian tumors

8. Adrenal tumors

9. Hyperthyroidism

10. Prolactinomas

Cancers of the adrenal gland and ovaries are a very rare cause

Cancers of the adrenal gland are rare and about 2 new cases are diagnosed every year per 1 million people. Cancers of the ovary are more common and currently ovarian cancer is the sixth most common cancer in women. Less than 1 % of patients presenting with hirsutism and other signs of hyperandrogegism have an ovarian or adrenal tumor - but it is important to diagnose early. 

Generally speaking a plasma testosterone concentration three times above the normal level (i.e. above 8.7 nmol/L or 200 ng/dL) with a normal DHEAS level raises the suspicion that the patient could have an underlying benign or malignant ovarian cause of their symptoms. Furthermore, a plasma testosterone concentration three times above the normal level (i.e. above 8.7 nmol/L or 200 ng/dL) with an elevated DHEAS level (above 16.3 umol/L or 600 ug/dL) raises the suspicion that the patient could have an underlying benign or malignant adrenal cause of their symptoms.It could of course be normal, but when levels are in this range - a full work up is mandatory. 

Further testing with elevated androgens 

Further testing may be advised depending on the degree of hormone elevation and associated signs and symptoms. As mentioned, a full history and physical examination are needed for all patients with elevated androgens. Generally a full hormonal panel with free and total testosterone, DHEAS, LH, FSH, estradiol, SHBG, prolactin, 17 hydroxyprogesterone and TSH are ordered. Other tests include AFP (alpha feto protein) and B-hCG may be ordered. A pelvic ultrasound or CT scan may be ordered for women with markedly elevated levels. Further stimulation and suppression testing (i.e a dexamethasone suppression test for a potential androgen secreting adrenal tumor) may be ordered upon referral to an endocrinologist. 

Conclusion

There are many causes of increased androgens in women. When associated with increased hair growth on the face, irregular periods, acne or hair loss, androgen hormone levels are frequently elevated. Conditions such as polycystic ovarian syndrome (PCOS) or ovarian hyperthecosis are common and frequently responsible. However, women with markedly evaluated androgen levels (especially three times above normal) require a full work up including referral to endocrinology, radiology and gynaecology specialists.

Reference

Pugeat M et al. Androgen secreting adrenal and ovarian neoplasms. Contemporary Endocrinology: Androgen Excess Disorders of Women: Polycystic Ovarian syndrome and other disorders. Second Edition. Humana Press.

Oral minoxidil for hair loss

Oral Minoxidil

Topical minoxidil was FDA approved in 1987 and we now have 30 years of experience with the drug. 

I'm increasingly asked about oral minoxidil. Does it work? Is it safe? What dose? 

Oral minoxidil is not FDA approved for treating hair loss. It was used in the 1980s for treating high blood pressure. When used at doses typical for treating blood pressure problems (5 mg twice daily), it can be associated with side effects - some quite serious. These include dizziness, low blood pressure, weight gain from fluid retention, high heart rate, heart rhythm problems. And of course hair growth can occur all over the body.

Lower doses of oral minoxidil may be safer and may still provide benefit. Doses ranging from 0.25 mg daily to up to 1 mg daily are generally well tolerated without a significantly increased risk of side effects. One does need to be closely monitored for blood pressure, weight changes, heart rate and excess hair growth on the body. For women, low dose minoxidil can be combined with spironolactone. In men low dose minoxidil can be combined with lower doses of finasteride.

 

Conclusion

Oral minoxidil is increasingly popular as men and women look for safer options for treating hair loss. Side effects of oral minoxidil must be respected and use of the medication must only be done in conjunction with a physician experienced in the use of oral minoxidil. Close monitoring is essential.

Gynecomastia (Enlargement of Breast Tissue) in Men using Finasteride and Dutasteride

Gynecomastia in Men using Finasteride and Dutasteride

It is well known that finasteride and dutasteride can cause enlargement of breast tissue in men. This phenomenon is known as ‘gynecomastia’. It is postulated that hormonal changes that accompany the reduction in DHT (particularly a small 13 % increase in estrogen) may be partly responsible.

New study shows risks greatest with dutasteride

A new study looked at the risk of gynecomastia in men using finasteride for prostate enlargement. The authors used the UK’s Clinical Practice Research Datalink (CPRD) to perform a case control study examining the risk of gynecomastia in individuals using finasteride compared to those who did not use.

The researchers showed that there was a three fold increased risk of gynecomastia in men using finasteride. A 5 fold increased risk of gynecomastia was seen with dutasteride.

Conclusion

It’s clear that these medications can cause gynecomastia. Dutasteride appears to carry greater risk.

Reference

Hagberg et al. Risk of gynecomastia and breast cancer associated with the use of 5-alpha reductase inhibitors for benign prostatic hyperplasia. Clinical Epidemiology 2017; 9; 83-91.

What's special about red light in promoting hair growth?

This perfect rainbow reminds us all that light is made up of many different wavelengths ranging from 400 nm to 700. Wavelengths around 650 nm produce red light.

Like many things in medicine, the use red light for hair growth came by chance. In the late 1960s, Dr Endre Mester, a Hungarian physician was studying whether a 694 nm ruby laser would cause cancer in mice. To his surprise, the laser did not cause cancer but rather dramatically stimulated hair growth!

It remains unclear exactly how red light stimulates hair growth. It appears that red light stimulates tiny organelles inside cells called mitochondria. A specific molecule known as cytochrome C oxidase (which is part of the mitochondria's cellular respiratory chain) has been proposed to be a key receptor molecule to absorb the red light and start the entire process.

To date, there have been 5 randomized double blind controlled trials studying the use of red light low level laser treatment (at 655 nm) for individuals with androgenetic alopecia. These include 2 studies with a laser "comb" device and 3 with a laser "helmet/cap" device. All studies showed improvement by 16-26 weeks compared to a placebo (sham) device.

There are many unanswered questions about using low level laser therapy. Which device is best? Is 655 nm really the best wavelength? Is the current 3 times per week really the best? Are laser combs better than laser helmets or are helmets better than combs? These are all unknown at present.

Do I have miniaturization?

Miniaturization

Most hairs on the scalp are 70-85 micrometers in diameter. During the process of several hair loss conditions, the diameter of the hair shaft reduces. For example, reduction in hair shaft diameter can be seen in androgenetic alopecia, as well as conditions such as traction alopecia and alopecia areata. In genetic hair loss, a hair that is originally 80 micrometers becomes 60 micrometers and then slowly over years finds itself at 20.

Once a hair follicle thins below 55 micrometers I consider labelling it a "miniaturized" hair.

There is a big difference between a "miniaturized" hair vs "miniaturization". If a hair is 55 micrometers or less and most neighbor hairs are 80 micrometers - we say that hair is "miniaturized." However there is no real "miniaturization" of hairs. One can not really tell if a hair 65 micrometers is thinner from a natural process or from androgenetic alopecia. (Maybe it was just genetically set out to be 65 micrometers). However if none of the neighbouring hairs are thinner, there is less than a 0.05 % chance that it is thinner from early androgenetic alopecia. However if well over 20 % of the neighbors are thinner, there is a 99.5 % or more chance in males this is from androgenetic alopecia. In this case there is a miniaturized hair present and there is also miniaturization.

Are newly growing hairs thinner than mature ones?

Newly Growing Hairs

The "miniaturization" of hairs refers to a process where hairs get thinner and thinner over time. It is frequently seen in hairs from the scalps of individuals with androgenetic alopecia (male balding and female thinning). The confirmation that a given person has miniaturized hairs frequently evokes a great amount of worry and questions about whether the individual does in fact have androgenetic alopecia. One must always keep in mind that a few conditions can produce thinner hairs - and one must not be too quick to jump to the conclusion that the patient has androgenetic alopecia.

Telogen effluvium is a hair shedding condition where hair sheds from factors such as low iron, stress, thyroid disorders or crash diets. As the hairs start growing back, they appear smaller at first until they thicken up over time. A patient with a consider number of newly regrowing hairs could be mistaken for having miniaturization due to androgenetic alopecia.

When one looks at the following picture of two trees, one can appreciate that the tree on the right is probably older than the one on the left. There is no reason to believe that with time the tree on the left won't achieve the same thickness as the tree on the right.

In cases of massive telogen effluvium, hairs thicken up to some degree over time. Re-evaluation of the patient's scalp a few months later can be helpful if one is unsure whether the patient has a TE, AGA or both.

Finasteride for Women

Can Finasteride (Propecia) be used in women?

Finasteride is not FDA approved for women. That does not mean we never use finasteride in women - in fact, I sometimes to prescribe this medication. The fact that it is not FDA approved just alerts us that there are important reasons to consider as to why it is not approved.  

 

Does FDA approval matter?

FDA approval does matter. It directs us to consider that considerable review has been done to evaluate that safety of a given medication. However, readers must keep in mind that 99 % of the medications that a hair loss doctor uses are not FDA approved!! When a medication that is not FDA approved is used, we say that this is a so called 'off label' use. 

When I use minoxidil for alopecia areata, I'm using the medication in an 'off label' manner. Minoxidil is not FDA approved for alopecia but but sure can help many patients.  In fact - there is not a single medication on the planet that is FDA approved for alopecia areata.

When I use Plaquenil for lichen planopilaris, I'm using the medication in an 'off label' manner. Plaquenil is not FDA approved for lichen planopilaris but but sure can help many patients.  In fact - there is not a single medication on the planet that is FDA approved for lichen planopilaris.

When I use clindamycin for folliculitis decalvans, I'm using the medication in an 'off label' manner. Clindamycin is not FDA approved for folliculitis decalvans but but sure can help many patients.   In fact - there is not a single medication on the planet that is FDA approved for folliculitis decalvans.

When I use minoxidil and steroid injections for traction alopecia, I'm using these medications in an 'off label' manner. Minoxidil and steroid injections are not FDA approved for traction alopecia but but sure can help many patients. In fact - there is not a single medication on the planet that is FDA approved for traction alopecia.

Finasteride for Women - It's off label.

When I use finasteride for androgenetic alopecia in women, I'm using these medications in an 'off label' manner. Finasteride is not FDA approved for androgenetic alopecia but but sure can help many patients. 

Some medications are appropriate for a given patient others are not. One really needs to sit down with a physician and discuss. Even Rogaine is not advised for some women (heart conditions, heart rhythm problems, pregnancy, other hormone abnormalities such as pheochromocytoma). 

Some physicians never prescribe finasteride to women regardless of age. Some physicians only prescribe to post menopausal women. Some physicians will prescribe to premenopausal with appropriate counceling on the risks during pregnancy and prescription of appropriate birth control.  

Finasteride must never be used by women who may become pregnant. Women with strong histories of estrogen dependent cancers (breast, ovarian, gynaecological cancers) should also review use with their doctors. This includes breast, ovarian and other gynecological cancers. Women with depression should also have a thorough discussion as to whether this drug is appropriate for them of not.

Different Hairs in AGA

Terminal, Vellus and Miniaturized

We will continue our discussion of how hair follicles change during the course of androgenetic alopecia (male pattern balding and female androgenetic alopecia). In general, hair follicles become thinner during the course of genetic hair loss. Before the onset of hair loss, most hairs in the scalp are thicker "terminal" hairs. These are typically 60 to 80 micrometers in diameter.

During the thinning process, terminal hairs become "miniaturized" hairs and eventually "miniaturized" hairs become "vellus" hairs. Vellus hairs are always less than 30 micrometers in diameters. During the course of balding, terminal hairs become less common and vellus hairs become more common. During advanced balding, vellus hairs outnumber terminal hairs in the areas of balding. In such a case, we say that the terminal to vellus ratio (T:V) ratio is much less than 1:2.