Treatment of Female Pattern Hair Loss: Why do I still see miniaturized hairs?
Why am I still losing short miniaturized hairs?
I’ve selected this question below for this week’s question of the week. It allows us to review some concepts regarding treatment of androgenetic alopecia and exaclty how much reversibility there can be.
Question
If miniaturized hair still falls after 100 mg spironolactone but the shedding stopped, does it mean that spironolactone is not helping the AGA?
Answer
Thanks for the question. This is a common question and one that I am asked often. The short answer is no, that would be an incorrect assumption.
Here’s the full answer.
A significant proportion of patients with androgenetic alopecia lose some degree of short hairs and miniaturized even when hair loss is successfully treated. Many people incorrectly assume the process of androgenetic hair loss will be shut off 100% after treatment - but generally it will not be 100% shut off.
In an “ideal” setting, a person with androgenetic hair loss gets complete and total reversal of all their hair problem. Hairs thicken up fully back to the thickness they once were and all short hairs become long hairs again.
Can this happen?
Yes, this can happen but happens in only a small proportion of patients with very early staged androgenetic hair loss who undergo aggressive treatment early on in the course of the condition. Hairs that went from an average of 78 micrometers in thickness down to 68 micrommeters in thickness when hair loss struck return to 78 micrometer after successful treatment. A scalp that once had only 10 % vellus hairs increases to 19 % vellus hairs when the hair loss occurred and then returns back to 10 % with successful treatment. A patient who once had very little in the way of shedding finds they shed more hairs - especially shorter thinner hairs when AGA occurs and then find shedding returns to normal and small hair seem to disappear with successful treatment. This all can occur - but it’s uncommon. Many people incorrectly think this is simply what is expected with treatment. Of course, marketing makes us think this is what should happen.
Most Patients Do Not Have Complete Reversal
Most patients with very early staged androgenetic hair loss who undergo aggressive treatment early on in the course of the condition will find things improve with treatment but treatment does not back things up 100 % to the way they were in the beginning. Sometimes fortunately it looks like it returned 100 % back to normal but the reality is that it did not. Many many clinical studies back up this statement.
Hairs that went from an average of 78 micrometers in thickness down to 68 micrometers in thickness when hair loss struck increase to 74 micrometer after successful treatment. A scalp that once had only 10 % vellus hairs increases to 19 % vellus hairs when the hair loss occurred and then decreases again to 13 % with successful treatment. A patient who once had very little in the way of shedding finds they shed more hairs - especially shorter thinner hairs when AGA occurs and then find shedding returns to normal and small hair seem to almost disappear with successful treatment. Some smaller hairs or shorter hairs might still be found even when a person feels that treatment has been a great success. This is because the androgenetic hair loss is reversed but not 100 %. We rarely reverse it 100 % although a “great” success in the present day and age would be to reverse it 70-85 %. Even when a person feels that hair loss was reversed 100 % - it’s not. It just feels and looks that way.
Most patients with very early staged androgenetic hair loss who undergo aggressive treatment early on in the course of the condition will find things improve with treatment but treatment does not back things up to the way they were in the beginning.
Some Patients Do Not Improve
Let’s not forget that some patients get only a little bit of improvement with treatment. Let’s not forget that some get no improvement at all but fortunately the treatment seems to block things from getting worse. Let’s not forget that some get no improvement and things get worse and some patients find that the treatment makes things entirely worse altogether. Fortunately that latter possibility is very rare.
Most Patients Get Some Degree of Improvement
Most patients with very early staged androgenetic hair loss who undergo aggressive treatment early on in the course of the condition will find things improve with treatment but treatment does not back things up 100 % to the way they were in the beginning. Sometimes fortunately it looks like it returned 100 % back to normal but the reality is that it did not.
Patients with Mild, Moderate and Severe AGA May Also Get Some Degree of Improvement
Patients with FPHL that has progressed a bit further than what would be considered “very early stage” who undergo aggressive treatment early on in the course of the condition may find things improve with treatment but treatment never back things up 100 % to the way they were in the beginning. It still may look like an incredible result for some (and some might look like it returned 100 % back to normal) but the reality is that it did not. A patient who once had moderate AGA may look like they have mild AGA. A patient who once had mild AGA may look like they don’t have hair loss at all to a complete stranger (although the patient themselves will say the hair is only 50 % of the fullness it once was).
Hairs that went from an average of 78 micrometers in thickness down to 52 micrommeters in thickness when hair loss struck increase to 61 micrometers after successful treatment. A scalp that once had only 10 % vellus hairs increases to 54% vellus hairs when the hair loss occurred and then decreases again to 36% with successful treatment. A patient who once had very little in the way of shedding finds they shed more hairs - especially shorter thinner hairs when AGA occurs and then find shedding returns to normal but a good proportion of small short hairs remain even with successful treatment. Some smaller hairs or shorter hairs might still be found even when a person feels that treatment has been a great success. This is because the androgenetic hair loss is reversed but not 100 %. In mild, moderate and severe AGA, no treatment reverses it 100 % although a great success in the present day and age would be to partially reverse it a good amount.
Goals of Treatment for FPHL
The hope with treatment is that we can 1) increase density as much as possible 2) reduce the number of short hairs 3) increase thickness of strands a bit and 4) bring shedding rates back to normal. Sometimes this requires one treatment. Sometimes 2 and sometimes three or four. Not all treatments are equally good. Some are a little bit helpful. Some are very helpful.
It is a mistake to assume that this process stops and all hair that gets shed in successfully treated AGA is full length hair. This is not what happens for many although it can happen if AGA is addressed in very early stages.
The key is not to focus on the length of hairs that a person sees but the fullness and thickness of the hair on the scalp and whether they are pleased with the coverage it gives.
Conclusion
If your shedding reduced, it’s likely spironolactone is helping. Of course, it could be that you had a completely different reason for your shedding in the first place so be sure to review this all with your doctor. But if shedding is due to AGA and shedding stops, it means the treatment is doing something. Treatments don’t work 100% as reviewed above. More aggressive treatments (higher doses, more treatments brought into the plan) could theoretically reduce the proportion of miniaturized hairs that a person sees and increase density further.