Female pattern alopecia management requires systematic approach

Key Points

Rochester, N.Y. - A systematic approach helps to guide the workup and management of female pattern alopecia (FPA), according to Mary Gail Mercurio, M.D.

"More recently, we're learning that androgens play less of a role than they do in male pattern androgenetic alopecia," she explains.

When a patient with possible FPA presents, Dr. Mercurio says she usually begins by exploring the problem's history. "Patients describe thinning as having less hair, or it stops growing - they can't achieve the same hair length they used to," she says.

For patients with thinning, "We think of FPA," Dr. Mercurio says. "In contrast, if the patient is leaving hair everywhere, it's more likely to be a telogen effluvium. Then there's a gray area" in which telogen effluvium unmasks underlying FPA. "You can determine that by following up over time," she says.

Hands on

Dr. Mercurio emphasizes the importance of a hands-on approach during the examination. "Most of my patients are referred by other dermatologists. And when I start examining their scalp, I can't tell you how many crane their heads back, in awe that I'm actually touching their scalp."

First, she looks for inflammation. "It's rare that a patient with FPA doesn't come in with a red or scaly scalp. Once they acknowledge that it's a hair loss issue, they wash their hair so gingerly and infrequently that they develop seborrhea," she says. "Often, we must clear up that inflammation before an accurate diagnosis of hair loss can be made." The inflammation caused by the seborrhea results in positive hair-pull tests, she says.

Dr. Mercurio also looks for scarring. "Typical female pattern hair loss takes a more diffuse pattern. And if you look closely, you can see fine or miniaturized hairs - it's not an obliteration of the hair follicles" as occurs with scarring types of alopecia, she says.

Women with FPA maintain a frontal hairline, Dr. Mercurio says. They also can have frontal accentuations or more diffuse hair loss that results in widening of the part from the frontal scalp to the vertex.

Additionally, "I'm seeing much more frontal fibrosing alopecia," she says. "This was not a condition we recognized when I was a resident. Because it's somewhat new, I get many referrals" for patients with this condition mistakenly diagnosed as FPA. However, she says that with frontal fibrosing alopecia, "The entire frontal-parietal hairline moves back," often leaving lone terminal hairs.