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Evaluating female hair loss and female baldness

Diagnosing female hair loss is time-consuming, yet extremely rewarding for physicians. It requires a detailed medical history, and an in-depth scalp examination, looking at clues for a diagnosis.


Scalp dermoscopy, which allows physicians to look closely at the impacted area, has emerged as an invaluable tool in rec­ognizing features of various hair loss not seen with the naked eye. Dermoscopy is particularly helpful in differentiating non-scarring alopecias, or types of hair loss.


An important finding that helps physicians design more effective therapies for female pattern hair loss is recognizing whether there is inflammation in the body. There is evidence that shows that therapies targeted at relieving this inflammation result in overall better results for female hair loss patients. Physicians have found that using topical corticosteroids to relieve inflammation, along with minoxidil, improves results in FPHL as compared to minoxidil alone. In the hopes of achieving even better results, physicians add low level laser therapy (LLLT) to this topical regimen and the results are further enhanced.


Evaluating female hair loss or female baldness patients generally also encompasses doing some laboratory blood work including measuring the vitamin D level. Vitamin D deficiency is increasingly common in the general population. The vitamin D receptor is intimately involved with activating hair growth, and mice genetically deficient in a vitamin D receptor antagonist generate more hair than controls. Vitamin D toxicity can result in systemic adverse effects, so the hope is to develop topical agents that selectively manipulate the vitamin D receptor in the scalp and hair follicles. It should be noted that while our focus is generally to look for dietary or other deficiencies as contributory to female hair loss (such as zinc, vitamin B12, and folate), we need to remember that toxicity due to environmental agents such as copper, arsenic, cadmium, or mercury can also be associated with hair loss. The recent popularity of eating sushi in the United States has prompted me to question patients about excessive dietary intake of fish containing high mercury levels (such as tuna, swordfish, or Chilean sea bass), and I have found abnormally high blood levels of mercury in some patients. Obviously, it is impossible to determine if mercury was in fact the causative agent.


Lastly, knowledge of hair cosmetics is extremely helpful when treating female hair patients. I have seen several women who presented with acute onset of hair loss following Brazilian keratin hair-straightening treatments. The hair loss appears to be secondary to both hair breakage and a form of effluvium with the most likely culprit being the formaldehyde in these products. Interestingly, a recent study measured the formaldehyde concentration in seven Brazil­ian keratin products and found that six had formaldehyde levels approximately 5 times higher than the level recommended by the United States Cosmetic Ingredient Review Panel. Some of these brands were, in fact, labeled as being “formaldehyde free.”


Female hair loss has been demonstrated to impact quality of life (QOL). An improvement of QOL was achieved in those individuals with successful hair treatment outcomes.

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