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This is common baldness or pattern baldness. It occurs after puberty and affects both sexes but less so in women. The appearance is familiar to anyone with fine vellus hairs in distinctive patterns such as frontal-temporal. In women, three main patterns have been identified. There is a diffuse frontal-vertical thinning, male pattern type, and diffuse thinning of the vertex. The second type may be accompanied with virilism.

This is a disorder characterized by vellus follicle formation. The terminal follicles, under the influence of androgenic stimulation, convert to vellus follicles. Hair follicles from areas of baldness have altered levels of enzymes responsible for converting androgens to active metabolites. This is the basis of antiandrogen therapy in these patients which may lead to improvement in 50% of patients.

The early changes observed under the microscope include progressive diminution in size of the terminal follicles to vellus hairs. There is a relative increase in the number of telogen and catagen hair follicles with telogen follicles outnumbering anagen follicles. Arao-Perkins bodies may be present. Sebaceous hyperplasia may be present but with advanced changes, there is a decrease. However, the pilar arrector muscles remain and may appear relatively large when compared to the hair follicle.


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Hair density, hair diameter and the prevalence of female pattern hair loss.

Birch MP, Messenger JF, Messenger AG.

Department of Dermatology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK.

Br J Dermatol 2001 Feb;144(2):297-304 Abstract quote

BACKGROUND: Female pattern hair loss is common but estimates of its prevalence have varied widely. The relationships between the clinical diagnosis of female pattern hair loss and objective measurements of hair density and hair diameter have not previously been evaluated.

OBJECTIVES: To determine the prevalence of female pattern hair loss and to relate the clinical findings to hair density and hair diameter.

METHODS: We examined 377 women, aged 18--99 years, who presented to a general dermatology clinic with complaints unrelated to hair growth (the unselected sample). A second group of 47 women referred with typical female pattern hair loss was included in analyses of the relationships between hair density, hair diameter and the clinical diagnosis. Hair density was measured using a photographic method. In each subject the major and minor axis diameters were measured in a random sample of 50 hairs.

RESULTS: Six per cent of women aged under 50 years were diagnosed as having female pattern hair loss, increasing to 38% in subjects aged 70 years and over. The mean +/- SEM hair density was 293 +/- 61.3 hairs cm(-2) at age 35 years, falling to 211 +/- 55.1 hairs cm(-2) at age 70 years. Hair density showed a normal distribution in the unselected sample. Most women classified as having female pattern hair loss had hair densities within the lower half of the normal distribution. The perception of hair loss was determined mainly by low hair density (ANOVA P < 0.001), but there was overlap in hair density between women classified as having Ludwig I hair loss and the no hair loss group, which was partly accounted for by differences in mean hair diameter (ANOVA P < 0.001). Low hair density was associated with fewer hairs of all diameters.

CONCLUSIONS: Hair density in women is distributed as a normal variable, indicating that it is determined as a multifactorial trait. Women with female pattern hair loss have a hair density which falls below the mean but lies within the spectrum of the normal distribution, although other factors, including hair diameter, may affect the subjective impression of hair loss. The hair diameter data suggest that low hair density is not due to progressive diminution in hair follicle size and that follicular miniaturization may occur within the space of a single hair cycle.


The prevalence and types of androgenetic alopecia in Korean men and women.

Paik JH, Yoon JB, Sim WY, Kim BS, Kim NI.

Department of Dermatology, College of Medicine, Kyung Hee University, 1 Hoeki-Dong, Dongdaemun-Ku, Seoul 130-702, Korea.

Br J Dermatol 2001 Jul;145(1):95-9 Abstract quote

BACKGROUND: There are racial differences in the prevalence and types of androgenetic alopecia (AGA). There have been several reports on the prevalence and types of AGA in the general population of caucasians, but few studies on Koreans with samples of sufficient numbers have been reported.

OBJECTIVES: To obtain a more precise estimate of the prevalence and types of AGA in Korean men and women and to compare the results with those in caucasians.

METHODS: The prevalence and types of AGA were analysed in 10,132 Koreans (5531 men and 4601 women) who had visited the Health Examination Centre at Kyung Hee University Hospital for regular health examinations between December 1997 and July 1999. To classify the degree of hair loss for each subject, the Norwood classification was used in men and the Ludwig classification in women. For AGA in men, 'female pattern' was added to the Norwood classification.

RESULTS: In Korean men, the prevalence of AGA (Norwood III or above) at all ages was 14.1%. It increased steadily with advancing age, but was lower than that of caucasians: 2.3% in the third decade, 4.0% in the fourth decade, 10.8% in the fifth decade, 24.5% in the sixth decade, 34.3% in the seventh decade and 46.9% over 70 years. Type III vertex involvement was the most common type in the third decade to the seventh decade; over 70 years, type VI was most common. A 'female pattern' was observed in 11.1% of cases. In Korean women, the prevalence of AGA (Ludwig I or above) at all ages was 5.6%. It also increased steadily with advancing age: 0.2% in the third decade, 2.3% in the fourth decade, 3.8% in the fifth decade, 7.4% in the sixth decade, 11.7% in the seventh decade and 24.7% over 70 years. Grade I was the most common type up to the sixth decade; over 60 years, grade I and II were similar in prevalence. Grade III (total baldness) was not observed. A family history of baldness was present in 48.5% of men and 45.2% of women with AGA.

CONCLUSIONS: The prevalence of AGA in Korean men and women was lower than that in caucasians, as recorded in the literature. Korean men tend to have more frontal hairline preservation and show a more 'female pattern' of hair thinning than caucasians. Therefore, 'female pattern' should be added to the classification of AGA.



Androgenetic alopecia and cardiovascular risk factors in men and women: a comparative study.

Arias-Santiago S, Gutiérrez-Salmerón MT, Castellote-Caballero L, Buendía-Eisman A, Naranjo-Sintes R.

Dermatology Unit, San Cecilio University Hospital, Granada, Spain.

J Am Acad Dermatol. 2010 Sep;63(3):420-9. Epub 2010 Jul 8.
Abstract quote

BACKGROUND: Numerous studies in recent decades have associated male androgenetic alopecia (AGA) with the risk of cardiovascular disease. However, only 3 studies have addressed this association in female patients. Most studies considered the risk of myocardial infarction or mortality as a result of heart disease, without analyzing cardiovascular risk factors.

OBJECTIVES: The objectives of this study were to analyze the presence of cardiovascular risk factors included in the Adult Treatment Panel-III criteria for metabolic syndrome, the prevalence of carotid atheromatosis, hormonal (aldosterone, insulin, testosterone, and sex hormone-binding globulin) factors, and acute phase reactant (C-reactive protein, fibrinogen, D-dimers, erythrocyte sedimentation rate) variables in male and female patients with AGA and in a control group, and to analyze differences among the groups.

METHODS: This case-control study included 154 participants, 77 with early-onset AGA (40 male and 37 female) and 77 healthy control subjects (40 male and 37 female) from the dermatology department at a university hospital in Granada, Spain.

RESULTS: Metabolic syndrome was diagnosed in 60% of male patients with AGA (odds ratio [OR] = 10.5, 95% confidence interval [CI] 3.3-32.5), 48.6% of female patients with AGA (OR = 10.73, 95% CI 2.7-41.2), 12.5% of male control subjects, and 8.1% of female control subjects (P < .0001). Atheromatous plaques were observed in 32.5% of male patients with AGA (OR = 5.93, 95% CI 1.5-22.9) versus 7.5% of male control subjects (P = .005) and 27% of female patients with AGA (OR = 4.19, 95% CI 1.05-16.7) versus 8.1% of female control subjects (P = .032). Aldosterone and insulin levels were significantly higher in the male and female patients with AGA versus their respective control subjects. Mean values of fibrinogen were significantly higher in male patients with AGA, whereas values of fibrogen, C-reactive protein, and D-dimers were significantly higher in female patients with AGA versus their respective control subjects.

LIMITATIONS: The study of a wider sample of patients with AGA would confirm these findings and allow a detailed analysis of the above factors as a function of the degree of alopecia or between menopausal and premenopausal women.

CONCLUSION: The determination of metabolic syndrome and ultrasound study of the carotid arteries may be useful screening methods to detect risk of developing cardiovascular disease in male and female patients with early-onset AGA and signal a potential opportunity for early preventive treatment.

Male pattern baldness is not associated with established cardiovascular risk factors in the general population.

Ellis JA, Stebbing M, Harrap SB.

Department of Physiology, The University of Melbourne, Victoria 3010, Australia.

Clin Sci (Lond) 2001 Apr;100(4):401-4 Abstract quote

A number of studies have shown an association between male pattern baldness (MPB) and cardiovascular disease. Few of these studies, however, have examined whether MPB is a novel risk factor, or is associated with abnormalities of established coronary risk factors.

We have therefore performed an analysis of MPB and cardiovascular risk factors in the general population. A total of 1219 male participants aged 18-70 years from the Victorian Family Heart Study were surveyed using a validated questionnaire for degree and pattern of baldness. Carefully standardized measures of height, weight, blood pressure, pulse rate, total and high-density lipoprotein cholesterol, and plasma fibrinogen were made. Subjects were grouped according to the degree and pattern of baldness as: no baldness, frontal baldness and vertex baldness. Bald men were older than non-bald men (P < 0.0001). Age was also associated with increased levels of coronary risk factors (P < 0.0001).

When multiple regression was used to adjust for age differences, the levels of coronary risk factors were not significantly different between the bald and non-bald groups.

The lack of association between baldness and established coronary risk factors implies that baldness may predispose to coronary heart disease through novel mechanisms yet to be defined.

Early onset of androgenetic alopecia associated with early severe coronary heart disease: a population-based, case-control study.

Matilainen VA, Makinen PK, Keinanen-Kiukaanniemi SM.

Department of Public Health Science and General Practice, University of Oulu, Finland.

J Cardiovasc Risk 2001 Jun;8(3):147-51 Abstract quote

CONTEXT: The relationship of ischaemic heart disease (IHD) with androgenic alopecia (AGA) has been demonstrated, but no differentiation between early and late onsets of alopecia with regard to the risk and severity of IHD has been made.

OBJECTIVE: To test if the early onset of alopecia is a risk factor for early severe, coronary artery disease (CAD) requiring surgery and to test if the early onset of AGA differs in this respect from the late onset of AGA.

DESIGN: Population-based case-control study.

SETTING AND PARTICIPANTS: All the 85 male persons living on 31 December 1999 in a Finnish town with total population of 7200, who had had a coronary revascularization procedure between March 1987 and January 1999, were drawn from the discharge register. For each case, an individually selected age-matched control person living in the same town was drawn from the official census register.

MAIN OUTCOME MEASURE: Alopecia defined as grade 3 vertex or more on the alopecia classification scale of Hamilton, modified by Norwood South Med J, 68:1359-1365, 1975.

RESULTS: The unadjusted odds ratio (OR) for coronary revascularization under the age of 60 years was 3.57 (95% confidence interval (CI) 1.19-10.72) in men with an early onset of AGA compared with men with normal hair status or late AGA. After multivariate adjustment for the traditional CAD risk factors, the corresponding OR was 3.18 (95% CI, 1.01-10.03). The unadjusted OR for the coronary revascularization procedure at any age was 2.14 (95% CI, 1.08-4.23) in the subgroup of the men with early AGA compared to those with late AGA or normal hair status. After adjustment for traditional risk factors this OR was 1.84, being nearly significant (95% CI, 0.90-3.77).

CONCLUSION: Our results support the hypothesis that the early onset of AGA is a risk factor for an early onset of severe coronary heart disease.


Acquired hair fragility in pili anulati: causal relationship with androgenetic alopecia.

Hofbauer GF, Tsambaos D, Spycher MA, Trueb RM.

Department of Dermatology, University Hospital, Zurich, Switzerland.

Dermatology 2001;203(1):60-2 Abstract quote

Pili anulati are defined by characteristic alternating light and dark banding in the hair shaft, due to air-filled spaces between the macrofibrillar units of the hair cortex, and are regarded as a congenital hair shaft disorder without increased hair fragility.

Two cases of pili anulati are presented, in which fragility of hair developed in a causal relationship with the onset of androgenetic alopecia. Accordingly, trichorrhexis-nodosa-like hair fracturing was exclusively limited to the androgenetic region.

In general, secondary trichorrhexis nodosa is an unspecific finding related to excess stress of hair in relation to its fragility. With onset of hair thinning due to androgenetic alopecia, progressive reduction of hair shaft diameter may cause increased fragility in pili anulati. In this case, hair shaft fracturing occurs within the area of androgenetic alopecia and colocalizes with the air-filled cavities of pili anulati.



Possible mechanisms of miniaturization during androgenetic alopecia or pattern hair loss.

Whiting DA.

Baylor Hair Research and Treatment Center, Dallas, TX 75246, USA.

J Am Acad Dermatol 2001 Sep;45(3 Suppl):S81-6 Abstract quote

In androgenetic alopecia, or pattern hair loss, follicles undergo miniaturization, shrinking from terminal to vellus-like hairs. Traditionally, this process is thought to progress gradually over a number of follicular cycles. However, it is unlikely that miniaturization can be explained only by a series of progressively shorter anagen cycles. Simple calculations show that this process would take too long for significant miniaturization to occur secondary to shorter anagen cycles alone, especially in view of the latent lag period seen in pattern hair loss that occurs between the loss of a telogen hair and the appearance of an anagen hair.

Evidence is presented to support a new concept that miniaturization is an abrupt, large-step process that also can be reversed in 1 hair cycle, as has been shown clinically, with confirmatory histologic evidence, in patients with pattern hair loss responding to finasteride treatment.

It is hypothesized that the miniaturization seen with pattern hair loss may be the direct result of reduction in the cell number and, hence, size of the dermal papilla.

Expression of androgen receptor coactivator ARA70/ELE1 in androgenic alopecia.

Lee P, Zhu CC, Sadick NS, Diwan AH, Zhang PS, Liu JS, Prieto VG.

Department of Pathology, The University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA.

: J Cutan Pathol. 2005 Sep;32(8):567-71. Abstract quote  

Background: Androgens have been implicated in androgenic alopecia as evidenced by the increased cutaneous expression of androgen receptor (AR), 5alpha-reductase, and decreased aromatase. Abnormalities of the AR-signal transduction pathway probably participate in the development of androgenic alopecia. ARA70/ELE1 is an AR coactivator with two isoforms, one full-length form (ARA70alpha/ELE1alpha), and an internally deleted form (ARA70beta/ELE1beta). We decided to examine the cutaneous expression of both isoforms in male androgenic alopecia.

Methods: Formalin-fixed, paraffin-embedded tissue sections from seven subjects with androgenic alopecia with matched punch biopsies from non-balding and balding areas were examined by in situ hybridization.

Results: Expression of at least one of the two probes for ARA70/ELE1 was present in all phases of the hair-growth cycle in all epithelial hair structures except for the inner root sheath. The dermal papilla and hair bulb expressed only the short (beta) but not the long (alpha) form of ARA70/ELE1. In situ labeling for ARA70beta/ELE1beta was weaker in the dermal papilla of balding recipient areas than those from donor ones.

Conclusions: Our data further support that the hair growth is regulated by androgens. The differential expression pattern of ARA70/ELE1 suggests that this key androgen receptor coactivator is involved in androgenic alopecia.

Polymorphism of the androgen receptor gene is associated with male pattern baldness.

Ellis JA, Stebbing M, Harrap SB.

Department of Physiology, The University of Melbourne, Victoria, Australia.

J Invest Dermatol 2001 Mar;116(3):452-5 Abstract quote

The common heritable loss of scalp hair known as male pattern baldness or androgenetic alopecia affects up to 80% of males by age 80. A balding scalp is characterized by high levels of the potent androgen dihydrotestosterone and increased expression of the androgen receptor gene.

To determine if the androgen receptor gene is associated with male pattern baldness, we compared allele frequencies of the androgen receptor gene polymorphisms (StuI restriction fragment length polymorphism and two triplet repeat polymorphisms) in cases with cosmetically significant baldness (54 young and 392 older men) and controls (107 older men) with no indication of baldness. The androgen receptor gene StuI restriction site was found in all but one (98.1%) of the 54 young bald men (p = 0.0005) and in 92.3% of older balding men (p = 0.000004) but in only 76.6% of nonbald men. The combination of shorter CAG and GGC triplet repeat lengths was also more prevalent in bald men (p = 0.03).

The ubiquity of the androgen receptor gene StuI restriction site, and higher incidence of shorter triplet repeat haplotypes in bald men suggests that these markers are very close to a functional variant that is a necessary component of the polygenic determination of male pattern baldness. Functional mutation in or near the androgen receptor gene may explain the reported high levels of expression of this gene in the balding scalp.


An Investigation of Apoptosis in Androgenetic Alopecia

Shawn E. Cowper, M.D.; Arlene S. Rosenberg, M.D.; Michael B. Morgan, M.D.

Am J Dermatopathol 2002; 24(3):204-208 Abstract quote

While the androgens, including dihydrotestosterone (DHT), have been implicated in the development of androgenetic alopecia (AGA), the exact mechanism by which they exert their effects is unknown.

As apoptosis is an integral component of the normal cycling of human hair, we investigated individuals clinically affected by AGA to assess whether objective differences in the expression of apoptosis related immunohistochemical markers could be observed in scalp biopsies.

Specimens from 13 alopecic male cadavers were stained with bcl-2 and terminal deoxynucleotidetransferase dUTP fluorescein nick end-labeling (TUNEL) methods to assess apoptotic activity in affected and unaffected areas of the scalp. Immunoreactivity was analyzed by quantifying nuclear staining differences within the same individual. Sections from two living human volunteers were obtained to establish the method validity. Significant differences in bcl-2 expression were observed between areas of the scalp clinically affected and unaffected by AGA. The Gaussian distribution of bcl-2 staining suggests that a relatively uniform population of follicles exists at the frontal hairline and/or synchrony of follicular cycling occurs in AGA.

The apoptosis "hot spot" described by TUNEL staining in the bulge-isthmus region of the murine follicle is also identifiable in the human follicle.




Contrast enhanced phototrichogram (CE-PTG): an improved non-invasive technique for measurement of scalp hair dynamics in androgenetic alopecia--validation study with histology after transverse sectioning of scalp biopsies.

Van Neste DJ.

Skinterface Sprl, 9, rue du Sondart, B 7500 Tournai, Belgium.

Eur J Dermatol 2001 Jul-Aug;11(4):326-31 Abstract quote

Global changes of scalp hair represent the cumulative end result of discrete changes of individual hair follicle structure and/or function. Monitoring of such changes requires an accurate non-invasive method. The phototrichogram (PTG) appears to be an appropriate choice to do so. However, a known weakness of the method is the lack of detection of less pigmented or thinning hair.

Balding scalp of male subjects with androgenetic alopecia (AGA) was analysed with our previously published PTG method and with contrast enhanced (CE-)PTG followed by biopsy and transverse section examination with the light microscope. As compared with PTG, the CE-PTG method significantly improved detection not only of thin but also of thick hair. Equal numbers of thick (diameter > 40 mm) hair were detected with CE-PTG and with histology. CE-PTG was also able to detect the severely miniaturised hair fiber (down to 8 mm diameter) and was comparable to scalp biopsy analysis. The latter could identify hair fibres, which did not reach the scalp surface, a measure that is considered as not clinically significant. All growth stages - anagen, catagen and telogen - as well as the empty follicle stage could clearly be observed with CE-PTG. Staging of the more severely affected hair follicles was not always possible neither with CE-PTG nor histology - even with serial sectioning.

The finding of such technological advantages makes the CE-PTG a first choice method for detailed analysis of hair cycling in androgenetic alopecia - a scalp disorder characterised by extreme hair follicle miniaturisation, decreased hair pigmentation and hair thinning.


Production rates of dihydrotestosterone in healthy men and women and in men with male pattern baldness: determination by stable isotope/dilution and mass spectrometry.

Vierhapper H, Nowotny P, Maier H, Waldhausl W.

Division of Endocrinology and Metabolism, Department of Internal Medicine III, University of Vienna, A-1090 Vienna, Austria

J Clin Endocrinol Metab 2001 Dec;86(12):5762-4 Abstract quote

Production rates of dihydrotestosterone (DHT) were determined in healthy men (n = 8), in healthy women during the follicular phase of their menstrual cycle (n = 7), and in young men with male pattern baldness (n = 8) using the stable isotope dilution technique and mass spectrometry.

[2,3,4-(13)C]DHT was infused for 10 h at doses of 15 microg/h (men) and 2 microg/h (women), and blood samples were obtained at 20-min intervals during the last 4 h of the observation period. Production rates estimated between April and June were 2.9 +/- 1.1 microg/h (women) and 17.8 +/- 6.2 microg/h (men).

In men production rates of DHT were similar (16.2 +/- 7.7 microg/h) when the investigation was repeated between October and December. Mean production rates of DHT in young men with male pattern baldness (60 +/- 50 microg/h) were higher than those in healthy men (P < 0.005). Although this group included two individuals with normal production rates of DHT, the production rate of DHT was markedly elevated (range, 32.0-161.0 microg/h) in the remaining patients. Stable isotope-labeled infusions of DHT are suitable for clinical use in a routine setting to obtain analytically correct estimates of DHT production in vivo.

In the majority of men with male pattern baldness endogenous production of DHT is markedly increased, providing a rationale for therapeutic 5 alpha-reductase inhibition in this disorder.


GENERAL In women, three main patterns have been identified. There is a diffuse frontal-vertical thinning, male pattern type, and diffuse thinning of the vertex. The second type may be accompanied with virilism.


Female-patterned alopecia in teenage brothers with unusual histologic features.

Department of Pathology, Divisions of Dermatopathology and Dermatology, Albany Medical College, New Scotland Ave, Albany, NY, USA.


J Cutan Pathol. 2006 Nov;33(11):741-8 Abstract quote

Background: Patterned hair loss, follicular miniaturization, and increased telogen hair counts characterize androgenic alopecia (AGA). Follicular inflammation in AGA has been associated with treatment resistance and progressive hair loss.

Case report: Brothers, 15 and 18 years old, presented with frontal and mid-scalp hair loss with an intact frontal hairline noted over a 1-year period. The elder reported past use of androgenic steroids. Laboratory assessment for metabolic and hormonal abnormalities was unrevealing, and hair pull test was negative. Scalp biopsies revealed decreased terminal hairs, marked diameter variation of anagen hairs, decreased terminal to vellus hair ratios (3.7:1/3.4:1, older/younger), and increased telogen counts (23%/21%). Infrabulbar and peri-isthmic (follicular bulge region) lymphocytic infiltrates were present. Hair loss has progressed, unabated by daily topical 0.5% clobetasol (for 6 months), daily 5% minoxidil (1 year), and latter, daily oral finasteride (2 years - older brother only).

Discussion: Based on patterned hair loss and miniaturized hairs, these brothers have AGA. The female pattern of hair loss (diffuse hair loss affecting the central scalp with preservation of frontal hair line) coupled with follicular isthmic lymphocytic inflammation represents an unusual presentation, possibly a treatment resistant, inflammatory variant of AGA. The differential diagnosis includes exogenous androgen-mediated hair loss, cicatricial pattern hair loss, or the superimposition of alopecia areata.

Diagnostic and predictive value of horizontal sections of scalp biopsy specimens in male pattern androgenetic alopecia.

Whiting DA.

University of Texas, Southwestern Medical Center, Dallas.

J Am Acad Dermatol 1993 May;28(5 Pt 1):755-63 Abstract quote

BACKGROUND: Vertical sections of small scalp biopsy specimens are often inadequate for the diagnosis of male pattern androgenetic alopecia (MPAA). Quantitative analysis of follicular structures in horizontal sections can provide more information.

OBJECTIVES: Our purpose was to establish better diagnostic criteria by comparing horizontal and vertical sections of scalp biopsy specimens from MPAA and normal control subjects and to determine the predictive value of horizontal sections, by relating counts of follicular structures in MPAA to subsequent hair regrowth from topical minoxidil therapy.

METHODS: Paired 4 mm punch biopsy specimens were taken from 22 normal control subjects and 106 patients with MPAA, for horizontal and vertical sectioning. In horizontal sections, hair bulbs, terminal anagen, catagen and telogen hairs, telogen germinal units, and vellus hairs were counted, as were follicular units and stelae.

RESULTS: The diagnosis of MPAA was confirmed by finding decreased terminal hairs and increased stelae and vellus hairs. The average horizontal section contained 22 terminal and 13 vellus hairs, a 1.7:1 ratio. Changes compatible with MPAA were found in most vertical and horizontal sections, but horizontal sections were required for follicular counts and showed terminal:vellus hair ratios diagnostic of MPAA in 67% of cases. Of 44 patients treated with topical minoxidil, five with less than 2 follicular structures/mm2 showed no hair regrowth, 32 with 2 to 4 follicular structures/mm2 showed regrowth in 72%, and seven with more than 4 follicular structures/mm2 showed regrowth in 86% of cases. In MPAA with no significant inflammation, regrowth occurred in 77% of cases, versus 55% in cases with significant inflammation.

CONCLUSION: Horizontal sections of scalp biopsy specimens in MPAA provide more diagnostic information than vertical sections and appear to have a predictive value for hair regrowth.


Fibrosing alopecia in a pattern distribution: patterned lichen planopilaris or androgenetic alopecia with a lichenoid tissue reaction pattern?

Zinkernagel MS, Trueb RM.

Department of Dermatology, University Hospital of Zurich, Switzerland.

Arch Dermatol 2000 Feb;136(2):205-11 Abstract quote

BACKGROUND: Androgenetic alopecia is characterized by a defined area of progressive nonscarring alopecia. The clinical and histological findings in 15 women and 4 men with progressive scarring alopecia in a pattern distribution were studied. The results were evaluated and compared with clinicopathologic entities that feature scarring of the central scalp area, specifically, lichen planopilaris, pseudopelade, and follicular degeneration syndrome.

OBSERVATIONS: Patients developed progressive fibrosing alopecia of the central scalp, without the multifocal areas of involvement typical of lichen planopilaris and pseudopelade. Perifollicular erythema, follicular keratosis, and loss of follicular orifices were limited to a patterned area of involvement. Biopsy specimens of early lesions demonstrated hair follicle miniaturization and a lichenoid inflammatory infiltrate targeting the upper follicle region. Advanced lesions showed perifollicular lamellar fibrosis and completely fibrosed follicular tracts indistinguishable from end-stage lichen planopilaris, pseudopelade, or follicular degeneration syndrome.

CONCLUSIONS: Some patients with androgenetic alopecia might have additional clinical and histological features of inflammation and fibrosis limited to the area of androgenetic hair loss. In these patients, the histological findings of early lesions are identical to those seen in lichen planopilaris. The lichenoid tissue reaction leading to follicular destruction in these patients might be pathogenetically related to the events underlying androgenetic alopecia


Distinguishing androgenetic alopecia from chronic telogen effluvium when associated in the same patient: a simple noninvasive method.

Rebora A, Guarrera M, Baldari M, Vecchio F.

Department of Endocrinological and Metabolic Sciences, Section of Dermatology, University of Genoa, Genoa, Italy.
Arch Dermatol. 2005 Oct;141(10):1243-5. Abstract quote  

BACKGROUND: Distinguishing chronic telogen effluvium (CTE) from androgenetic alopecia (AGA) may be difficult especially when associated in the same patient.

OBSERVATIONS: One hundred consecutive patients with hair loss who were clinically diagnosed as having CTE, AGA, AGA + CTE, or remitting CTE. Patients washed their hair in the sink in a standardized way. All shed hairs were counted and divided "blindly" into 5 cm or longer, intermediate length (>3 to <5 cm), and 3 cm or shorter. The latter were considered telogen vellus hairs, and patients having at least 10% of them were classified as having AGA. We assumed that patients shedding 200 hairs or more had CTE. The kappa statistic revealed, however, that the best concordance between clinical and numerical diagnosis (kappa = 0.527) was obtained by setting the cutoff shedding value at 100 hairs or more. Of the 100 patients, 18 with 10% or more of hairs that were 3 cm or shorter and who shed fewer than 100 hairs were diagnosed as having AGA; 34 with fewer than 10% of hairs that were 3 cm or shorter and who shed at least 100 hairs were diagnosed as having CTE; 34 with 10% or more of hairs that were 3 cm or shorter and who shed at least 100 hairs were diagnosed as having AGA + CTE; and 14 with fewer than 10% of hairs that were 3 cm or shorter and who shed fewer than 100 hairs were diagnosed as having CTE in remission.

CONCLUSION: This method is simple, noninvasive, and suitable for office evaluation.



Management of androgenetic alopecia.

Bolduc C, Shapiro J.

Division of Dermatology, Health Sciences Centre, Vancouver Hospital, Vancouver, Canada. \

QAm J Clin Dermatol 2000 May-Jun;1(3):151-8 Abstract quote

Androgenetic alopecia is by far the most common cause of hair loss. It affects approximately 50% of men by the age of 50 and 20 to 53% of women by the age 50. Although it is a medically benign condition, it is a significant psychosocial issue for many patients. Various different treatment options are now available for androgenetic alopecia.

The best treatment option for women with androgenetic alopecia Ludwig stage I and II is minoxidil 5% solution. If it is not effective after 1 year, antiandrogens can be tried, but there are no large studies showing their efficacy and they have considerable adverse effects. Also, for patients with alopecia that is unresponsive to treatment or with Ludwig stage III, hair transplantation can be offered if the occipital donor area is sufficient.

For men, we always offer minoxidil or finasteride therapy and leave the choice of therapy to the patient. Some patients may prefer a systemic agent, whereas others may favor a topical agent. If the condition is not stabilized after 1 year or if the patient wants greater hair density, hair transplantation can be discussed.

There have been tremendous advances in the treatment of hair loss in recent years and the future is very encouraging. As our knowledge of androgenetic alopecia pathophysiology increases, novel targeted treatments will potentially be developed.


Finasteride: a review of its use in male pattern hair loss.

McClellan KJ, Markham A.

Adis International Limited, Mairangi Bay, Auckland, New Zealand.

Drugs 1999 Jan;57(1):111-26 Abstract quote

The 5alpha-reductase inhibitor finasteride blocks the conversion of testosterone to dihydrotestosterone (DHT), the androgen responsible for male pattern hair loss (androgenetic alopecia) in genetically predisposed men.

Results of phase III clinical studies in 1879 men have shown that oral finasteride 1 mg/day promotes hair growth and prevents further hair loss in a significant proportion of men with male pattern hair loss. Evidence suggests that the improvement in hair count reported after 1 year is maintained during 2 years' treatment. In men with vertex hair loss, global photographs showed improvement in hair growth in 48% of finasteride recipients at 1 year and in 66% at 2 years compared with 7% of placebo recipients at each time point. Furthermore, hair counts in these men showed that 83% of finasteride versus 28% of placebo recipients had no further hair loss compared with baseline after 2 years.

The clinical efficacy of oral finasteride has not yet been compared with that of topical minoxidil, the only other drug used clinically in patients with male pattern hair loss. Therapeutic dosages of finasteride are generally well tolerated.

In phase III studies, 7.7% of patients receiving finasteride 1 mg/day compared with 7.0% of those receiving placebo reported treatment-related adverse events. The overall incidence of sexual function disorders, comprising decreased libido, ejaculation disorder and erectile dysfunction, was significantly greater in finasteride than placebo recipients (3.8 vs 2.1%). All sexual adverse events were reversed on discontinuation of therapy and many resolved in patients who continued therapy. No other drug-related events were reported with an incidence > or =1% in patients receiving finasteride. Most events were of mild to moderate severity. Oral finasteride is contraindicated in pregnant women because of the risk of hypospadias in male fetuses. C

ONCLUSIONS: Oral finasteride promotes scalp hair growth and prevents further hair loss in a significant proportion of men with male pattern hair loss. With its generally good tolerability profile, finasteride is a new approach to the management of this condition, for which treatment options are few. Its role relative to topical minoxidil has yet to be determined.

Changes in hair weight and hair count in men with androgenetic alopecia after treatment with finasteride, 1 mg, daily.

Price VH, Menefee E, Sanchez M, Ruane P, Kaufman KD.

University of California, San Francisco, Trichos Research, Richmond, and Biostatistics and Clinical Research, Merck Research Laboratories, Rahway.

J Am Acad Dermatol 2002 Apr;46(4):517-23 Abstract quote

BACKGROUND: Finasteride, a type II 5alpha-reductase inhibitor, reduces scalp and serum dihydrotestosterone and has been shown to be effective in men with androgenetic alopecia (AGA).

OBJECTIVE: The purpose of this study was to determine the effect of finasteride on scalp hair weight in men with AGA.

METHODS: Sixty-six men with AGA received finasteride, 1 mg/d, or placebo in a 48-week study, and 49 men continued in a 48-week extension. Efficacy was assessed by scalp hair weights and hair counts.

RESULTS: As expected, hair counts improved with finasteride (net mean percent change +/- SE [95% CI] compared with placebo = 9.2% +/- 2.8% [3.8, 14.6] and 15.4% +/- 3.2% [9.1, 21.7] at 48 and 96 weeks, respectively; P <.01 for both time points), and net improvements in hair weight were greater (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). Finasteride was generally well tolerated.

CONCLUSION: In this study, finasteride, 1 mg, increased hair weight in men with AGA. Hair weight increased to a larger extent than hair count, implying that factors other than the number of hairs, such as increased growth rate (length) and thickness of hairs, contribute to the beneficial effects of finasteride in treated men.

Hair loss in women with hyperandrogenism: Four cases responding to finasteride.

Shum KW, Cullen DR, Messenger AG.

Departments of Dermatology and Endocrinology, Royal Hallamshire Hospital.

J Am Acad Dermatol 2002 Nov;47(5):733-9 Abstract quote

Oral finasteride, a type II 5 alpha-reductase inhibitor, has been shown to increase hair growth and slow progression of thinning in men with androgenetic or male pattern balding (Hamiliton type) but has no affect on hair growth in postmenopausal women with female pattern hair loss (Ludwig type).

We describe 4 cases of hair loss with characteristics of both male and female patterns in women with hyperandrogenism in which finasteride has improved or stabilized the alopecia. Improved hair growth was seen after 6 months, 1 year, 2 years, and 2.5 years, respectively.

The finding that finasteride treatment improves pattern hair loss in women with hyperandrogenism but does not affect those postmenopausal women with female pattern hair loss without hyperandrogenism supports the concept that not all types of female hair loss have the same pathophysiology.


Topical minoxidil useful in 18% of patients with androgenetic alopecia: a study of 430 cases.

Tosti A.

Dermatologica 1986;173(3):136-8 Abstract quote

A 1% minoxidil lotion was used to treat 670 male patients affected by androgenetic alopecia. Of the 430 patients who completed the 6 months' treatment, only 78 (18%) had good results.

A 1-year follow-up after the drug was suspended showed that the regrowth was present only in 33% of the patients who had good results, i.e. 6% of the 430.

Five-year follow-up of men with androgenetic alopecia treated with topical minoxidil.

Olsen EA, Weiner MS, Amara IA, DeLong ER.

Department of Medicine, Duke University Medical Center, Durham, NC 27710.

J Am Acad Dermatol 1990 Apr;22(4):643-6 Abstract quote

Thirty-one men with androgenetic alopecia completed 4 1/2 to 5 years of therapy with 2% and 3% topical minoxidil. Hair regrowth with topical minoxidil tended to peak at 1 year with a slow decline in regrowth over subsequent years.

However, at 4 1/2 to 5 years, maintenance of nonvellus hairs beyond that seen at baseline was still evident. Topical minoxidil appears to be effective in helping to maintain nonvellus hair growth in men with androgenetic alopecia.

A randomized clinical trial of 5% topical minoxidil versus 2% topical minoxidil and placebo in the treatment of androgenetic alopecia in men.

Olsen EA, Dunlap FE, Funicella T, Koperski JA, Swinehart JM, Tschen EH, Trancik RJ.

Duke Dermatopharmacology Study Center, Durham, North Carolina, USA.

J Am Acad Dermatol 2002 Sep;47(3):377-85 Abstract quote

BACKGROUND: Topical minoxidil solution 2% stimulates new hair growth and helps stop the loss of hair in individuals with androgenetic alopecia (AGA). Results can be variable, and historical experience suggests that higher concentrations of topical minoxidil may enhance efficacy.

OBJECTIVE: The purpose of this 48-week, double-blind, placebo-controlled, randomized, multicenter trial was to compare 5% topical minoxidil with 2% topical minoxidil and placebo in the treatment of men with AGA.

METHODS: A total of 393 men (18-49 years old) with AGA applied 5% topical minoxidil solution (n = 157), 2% topical minoxidil solution (n = 158), or placebo (vehicle for 5% solution; n = 78) twice daily. Efficacy was evaluated by scalp target area hair counts and patient and investigator assessments of change in scalp coverage and benefit of treatment.

RESULTS: After 48 weeks of therapy, 5% topical minoxidil was significantly superior to 2% topical minoxidil and placebo in terms of change from baseline in nonvellus hair count, patient rating of scalp coverage and treatment benefit, and investigator rating of scalp coverage. Hair count data indicate that response to treatment occurred earlier with 5% compared with 2% topical minoxidil. Additionally, data from a patient questionnaire on quality of life, global benefit, hair growth, and hair styling demonstrated that 5% topical minoxidil helped improve patients' psychosocial perceptions of hair loss. An increased occurrence of pruritus and local irritation was observed with 5% topical minoxidil compared with 2% topical minoxidil.

CONCLUSION: In men with AGA, 5% topical minoxidil was clearly superior to 2% topical minoxidil and placebo in increasing hair regrowth, and the magnitude of its effect was marked (45% more hair regrowth than 2% topical minoxidil at week 48). Men who used 5% topical minoxidil also had an earlier response to treatment than those who used 2% topical minoxidil. Psychosocial perceptions of hair loss in men with AGA were also improved. Topical minoxidil (5% and 2%) was well tolerated by the men in this trial without evidence of systemic effects.

Commonly Used Terms

Arao-Perkins bodies-Small elastin bodies present in the connective tissue streamers which are present beneath the vellus follicles. Indicative of sites of the papillae of each preceeding hair follicle.

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