•442 JOURNAL OF THE SOCIETY OF COSMETIC CHEMISTS ANDROGENIC STIMULATION Many of our patients showed symptoms indicative of androgenic stimu- lation. Seventy-two of our patients complained of heavy oiliness of their scalp, moderate hirsutism was present in five, and slight hirsutism in eight patients. Six patients were previously treated for several years with preparations containing testosterone and oestradiol. We started to measure 17-ketosteroid excretion using Zimmermann's method (21) and in 15 patients we obtained a mean value of 6.55 mg/24 hr ,(with a range of 2.42 - 11.85 mg/24 hr). We then started chromatographic fractionation, and utilized the method of Dingemanse (22), modified by Ahrens (23). Four patients with severe diffuse alopecia, of whom three were also moderately hirsute, were shown to have elevated levels of andro- sterone ranging from 4.54 to 7.06 mg/24 hr. While this observation is of interest, we recognize that the most potent androgen which affects follicles of the scalp is testosterone. The production of testosterone could be increased without affecting the urinary excretion of 17-ketosteroids and, on the other hand, androsterone is a metabolite of several steroids and is not necessarily derived from testosterone. It is also pertinent that Hamilton (17) failed to find abnormally high 17-ketosteroid production in men with extensive and precocious baldness. For these reasons we are now performing direct measurements of testosterone excretion in female patients with diffuse alopecia. Determina- tions of oestrogen and gonadotropin levels are being carried out in parallel. SUMMARY Diffuse alopecia in women occurs more frequently than is generally believed. In 102 patients examined within a period of three years the following three types were observed: (1) Diffuse sparseness of the hair involving the whole vertex, (2) orbicular thinning of the hair around the crown, resembling a small scull-cap, and (3) diffuse sparseness of the hair on the vertex, combined with fronto- parietal recessions imitating the pattern of common baldness. Although there is no universal agreement concerning the nature and etiology of these forms of diffuse alopecia in women, they are considered to be the expression of common baldness in the female sex. As common baldness is the result of androgenic stimulation of scalp hair follicles with a genetically determined increased responsiveness to androgens, the heredity aspects and the symptoms of androgenic stimulation were studied. Eighty- two (80%) of the patients had bald, first degree relatives. Seventy-two (70%) complained of oiliness of the scalp indicating androgenic stimulation

ALOPECIA IN WOMEN : ITS CLINICAL FORMS AND PROBABLE CAUSES 443 of the sebaceous glands. The values of urinary 17-ketosteroids determined in 15 patients were within normal limits. In four patients increased values of androsterone (ranging from 4.54 to 7.06 mg/24 hr) were found by chromato- graphic separation of the total urinary 17-ketosteroids. At present, direct measurements of testosterone excretion values are being carried out in female patients with diffuse alopecia. Parallel deter- minations of oestrogens and gonadotropin levels are also being performed. (Received .' loth April 1964.) REFERENCES (1) R. Sabouraud Les maladies sdborrhdiques (243-248) (1902) (Masson & Cie., Paris). (2) L. McCarthy Diagnosis and treatment of diseases of the hair 492 (1944) (C. V. Mosby Company, St. Louis). (3) E. Juster Presse todd. 56 252 (1948). (4) H. T. Behrman The Scalp in Health and Disease 177 (1952) (C. V. Mosby Company, St. Louis). (5) E. Ludwig Hautarzt 13 338 (1962). (6) E. Ludwig Parfiimerie u. Kosmetik 43 373 (1962). (7) F. Tenchio Dermatologica 115 743 (1957). (8) M. Sannino and D. Montemurri Minerva dermatol. 32 (Suppl.) 97 (1957). (9) E. Sidi and Bourgeois-Spinasse Presse mid. 66 1767 (1958). (10) M. Binazzi and T. Wierdis Giorn. ital. dermatol. e sifilol. 96 243 (1960). (11) O. Braun-Falco and H. Zaun Arch. hlin. u. exptl. Dermatol. 215 165 (1962). (12) M. B. Sulzberger, V. H. Witten and A. W. Kopf A.M.A. Arch. Dermatol., 81 556 (1960). (13) A.M. Kligman A.M.A. Arch. Dermatol. 83 175-198 (1961). (14) E. Ludwig Arch. klin. u. exptl. Dermatol. In press. (15) M. Binazzi and T. Wierdis Ann. dermatol. syphilig. 89 382 (1962). (16) S. Rothman, see Th. B. Fitzpatrick A.M.A. Arch. Dermatol 84 687 (1961). (17) J. B. Hamilton Ann. N.Y. Acad. Sci. 53 708 (1951). (18) W. Montagna Ann. N.Y. Acad. Sci. 83 362 (1959). (19) J. B. Hamilton and H. Terarda, in R. B. Greenblatt The hirsute female 20 (1963) (Charles C. Thomas, Springfield, Ill.). (20) M. A. Smith and R. S. Wells Arch. Dermatol. and Syphilol. 89 95-98 (1964). (21) •¾. Zimmermann Chemische Bestimmungen yon Steroiden in K6rperfiiissigkeiten 63 {1955) (Springer, Berlin). (22) E. Dingemanse, L. Huis, T. in Veld and S. L. Hartogh-I•atz f. Clin. Endocrinol. and Metabolism 12 66 (1952). (23) D. Ahrens Z. Vitamin-Hormon-u. Fermentforsch. 12 15 (1961). DISCUSSION MR. N.J. VAN ABBE : I see no reference in your paper to the mechanical effect on the hair of women--to what has been called traction alopecia. Does this not account for a number of cases of female alopecia ? THE LECTURER: Traction alopecia is a well defined clinical entity and occurs mainly in the pony style. Such cases were carefully excluded. I would like to add that traction alopecia will occur without all the other accompanying symptoms which I mentioned. MR. N.J. VAN ABBE: Concurrently with loss of hair, as described, one might expect changes in the growth rate and probably in the hair diameter. Can you comment ? THE LECTURER: You are perfectly correct. The reduction in the number