492 JOURNAL OF COSMETIC SCIENCE UPDATE ON THE DIAGNOSIS AND TREATMENT OF COMMON CAUSES OF ALOPECIA AND POTENTIAL INTERACTION OF HAIR COSMETICS Elise A. Olsen, M.D. Duke University Medical Center Alopecia is a very common problem, affecting at least 50% of the US population by age 50. The spectrum includes those with barely discernable hair loss to those with near total baldness and may be of hereditary, hormonal, or infectious etiology, self induced, or related to underlying medical problems or medications. The problem is particularly vexing in women in whom the differential diagnosis for the alopecia is broad. This is also the very population who, with the concomitant use of certain hair products, may either aggravate the underlying condition or initiate a new confounding problem. The most common type of hair loss is hereditary --male pattern hair loss (MPHL)--occurring in almost 50% of men by age 50. This condition is androgen related, proven initially by Hamilton through the observation of hair loss in eunuchs only after testosterone supplementation. The specific change in the hair is a decrease in the diameter of the hair, the amount of hair in anagen, and the duration of anagen along with a prolongation of ketogen, the lag phase after ejection of the telogen hair and before anagen. The specific importance of dihydrotestosterone (DHT) was noted through the absence of MPHL in adult males with the genetic condition of 5 alpha reductase deficiency in which testosterone is unable to be metabolized to DHT and by the hair regrmvth demonstrated in about 2/3 of men ages 18-41 who were treated with finasteride, a 5 alpha reductase blocker. Why the other 1/3 of men with MPHL did not respond to finasteride is uncertain: the answer could be in the incomplete suppression of DHT with finasteride (which suppresses the serum and scalp levels of DIrT by about 2/3), the amount of 5 alpha reductase in an individual's affected scalp, the amount of androgen receptor in ma individual's affected scalp, or the amount of fibrosis in the affected scalp and hence irreversibility of the hair loss. Inflammation is also seen histologically in MPHL and how this effects the hair loss and whether this inflammation should. be a therapeutic target is unknown. These are important questions that need to be answered to fully understand MPHL. We do know that one can stimulate hair grmvth without affecting the amount of DHT present in the scalp. Topical minoxidil 5% applied twice daily is able to lead to discernable hair growth in 58% of men with MPHL at one year. This hair growth is maximum at about 4 months but still persistent at one year and later. It is thought that minoxidil, a calcium channel opener, encourages hair growth by the promotion of anagen and increasing the duration of anagen. Topical minoxidil is delivered in a vehicle of alcohol and propylene glycol which can be irritating, especially to those with underlying atopic dermatitis or seborrheic dermatitis. To use this agent effectively, patients must make sure that concurrent hair care products do not dry the scalp or are inherently irritating themselves. Although MPHL is the most common type of hair loss, the most common causes of hair loss for which patients seek medical attention are (in order of patient volume, not severity) female pattern hair loss, alopecia areata, telogen effluvium and cicatricial alopecia. These conditions can be clinically separated by the pattern of hair loss the number, location and type of hair removed by hair pull examination, microscopic examination of the distal ends of hairs collected from the hair pull, and scalp biopsy. Female pattern hair loss (FPHL) has t•vo main times of onset-- post-puberty to early 3 ra decade and early 5 • decade through menopause--and 3 possible patterns of hair loss, all involving the central scalp. Clinically there may be diffuse hair loss over the entire top of the scalp (Ludwig), frontal accentuation (Olsen) or male pattern of loss (Hamilton). The male pattern of hair loss (rare)

2004 ANNUAL SCIENTIFIC SEMINAR 493 and either of the other two patterns of loss when accompanied by hirsutism or oligomenorrhea are almost always associated with hyperandrogenemia. Most women with FPHL, hmvever, have neither signs nor laboratory abnormalities suggestive of androgen excess. Anti-androgens (ex, spironolactone) have not been shown to be uniformly effective in FPHL but rather only in a smaller subgroup of these women with hyperandrogenemia. Similarly, finasteride has been reported to be effective only in those women with FPHL who also have hyperandrogenemia and not to be useful in postmenopausal women with FPHL without these signs. Thus there appears to be a discordant response to anti androgens or 5 alpha reductase inhibitors in women with the clinical pattern of FPHL with or without androgen excess. This is an important distinction since no further progression can occur in basic or clinical research in this area without evaluating these two groups of women separately. Treatment for FPHL, other than systemic therapy in a select population as noted above, is today primarily topical minoxidil. Although the 5% topical minoxidil solution is not FDA approved for women, it has been tested and found to be more effective than the 2% topical minoxidil therapy. The alcohol and propylene glycol base of topical minoxidil offer certain challenges for uses. The alcohol dries the hair and scalp and the propylene glycol (higher in the 5% preparation than the 2% preparation) makes the fine hair limp (and most women •vith FPHL do have fine hair). Those women who apply hair color, especially those in the older age group, report that the color is stripped off much more quickly from the roots when using Rogaine. The cosmetic challenge is to find hair shampoos and/or conditioners that moistufize the fine hair without making it limp and hair color that is resistant to alcohol based vehicles. Other major types of hair loss such as alopecia areata, telogen effluvium, and trichotillomania, do not effect the caliber of the hair, just the density of the hair and the involved hair in these conditions should not require any special treatment. There is, however, another major cause of hair loss in which the hair requires special handling but for which presently there is a void in specific products to recommend. Follicular degeneration syndrome or central centrifugal cicatricial alopecia is a condition that occurs almost exclusively in African American women (and some African American men) in which the central scalp hair is permanently lost. It has been blamed on hair cosmetics including relaxers, permanents or heat processing, but the relatedness of these to the hair loss has never been proven. The hair follicle of Negroid lineage is much more curved and generally thicker in diameter than Oriental or Causcasian hair leading to tightly curled or kinky hair which is more fragile despite the thickness of the individual hairs. Shampooing, because of its drying effect, must be limited. Emo!lients are necessary to help cut down on the friction when combing the hair although many times the products used are occlusive, potentially irritating and may serve as a nidus for infection. Trauma to the curved follicle is invariable when the hair is manipulated by combing or braiding or when permanent wave, relaxer, or heat is applied in order to straighten the hair. The end result is hair breakage and alopecia. Much more information is needed on the relatedness of hair grooming techniques to hair loss and alternative means of grooming and managing African American hair. References: Olsen, EA (ed) Hair Disorders: Diagnosis and Treatment. McGraw Hill, New York, 2003