Advise Patients on Self-Management, Prevention of Androgenetic Alopecia and When to Seek Medical Care

There are several types of hair loss, but androgenetic alopecia, also referred to as pattern hereditary hair loss, is the most predominant type, affecting more than 50 million men and 30 million women in the United States.^1-4 Androgenetic alopecia is the only type of alopecia for which FDA-approved nonprescription medications are available.¹

Image credit: Nadya Kolobova | stock.adobe.com

Androgenetic alopecia is characterized by gradual and progressive hair loss in a distinctive and reproducible pattern from the scalp.⁵ Although the clinical presentation and degree of severity varies, hair loss is most prominent in the vertex and frontotemporal regions among men. In women, the frontal hairline is characteristically spared with diffuse hair loss at the crown and top of the head, with loss often observed by a wider center part.^1,5

Androgenetic alopecia can be caused by genetic factors, environmental factors, or both. An estimated 13% of premenopausal women reportedly have some evidence of androgenetic alopecia, and an estimated 40% to 70% of women are affected by age 70. It affects an estimated 80% of men by age 80 and affects Caucasian men more than other groups.^1-7

Numerous studies have suggested that elevated levels of dihydrotestosterone and excessive expression of the androgen receptor gene are correlated with the pathogenesis of androgenetic alopecia.⁶

A recent publication in the journal Cureus indicated that the pathogenesis of androgenetic alopecia is contingent on several factors, including age, lifestyle, and hormonal disorders, and this type of hair loss typically affects more individuals of advanced age and with stressful lifestyles.⁶ Literature also indicates that alopecia can negatively affect an individual’s self-esteem and confidence; affect quality of life, including personal and work interactions; and cause embarrassment, depression, and anxiety.¹

As frontline health care providers, pharmacists are likely to encounter patients seeking guidance on therapies for managing and preventing hair loss. Pharmacists can encourage patients to seek medical evaluation from their primary health care provider or dermatologists to identify possible causes of hair loss and initiate appropriate therapy early on. It is important to note that implementing effective patient education initiatives about hair loss and potential treatments, discussing expectations for treatment, and directing patients to valuable patient resources for psychological support are vital components of therapy.

OTC TREATMENT

Currently, the only FDA-approved nonprescription products available for the treatment of androgenetic alopecia in adults include hydroalcoholic topical solutions of minoxidil (Rogaine; Johnson & Johnson) in concentrations of 2% and 5%, and a 5% solvent-free foam.¹ Topical minoxidil is indicated for the treatment of baldness at the crown of the head in men and thinning of hair at the frontoparietal region in women.¹

Minoxidil exerts its pharmacological effects via the influx of calcium ions that upregulate adenosine triphosphate (ATP) synthase, which enhances the process of stem cell differentiation and promotes hair growth; it is typically applied twice daily.^1,6 Both concentrations of topical minoxidil can be used in men and women, but 5% topical minoxidil is typically recommended for use in men.1 Formulations for women are typically 2% concentrations, but 5% formulations are also available for women to use once daily.¹ The most commonly documented adverse effects include contact or irritant dermatitis, pruritus, skin irritation and erythema, and facial hypertrichosis.^1,6,8 Use is not recommended during pregnancy or if breastfeeding.¹

During counseling, pharmacists should educate patients on the proper application of topical minoxidil and remind them to adhere to the manufacturer’s recommendations. Patients should also understand the critical nature of continuous use to maintain hair regrowth because cessation of treatment produces a rapid reversion to the pretreatment balding pattern.¹ Topical minoxidil should not be applied to damaged or inflamed areas of the scalp and should not be applied 24 hours before or after using a hair color, relaxer, or permanent.¹

Patients should also understand that the product may not be effective for everyone and is a suppressive therapy, not a curative one.¹ After initiation of treatment, any noticeable hair growth may take up to 4 months. If hair growth does not occur after 4 months of consistent use, patients should discuss other potential treatments with their primary health care provider.¹

RECENT NEWS AND CLINICAL DATA

In the study published in Cureus, the authors said pharmacological interventions, such as minoxidil, have demonstrated efficacy in promoting hair growth and decelerating hair loss in many individuals. However, the treatments’ effectiveness can vary among patients, and they may be associated with certain adverse drug reactions; the longterm outcomes and maintenance of hair growth with these medications warrant further investigation.⁶

According to a study published in the European Review for Medical and Pharmacological Sciences, the coexistence of androgenetic alopecia and metabolic syndrome may be associated with a large increase in subcutaneous adipose tissue and less favorable metabolic parameters.⁹

A study published in JAAD International indicated that observational reports have documented links between COVID-19 and various types of alopecia, including androgenetic alopecia, alopecia areata, telogen effluvium, and anagen effluvium; however, further research is warranted to understand the correlation.¹⁰

Finally, a study published in Dermatology and Therapy revealed that androgenetic alopecia is complex and multifactorial and may be correlated with endocrine diseases, certain cancers, depression, anxiety, metabolic diseases, cardiovascular diseases, urinary system diseases, nutritional deficiencies, genetic polymorphism, social and daily behaviors, and infection with COVID-19, demonstrating that this type of hair loss may be a complication and manifestation of underlying systemic diseases.¹¹

ROLE OF THE PHARMACIST AND VALUE OF PATIENT EDUCATION

Before recommending the use of OTC hair loss products, pharmacists should establish whether self-treatment is suitable and whether the source of the hair loss has been identified. Patients less than 18 years of age with chronic medical conditions and signs of dermatological infections should always be encouraged to seek care from their primary care physician or dermatologist for further evaluation, especially if the cause of hair loss is unknown, occurs abruptly, and is severe. It is imperative for women who experience abrupt and significant hair loss to seek medical evaluation from their primary care provider to identify causes or contributing factors, including thyroid disorders, polycystic ovary syndrome, or metabolic syndrome.¹

Because of their drug expertise, pharmacists can be instrumental in identifying medications (eg, angiotensin-converting enzyme inhibitors, β-blockers, anticonvulsants, anticoagulants, antidepressants, androgenic agents, and chemotherapeutic agents) that may contribute to or exacerbate hair loss and make clinical recommendations accordingly.¹ Pharmacists can also identify other possible causes of hair loss, including hormonal changes; chronic illness; dietary changes and deficiencies; and local trauma, such as tinea capitis, and encourage patients to seek further medical evaluation to initiate appropriate therapy.¹

About the Author

Yvette C. Terrie, BSPHARM, RPH, is a consulting pharmacist and medical writer in Northern Virginia.

References

1. Berry TM. Hair loss. In: Krinsky DL, Ferreri SP, Hemstreet BA, Hume AL, Rollins CJ, Tietze KJ, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 20th ed. American Pharmacists Association; 2020.
2. Levinbook WS. Alopecia. Merck Manual Professional Version. Updated September 2022. Accessed August 31, 2023. https://www.merckmanuals.com/professional/dermatologic-disorders/hair-disorders/alopecia
3. Adil A, Godwin M. The effectiveness of treatments for androgenetic alopecia: a systematic review and meta-analysis. J Am Acad Dermatol. 2017;77(1):136-141. doi:10.1016/j.jaad.2017.02.054
4. Types of hair loss. NYU Langone Health. Accessed August 30, 2023. https://nyulangone.org/conditions/hair-loss/types
5. Ho CH, Sood T, Zito PM. Androgenetic alopecia. In: StatPearls. StatPearls Publishing; 2023.
6. Bajoria PS, Dave PA, Rohit RK, et al. Comparing current therapeutic modalities of androgenic alopecia: a literature review of clinical trials. Cureus. 2023;15(7):e42768. doi:10.7759/cureus.42768
7. Thomas J. Androgenetic alopecia – current status. Indian J Dermatol. 2005;50:179-190.
8. Nestor MS, Ablon G, Gade A, Han H, Fischer DL. Treatment options for androgenetic alopecia: efficacy, side effects, compliance, financial considerations, and ethics. J Cosmet Dermatol. 2021;20(12):3759-3781. doi:10.1111/jocd.14537
9. Dayanan R, Bilen A, Çiftel S, et al. Increase in subcutaneous adipose tissue in the frontal scalp may be associated with androgenetic alopecia and metabolic syndrome. Eur Rev Med Pharmacol Sci. 2023;27(12):5748-5756. doi:10.26355/eurrev_202306_32813
10. Nguyen B, Tosti A. Alopecia in patients with COVID-19: a systematic review and meta-analysis. JAAD Int. 2022;7:67-77. doi:10.1016/j.jdin.2022.02.006
11. Chen S, Xie X, Zhang G, Zhang Y. Comorbidities in androgenetic alopecia: a comprehensive review. Dermatol Ther (Heidelb). 2022;12(10):2233-2247. doi:10.1007/s13555-022-00799-7