Treatment of Hyperandrogenic Alopecia in Women

Abstract

Many women with androgenic alopecia have normal circulating androgen levels. Increased scalp sensitivity to androgens may account for these cases. Even when androgen levels are increased, no particular pattern has emerged. Classical anti-androgen measures have proved disappointing, in contrast to the results obtained in women with hirsutism or acne. This study evaluated flutamide and finasteride in 36 premenopausal, hyperandrogenic women presenting with androgenic alopecia. Frontal hair thinning was assessed in photos of the frontoparietal region using the Ludwig grading system. Thirty ovulatory women matched for age and body weight served as a control group. Groups of 12 subjects received 50 mg cyproterone acetate (CPA) on cycle days 5-15 plus 25 μg ethinyl estradiol (EE) on days 5-25, 250 mg flutamide daily, or 5 mg finasteride daily, all for 1 year. The alopecic women had significantly higher serum levels of testosterone, unbound testosterone, and dehydroepiandrosterone than the normal control women. Women in all treatment groups had comparable serum androgen levels and alopecia scores at the outset. After a year of treatment, only flutamide significantly relieved alopecia, lowering Ludwig scores by 21% (Fig. 1). Self-reports supported this finding. Eight of 12 flutamide-treated patients reported that hair loss had slowed, but hair regrew in only 3 cases. Three women given CPA-EE and 1 given finasteride reported a slowing of hair loss. Assessment by the investigators also showed flutamide to be the most effective treatment, but the difference from CPA-EE treatment was not significant (Fig. 2). Two patients had mildly increased liver enzymes after 6 months on flutamide. Treatment continued, and no worsening was noted; the enzymes were normal 2 months after treatment ended. Flutamide, in a daily dose of 250 mg, led to modest improvement in alopecia after 1 year in these hyperandrogenic women. Possibly more extended treatment would yield better results.