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Hyperandrogenism and Pathogenesis


It may be:

  • Ovarian (Polycystic ovarian disease)
  • Adrenal (late onset congenital adrenal hyperplasia)


The hair loss occurs due to end organ hyper-reactivity rather than increased levels of androgens. The conversion of a terminal to vellus hair follicle is the central event in the pathogenesis of androgenetic alopecia. The process occurs thru’ androgenic stimulation of susceptible follicles.


Testosterone is converted to its more potent active metabolite-5-alpha dihydrotestosterone by 5-alpha reductase in skin. DHT binds to androgen receptors of genetically marked follicles. The hormone-receptor complex is then carried to nucleus where it activates genes responsible for gradual transformation into vellus follicle. It’s a gradual process resulting in shortening of anagen phase & progressively smaller hair follicles.


There are 2 distinct isoenzymes of 5-alpha reductase, type1 & type2.

Type1 iso-enzyme----Sebaceous glands particularly after puberty.

Type2 iso-enzyme----Hair follicles in neo-nates, fetal genital skin,         male accessory sex glands in adults (particularly the prostrate)


Finasteride inhibits the Type 2 iso-enzyme 70-100 times more than Type 1 iso-enzyme.


The Cytochrome P450 aromatase enzyme has a protective role on follicles because it increases the conversion of testosterone to estradiol & estrone (therefore lessens the conversion to DHT)


Frontal follicles in women have 6 times more aromatase than in men with AGA.


In women, frontal follicles have twice the amount of aromatase in occipital follicles. That’s the reason why female express AGA in a different pattern.

Other reasons for difference in presentation are-

  • Lower androgen & 5 alpha reductase levels
  • Differences in the distribution of androgen sensitive follicles
  • Estrogens play a protective role in pre-menopausal women by lowering free androgen levels by increasing sex binding globulin levels.


Reassurance that they are not going to turn bald in the immediate future & that even later they may have substantial hair for most of their life.


Treatment in Men-

Mild to moderate hair loss involving frontal area-Topical minoxidil 5% &/or oral finasteride 1mg/day.


AGA involving the vertex-choice of Rx depends on individual preference for systemic/topical Rx.

Frontal recession- Finasteride-drug of choice.


Men with higher grades-Miniaturization is more advanced & there may be actual follicular loss-Surgical treatment or hairpieces are only option. Surgical approaches include transplant, scalp reduction, rotation flaps, punch grafting & single follicle transplantation.


Surgical treatment not recommended for men below 25 years b’cos    ultimate extent & pattern of hair loss cannot be predicted.


Treatment in Women-

Topical minoxidil-2%, incidence of hypertrichosis is less.

Finasteride –post menopausal women with AGA.


Medical therapy:


Minoxidil- Effective vasodilator.

  • It is a K+ channel opener thereby enhancing the growth of sub-optimal follicles.
  • It is a 1-3% solutn in a base of 10% propylene glycol, 20% distilled water & 70% alcohol.
  • It converts vellus hairs to terminal ones in 30% cases.
  • Rx needs to be continued forever if improvement is to be maintained.
  • 1-4% is absorbed systematically. Therefore; systemic side-effects are rare.
  • Avoid in patient’s with hypertension & cardiac disease.
  • S/E- Local allergy, irritation
  •  Available in concentration- 2%, 5%, 10%.


  • Synthetic azasteroid
  • Inhibitor of 5-alpha reductase (Type II isoenzyme)
  • It prevents conversion of testosterone to DHT
  • Peak plasma concentration reached within first 2hrs of dosing.
  • Finasteride-1mg/day causes reduction of serum DHT by 65%.
  • Metabolism in the liver, therefore use with caution in men with abnormal liver function.
  • Half life- 5-6hrs.
  • Elimination in faeces, therefore no dosage requirement on basis of age/renal function.


S/E- Decreased libido, Erectile dysfunction, ejaculatory dysfunction.

These side effects resolve in days to weeks after discontinuation of Rx.

Finasteride does not affect spermatogenesis, sperm concentration, count per ejaculate, morphology or motility.




It should be considered after the age of 30yrs.

  • Hair transplantation
  • Scalp reduction

Other Surgeries-

  • Punch grafts
  • Temporoparieto-occipital flap
  • Strip grafts
  • Synthetic Hair-synthetic wig fibers.
  • Cosmetic Treatment – Camouflage.



Newer Treatments:

  • Mesotherapy
  • Stem cell therapy---
  • Tripeptide therapy
  • Minoxidil with Tretinoin – Minoxidil enhances hair growth by prolonging the anagen phase and induces new hair growth. Whereas retinol improves scalp skin condition and helps in hair growth by promoting & regulating cell proliferation, differentiation in epithelium & may promote vascular proliferation.

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