Improvement in scalp hair growth in androgen-deficient women treated with testosterone: a questionnaire study

Background Androgens are thought to have an adverse effect on female scalp hair growth. However, our clinical experience of androgen replacement therapy in women with androgen deficiency, in which hair loss was seldom reported, led us to question this concept. Objectives To evaluate the effect of subcutaneous testosterone therapy on scalp hair growth in female patients. Methods A total of 285 women, treated for a minimum of 1 year with subcutaneous testosterone implants for symptoms of androgen deficiency, were asked to complete a survey that included questions on scalp and facial hair. Age, body mass index (BMI) and serum testosterone levels were examined. Results Out of the 285 patients, 76 (27%) reported hair thinning prior to treatment; 48 of these patients (63%) reported hair regrowth on testosterone therapy (responders). Nonresponders (i.e. no reported hair regrowth on therapy) had significantly higher BMIs than responders (P = 0·05). Baseline serum testosterone levels were significantly lower in women reporting hair loss prior to therapy than in those who did not (P = 0·0001). There was no significant difference in serum testosterone levels, measured 4 weeks after testosterone implantation, between responders and nonresponders. No patient in this cohort reported scalp hair loss on testosterone therapy. A total of 262 women (92%) reported some increase in facial hair growth. Conclusions Subcutaneous testosterone therapy was found to have a beneficial effect on scalp hair growth in female patients treated for symptoms of androgen deficiency. We propose this is due to an anabolic effect of testosterone on hair growth. The fact that no subject complained of hair loss as a result of treatment casts doubt on the presumed role of testosterone in driving female scalp hair loss. These results need to be confirmed by formal measurements of hair growth.     

The Ludwig pattern of androgenetic alopecia is due to a hierarchy of androgen sensitivity within follicular units that leads to selective miniaturization and a reduction in the number of terminal hairs per follicular unit

Background Hair follicles exist within follicular units (FUs). In utero the central primary hair follicles are surrounded by smaller secondary follicles. Each FU is nourished by a single arborizing arrector pili muscle that attaches circumferentially around the primary follicle with variable attachment to other follicles. Androgenetic alopecia (AA) miniaturizes susceptible scalp hair follicles in a distinctive and reproducible fashion manifesting in different patterns between men and women. Objectives We hypothesized that there is an additional layer to the patterning in AA, with a hierarchy of susceptibility within FUs to AA, and that the diffuse hair loss seen in women with AA is due to a reduction in the number of terminal hairs per FU rather than uniform miniaturization of entire FUs. Methods We compared the mean numbers of FUs and terminal hairs per FU in 4‐mm scalp punch biopsies in 24 women with AA with those in 21 controls. Results There was no significant difference in the number of FUs; however, women with AA had 2·40 terminal hairs per FU compared with 3·38 in the control group (P = 0·0001) associated with a mean increase of 0·6 vellus hairs per FU. Complete miniaturization of all hairs within the FU was not seen. Conclusions Diffuse hair loss in women with AA is due to a reduction in the number of terminal hairs per FU and an increase in the number of vellus hairs. This supports the hypothesis of a hierarchy of susceptibility within FUs to AA. Further investigation is required to ascertain whether secondary and tertiary hair follicles are more susceptible than primary follicles.     

Prevalence and distribution of melanocytic naevi on the scalp: a prospective study

Background Few studies have examined the incidence and characteristics of naevi on the scalp. Most studies of scalp naevi have been performed in children, whose incidence of scalp naevi is relatively high, at about 0·5–11·7% of the total body count of common naevi. Objectives To investigate the prevalence and distribution of scalp melanocytic naevi in patients of all ages. To our knowledge, ours is the first study to analyse in detail the relationships between melanocytic naevi on the scalp and total body naevi and total body atypical naevi. Methods We conducted a prospective study of patients visiting the dermatology outpatient clinic at the University of Florence, for examinations unrelated to the presence of naevi or melanoma. The study enrolled 795 subjects (417 females; 52·4%), with a median age of 35 years (range 4–80). Results The number of melanocytic naevi on the scalp increased significantly (r = 0·2057, P = 0·0008) as the number of total body melanocytic naevi increased and a correlation was found between the number of clinically atypical total body naevi and the number of scalp naevi. Relatively few naevi (15·5%) were located at the frontal region compared with other regions of the scalp, although the frontal region is more exposed to ultraviolet (UV) rays. Compared with subjects without alopecia, whose hair shields the scalp from UV rays, subjects with androgenetic alopecia showed no significant increase in number of scalp naevi. Conclusions Despite practical difficulties, early diagnostic screening for melanoma or screening during follow‐up examination for previous melanoma should involve examination of the entire skin surface, scalp included.     

Getting under the skin of hair aging: the impact of the hair follicle environment

Like the skin, our hair shows striking changes with age, producing hairs with altered diameter, lustre and texture. The biology of hair aging has focused predominately on various aspects of the hair cycle, follicle size and the fibre produced, but surprisingly the impact of the aging scalp dermal environment on the hair follicle and fibre has been generally overlooked. Hair loss affects both sexes with incidence increasing with age. In men, male pattern-balding (androgenetic alopecia) is driven by androgens and follows a specific pattern of frontotemporal and vertex regression. Women also experience female pattern hair loss (FPHL), presenting as more general, diffuse hair thinning. Hair thinning in women is commonly associated with the menopause, corresponding with other age-related changes in skin. The rapidly growing hair follicle undergoes continued renewal throughout the life span of an individual, where it is exposed to a substantial number of extrinsic and intrinsic stressors. As the hair follicle sits deep within the dermis with its bulb residing in the hypodermis, detrimental age-related changes in the surrounding scalp skin may likely disrupt the hair follicle machinery. The impacts of these changes are unknown, but evidence suggests that scalp skin aging and hair follicle aging go hand-in-hand. Herein, we summarize the evidence that the age-related changes observed in sun-exposed human skin also occur in scalp skin and that these changes are likely to play a contributing role in the aging hair phenotype.     

Chronic telogen effluvium: Increased scalp hair shedding in middle-aged women

Background: Diffuse loss of scalp hair is a common problem in middle-aged women. A segment of these cases represents idiopathic chronic telogen effluvium (CTE).Objective: The purpose was to establish distinctive clinical and pathologic criteria for the diagnosis of CTE to facilitate its differentiation from androgenetic alopecia (AGA) and systemic causes of chronic diffuse hair loss.Methods: A group of 355 patients (346 females, 9 males) with diffuse generalized thinning of scalp hair of unknown origin were classified as having CTE and were included in the study. Characteristically they presented with a history of hair loss with both increased shedding and thinning of abrupt onset and fluctuating course and showed diffuse thinning of hair all over the scalp, frequently accompanied by bitemporal recession. Two 4 mm punch biopsy specimens were taken mostly from the mid or posterior parietal scalp of these patients. The biopsies were performed at these same areas in 412 patients with AGA (193 male, 219 female). Similar paired biopsy specimens were also taken from 22 normal control subjects (13 males, nine females). Specimens were sectioned horizontally and vertically and were examined for terminal and velluslike (miniaturized) hairs, follicular stelae, follicular units, and perifollicular inflammation and fibrosis.Results: In horizontal sections of 4 mm punch biopsy specimens from patients with CTE the average number of hairs was 39, the terminal/velluslike hair ratio was 9:1, 89% of the terminal hairs were in anagen, and 11% were in telogen. In AGA these values were 35, 1.9:1, 83.2%, and 16.8%, respectively, and in normal control subjects 40, 7:1, 93.5%, and 6.5%, respectively. Significant degrees of inflammation and fibrosis were present in only 10% to 12% of cases of CTE and normal controls, but occurred in 37% of cases of AGA. CTE ran a prolonged and fluctuating course in many patients.Conclusion: CTE, which usually affects 30- to 60-year-old women, starts abruptly with or without a recognizable initiating factor. It may be distinguished from classic acute telogen effluvium by its long fluctuating course and from AGA by its clinical and histologic findings.     

Hutchinson–Gilford Progeria Syndrome Caused by an LMNA Mutation: A Case Report

Hutchinson–Gilford progeria syndrome is a rare genetic disorder characterized by premature aging of the skin, bones, heart, and blood vessels. We report a 6‐year‐old boy who was born at full term but presented with scleroderma‐like appearance at 1 month of age and gradually developed clinical manifestations of progeria. He had characteristic facial features of prominent eyes, scalp, and leg veins; loss of scalp hair, eyebrows, and eyelashes; stunted growth; scleroderma‐like changes of the skin; and a premature aged appearance. Metabolic investigations showed transient methylmalonic aciduria, and genetic testing of the peripheral blood identified the c.1824C>T heterozygous LMNA mutation. The present case is reported because of its rarity.     

USE OF TOPICAL MINOXIDIL THERAPY FOR ANDROGENETIC ALOPECIA IN WOMEN

Background. Androgenetic alopecia is the most common cause of hair loss in men and women. Androgenetic alopecia in women begins as a diffuse and progressive thinning of the frontoparietal area of the scalp. In women, hair loss at any age is socially unacceptable and may be the basis of psychiatric illness. Methods. A 32-week, double-blind, placebo-controlled trial was conducted in 10 European centers to assess the efficacy and safety of 2% topical minoxidil solution for the treatment of androgenetic alopecia in women. Two hundred ninety-four of the 346 women enrolled (85%) completed the 32-week trial. Photographic and computer imaging techniques were used at each visit to determine objectively the number of nonvellus hairs present in a 1-cm² area selected as the target evaluation site. Results. In the 2% minoxidil group, the mean increase in nonvellus hair count was 33 hairs, which was significantly greater than that of 19 hairs in the placebo group (P = 0.0001). The investigators observed that 44% of the patients in the 2% minoxidil group achieved new hair growth compared with 29% in the placebo group. When asked to evaluate their own hair growth, 55% of the women in the 2% minoxidil group compared to 41% of the women in the placebo group believed that they had achieved new hair growth. No clinically significant changes in vital signs were observed during the study and no serious or unexpected medical events were reported. Conclusion. Topical minoxidil solution was significantly more effective than placebo in the treatment of androgenetic alopecia in women.     

The lack of significant changes in scalp hair follicle density with advancing age

BACKGROUND: Age-related reduction in hair is seen in the axillary and pubic regions as well as the scalp; however, it has not been investigated qualitatively on the scalp. Horizontally sectioned scalp biopsy is an ideal tool to investigate the impact of advancing age on scalp hair follicle density and morphology. OBJECTIVES: To examine the effect of age and follicle miniaturization on total hair count in 1666 horizontally sectioned mid-scalp biopsies from 928 women aged between 13 and 84 years with hair loss. METHODS: Setting: Specialist hair loss referral clinic in a teaching hospital. Design: Analysis of data set. Methods: All scalp biopsies were 4 mm in diameter and taken from the crown. Miniaturization was assessed by calculating the ratio of terminal to vellus-like hairs (T/V) at the mid-isthmus level and considered significant if the ratio was < or = 4 : 1. Fibrosis was documented when present. Linear regression was used to examine the association between total hair count, age and miniaturization. RESULTS: The average number of hair follicles per biopsy was 39.6 (SD +/- 10.8). A highly significant negative association (P < 0.0001) was found between age and total follicle number, although the predictive value of age in total hair count was found to be small [root error mean square (R2) < 2%]. Controlling for T/V < or = 4 : 1, the association was weakened, but remained significant. The relationship unconfounded by T/V < or = 4 : 1 shows that for every additional year of ageing, 0.077 total hair follicles (0.22%) are lost per biopsy. CONCLUSIONS: Age and follicular miniaturization were found to be extremely weak predictors of total hair count in women with hair loss.     

What women want - quantifying the perception of hair amount: an analysis of hair diameter and density changes with age in caucasian women

Background It has long been known that women lose satisfaction with their hair with ageing. Our data show that caucasian women perceive a decrease in hair amount in their mid 40s with a further decrease in the mid to late 50s, which leads to this dissatisfaction. Neither loss of density (hairs per cm²) nor shaft diameter alone can fully account for this perception. A new metric, ‘hair amount’, is proposed as a quantitative metric combining the impact of both density and diameter on the perception of hair loss. Objectives Creation of a single parameter combining the contribution of diameter and density to perception of female age‐related hair loss. Methods In total, 1099 caucasian women (ages 18–66 years) with self‐perceived hair loss and 315 caucasian women (ages 17–86 years) with no complaint of hair loss were evaluated. Scalp hair diameter was measured using optical fibre diameter and image analysis. Scalp hair density was measured by phototrichogram with manual or automated counting. Results Parietal scalp hair diameter increased from ages 20 to 40–45 years, then decreased. Hair density was highest in the youngest group, age 20–30 years, and decreased thereafter with increasing rate. In women self‐perceiving hair loss, the rate of decrease in density was significantly faster than for women with no self‐perception of hair loss. The combined metric ‘hair amount’ was relatively constant at younger ages, increasing very slightly to age 35 years, then decreasing significantly. Conclusions Increasing hair shaft diameter offsets decreasing hair density through the mid 30s. After that, a lower rate of diameter increase combined with the decrease in density begins to significantly impact the perception of hair amount so that thinning becomes increasingly more noticeable in the mid 40s to the mid to late 50s. Quantitative determination of hair amount is a useful tool to combine the contributions of hair density and diameter to women’s perception of age‐related hair loss.     

Characteristic features of ageing in Korean women’s hair and scalp

Background The effect of age on hair properties has previously been investigated in white and Japanese women; however, little is known of the age‐related characteristic features of hair in Korean women. Objectives To determine the ageing features of Korean women’s hair by examining physical and biological factors in sufficient numbers of participants. Methods In total, 150 healthy Korean women (aged 23–69 years) living in Seoul were allocated to five age‐graded groups. Age‐related changes of various features of the scalp and hair shaft were measured, including hair density, diameter, tensile strength and lustre, and grey‐hair ratio. The hair‐shaft compositions of minerals, amino acids and steroid hormones were analysed by high‐performance liquid chromatography. Results Hair‐loss parameters (hair density, diameter and tensile strength) and hair lustre decreased significantly with age, beginning in the subjects’ 40s. The hair‐whiteness value increased significantly with age, beginning in their 60s, due to an increase in the ratio of grey hair. Calcium and magnesium levels greatly exceeded the reference ranges and declined in an age‐dependent manner, while potassium and phosphorus levels increased with age. No age‐related change of hair‐shaft amino acid content was evident. The contents of sterols and their metabolites (cholesterol, desmosterol, lanosterol and pregnenolone) increased significantly with age, but there was no correlation between the examined sex steroids and age. Conclusions  These results show that intrinsic ageing produces diverse changes in the hair and scalp features of Korean women from their 40s, and the ageing features of Korean women’s hair could be partially different from that of women in other countries.     

Could azathioprine be considered as a therapeutic alternative in the treatment of alopecia areata? A pilot study

Alopecia areata is an autoimmune disease resulting in partial or total nonscarring hair loss and the treatment of severe alopecia areata is difficult. The aim of this study was to evaluate the efficacy and safety of azathioprine as a systemic monotherapy for moderate to severe alopecia areata. A total of 20 patients [14 men (70%) and six women (30%)] with minimum 6 months history of alopecia areata were included. The extent of scalp hair regrowth during and after the completion of the 6 months treatment was evaluated by the Severity of Alopecia Tool (the SALT score). The daily drug intake was calculated as 2 mg/kg of body weight. Mean duration of current episode of scalp hair loss was 26.4 (26.4 ± 17) months. Mean regrowth percentage was 52.3% (52.3 ± 38.4). Mean hair loss percentage before treatment was 72.7% (72.7 ± 28.3) compared with 33.5% (33.5 ± 30.7) after 6 months of azathioprine treatment. This showed a highly significant statistical difference (Paired t‐test, CI 95% = 21.5–54.1). Mean hair loss score (S₀–S₅) before treatment was 3.9 (3.9 ± 1.6) and after 6 months of azathioprine treatment was 1.8 (1.8 ± 1.3). Assessment showed significant difference from baseline score (sign test, P < 0.0001). No significant statistical difference was observed with respect to gender before and after azathioprine treatment. Treatment with azathioprine as a systemic monotherapy clinically produces relevant improvement in moderate‐to‐severe alopecia areata. Generally azathioprine is a low‐cost and well‐tolerated drug and with controlled studies on larger number of patients, long‐term efficacy and safety of this treatment should be investigated.     

There is no clear association between low serum ferritin and chronic diffuse telogen hair loss

BACKGROUND: Low iron stores are considered a possible cause of chronic diffuse telogen hair loss in women. Estimation of serum ferritin is recommended as part of the initial assessment when women present with chronic diffuse telogen hair loss, and iron supplementation therapy is commonly recommended for those found to have low iron stores. OBJECTIVES: To evaluate the relationship between low serum ferritin ( 20 micro g L-1. Cessation or reversal of hair loss was not seen in any of these women. CONCLUSIONS: No direct relationship between low serum ferritin and hair loss can be established. The usefulness of serum ferritin in the routine investigation of women with chronic diffuse telogen hair loss is unclear, as is the role of iron supplementation therapy in the management of hair loss.     

Review of treatment for alopecia totalis and alopecia universalis

Alopecia areata (AA) is an autoimmune disease directed at the hair follicle. Although usually limited to patchy hair loss over the scalp (focalis), AA can present as total loss of scalp hair (totalis; AT) or as total loss of both scalp and body hair (universalis; AU). Management of AT and AU can be challenging, and although multiple treatment modalities have been explored, no therapy is currently FDA‐approved. This review focuses on the evidence for current treatment options for AT and AU. The PubMed database was searched from January 1, 2000, to September 1, 2016, for clinical trials, retrospective studies, and case reports of treatments for AT and AU. A total of 40 studies were retrieved and analyzed. Therapies studied for AT/AU included: topical immunotherapy, steroids, photodynamic therapy, immunosuppressive agents, TNFα inhibitors, and other therapies, such as sulfasalazine, bexarotene, JAK inhibitors, and simvastatin/ezetimibe. Although certain treatments showed significant hair regrowth, no treatment was completely effective. The most promising therapies with the highest quality data include diphenylcyclopropenone, squaric acid dibutylester, photodynamic therapy, steroids, and cyclosporine in combination with methylprednisolone. High‐quality randomized‐controlled trials with large sample sizes are lacking. Unified outcome guidelines are encouraged to facilitate the comparison of future studies.     

Hair removal in hirsute women with normal testosterone levels: a randomized controlled trial of long‐pulsed diode laser vs. intense pulsed light

Background Hirsutism is a common disorder in women of reproductive age, and androgen disturbances may aggravate the condition. Limited evidence exists regarding efficacy of hair removal in this specific population and no data are available for patients with verified normal testosterone levels. Objectives To compare efficacy and safety of intense pulsed light (IPL) vs. long‐pulsed diode laser (LPDL) in a well‐defined group of hirsute women with normal testosterone levels. Methods Thirty‐one hirsute women received six allocated split‐face treatments with IPL (525–1200 nm; Palomar Starlux IPL system) and LPDL (810 nm; Asclepion MeDioStar XT diode laser). Testosterone levels were measured three times during the study period. Patients with intrinsically normal or medically normalized testosterone levels throughout the study were included in efficacy assessments (n = 23). Endpoints were reduction in hair counts assessed by blinded photoevaluations at baseline and 1, 3 and 6 months after final treatment, patient‐evaluated reduction in hairiness, patient satisfaction, treatment‐related pain and adverse effects. Results IPL and LPDL reduced hair counts significantly, with median reductions from baseline of 77%, 53% and 40% for IPL and 68%, 60% and 34% for LDPL at 1, 3 and 6 months, respectively. At 6 months follow‐up, there was no significant difference between treatments in terms of hair reduction (P = 0·427), patient assessment of hairiness (P = 0·250) and patient satisfaction (P = 0·125). Pain scores were consistently higher for IPL [median 6, interquartile range (IQR) 4–7] than LPDL (median 3, IQR 2–5) (P < 0·001). Conclusion Hirsute women with normal or medically normalized testosterone levels responded equally well to IPL and LPDL treatments of facial hairiness, but the efficacy declined over 6 months.     

Severe diffuse non‐scarring hair loss in systemic lupus erythematosus – clinical and histopathological analysis of four cases

Background Although diffuse non‐scarring hair loss been found common in systemic lupus erythematosus (SLE), study that conduted on the severe type has been scarce. Objective This study aims to explore the dermoscopic and pathological features of severe diffuse hair loss in SLE. Method Data including clinico‐laboratory, dermoscopic and histopathological findings of four patients with SLE with severe diffuse hair loss were analysed retrospectively. Results All four patients were women aged 41, 39, 14 and 48 with complaints of hair loss involving 55%, 100%, 60% and 55% of their scalp respectively. Common clinical findings observed in the patients were sparse scalp hair with clusters of newly regrown hair. Scalp dermoscopy showed scaling, perifollicular telangiectasia, increased numbers of short vellus hairs, focal atrichia and decreased hair shaft pigmentation. Scalp tissue histopathology revealed typical changes of SLE such as epidermal atrophy with focal liquefaction, degeneration of the basement membrane zone, pigment incontinence, mild focal perivascular and perifollicular lymphocytic infiltrates and deposition of immunoglobulins at the dermal–epidermal junction. Treatment and improvement in SLE disease activity indices had a favourable impact on hair regrowth. Conclusion The severe type of hair loss in patient with SLE presents a unique set of clinical, dermoscopic and histopathological features.     

Metabolic alterations of DHEA and cholesterol sulphates in the hair of patients with acne measured by liquid chromatography–mass spectrometry

Please cite this paper as: Metabolic alterations of DHEA and cholesterol sulphates in the hair of patients with acne measured by liquid chromatography–mass spectrometry. Experimental Dermatology 2010; 19 : 694–696. Abstract: As the hormonal levels in scalp hair reflects the condition of skin appendage, the level of dehydroepiandrosterone‐3‐sulphate (DHEAS) and cholesterol sulphate (CS) was evaluated in scalp hair obtained from patients with acne. The hair samples were extracted by alkaline solution and were analysed by liquid chromatography–mass spectrometry coupled to column switching system. The levels of DHEAS in scalp hair of women with acne were higher (P < 0.001) than controls, while the levels of CS in scalp hair of women and men with acne were higher (P < 0.001) than both control subjects. Increased hair levels of both DHEAS and CS could indicate acne development because of its direct action or stimulatory effect on local enzyme activity. It may be also helpful to understand the pathogenesis of acne based on follicular retention hyperkeratosis and increased sebum production of both steroid sulphates.     

Baseline sebum IL‐1α is higher than expected in afro‐textured hair: a risk factor for hair loss?*

Objective To investigate changes in sebum cytokines in response to hair cosmetics. Design and setting A prospective study at a University hospital. Methods We used a novel method for scalp surface sebum collection (Sebutape^®) on three visits, sequentially a week apart, to investigate changes in six cytokines in 36 healthy women before and after shampoo and compared various chemical treatments (ammonium thioglycolate, “lye” sodium hydroxide and “no‐lye” guanidine hydroxide relaxers) performed by a professional hairdresser. Results Significant levels detected were IL‐1 alpha (IL‐1α) and IL‐1 receptor antagonist (IL‐1ra), which were higher in untreated scalp vs. forehead: P < 0.001. Baseline levels of scalp sebum IL‐1α were 18 times higher than IL‐1ra. The levels of IL‐1α decreased uniformly after shampoo (visit 1) and various chemical treatments (both crown and vertex all P < 0.001 – visit 2) but increased on follow‐up at visit 3. Decreases in IL‐1ra mimicked IL‐1α at the vertex [after shampoo (P = 0.018) and visit 3 (P = 0.014)], but not on the crown, a finding which may suggest site‐specific scalp predisposition to inflammation. The ratio of IL‐1ra/IL‐1α increased in all groups after all chemical treatments and on follow‐up (all P < 0.001) but was surprisingly not significantly different from natural hair that underwent shampoo. Limitations A wider cytokine panel may reveal response differences in treatment groups. Conclusions Baseline inflammatory scalp cytokines are higher than expected and reduce with shampooing. Scrutiny of the influence of hair moisturizer formulations and shampoo intervals and studies investigating pro‐fibrotic cytokines are required. This may elucidate the predilection of afro‐textured hair to scarring alopecia.     

Intractable Diffuse Alopecia Caused by Multifactorial Side‐Effects in Treatment of Acute Lymphocytic Leukemia: Connection to Iatrogenic Failure of Estrogen Secretion

Abstract: Treatment of infantile acute lymphocytic leukemia (ALL) may cause failure to thrive and hypogonadism due to hypopituitarism induced by chemotherapy and whole‐brain radiotherapy. We report the case of a 22‐year‐old girl with a genetic predisposition to pattern hair loss who developed inveterate diffuse alopecia. The patient had onset of ALL at 8 years old and underwent bone marrow transplantation (BMT). Diffuse alopecia gradually advanced over her whole body. Her vellus scalp hair gradually came out, and hair loss progressed again at 8 years, after BMT. She later developed iatrogenic failure of secretion of estrogen and was treated with estrogen substitution therapy for 14 months from the age of 20. There was a small increase in the volume of hair during therapy, but alopecia returned to the former level after the therapy was suspended. Histopathologic examinations of the scalp performed during estrogen substitution therapy and 2 years after suspension of the therapy showed a 60% decrease in the number of hair follicles and prominent development of vellus hair. We conclude that estrogen influenced hair growth in the context of a genetic predisposition for pattern hair loss in this case.