Full evaluation prevents hairloss misdiagnoses

(Dermatology Times - 08/00/2000)
Full evaluation prevents hairloss misdiagnoses.
Author/s: Linda Benson
Issue: August, 2000

Cleveland -- Hairloss is "not always what it seems," Wilma Bergfeld, M.D., said, and a patient evaluation "needs to include the usual ingredients: medical exam and personal history, family history of disease, and endocrine disorders."

The evaluation also needs to include an extensive drug history that takes account of nonprescription medications and health supplements, said Dr. Bergfeld, head of clinical research in the department of dermatology at the Cleveland Clinic.

She pointed to the increasing popularity of natural products both on pharmaceutical and cosmetic levels, many of which can impact hair growth. "Understanding the chemical contents of these natural products is essential to the dermatologist," Dr. Bergfeld said, "but right now, everyone's knowledge is limited."

One example is the recent popularity of soy estrogens. "They appear to be helpful in reducing symptoms of menopause, but we don't know if they affect hairloss or hair gain," said Dr. Bergfeld, who chairs the expert panel of Cosmetic Ingredient Review.

OTC products: questionable claims?

Several other over-the-counter products bear further scrutiny. "Most hormones available over the counter that claim to increase your libido contain testosterone or androgen activity," she said. "DHEA is one. It might be good in small doses, but it can be quite a problem in menopausal females."

Saw palmetto, an antiandrogen herb being marketed to men for reducing the size of large prostates, is another product of questionable merits.

Some of the pharmaceutical companies are looking at many of these herbals to see if they do what they claim -- for both hairloss and hair growth. In the nutrient area, Dr. Bergfeld noted that vitamin B6 and zinc could be helpful for hair growth on the scalp. For alopecia, topical minoxidil (Rogaine) is the drug of choice for women. It is nonhormonal and nonimmunologic in its action.

Goal: inhibit conversion to DHT

"In hairloss, the aim is to inhibit the metabolic pathway of the enzyme necessary for the conversion of testosterone to DHT," Dr. Bergfeld said. She noted some drugs available that are not approved specifically for this use, and another agent, cyproterone acetate, which is not available in the United States because it is a fetal teratogen.

Dr. Bergfeld's discussion also included the problems of hirsutism as part of androgen excess syndrome. "Hirsutism should be considered part of the androgen excess syndrome unless other etiologies can be established such as androgen-producing tumors or drugs," she said.

When hirsutism is associated with obesity and menstrual abnormalities, the source of the androgen excess is frequently ovarian. Polycystic ovarian syndrome (PCOS) is the most common cause of hirsutism. When untreated, PCOS has a high association with endometrial cancer and osteoporosis.

"If these patterns show up in a patient with average weight and normal menses, the source is most often adrenal. The androgen source is pituitary less than 5 percent of the time," she said.

In the discussion that followed, many questions centered on evaluating and monitoring female patients. Dr. Bergfeld said spironolactone (Aldactone) is the most popular antiandrogen therapy for hirsutism in the United States, and it is commonly prescribed in combination with oral contraception to improve its effectiveness, reduce menstrual abnormalities, and prevent potential fetal abnormalities. Antiandrogen therapies include drugs that block androgens at the P450 cytochrome receptors and result in decreased testosterone, dihydrotestosterone, and DHEAS. However, antiandrogen therapies, with the exception of cortisone, are fetal teratogens that can feminize a male fetus.

"For this reason, birth control is an essential element of treatment during the reproductive years of the patient. Birth control pills suppress the androgen, and are a treatment for polycystic ovary disease," Dr. Bergfeld said.