Guideline for Diagnostic Evaluation in Androgenetic Alopecia

Aetiology

Men

AGA is an androgen-dependent trait, which leads to progressive miniaturization of the hair follicle in predisposed men.^[10] It is thought that enhanced androgen effects at the genetically predisposed hair follicles are mediated by raised androgen receptor density and/or increased activity of 5-alpha-reductase type II.^[2] Nearly all men afflicted with AGA have normal circulating androgen levels. The predisposition to AGA is predominately due to genetic factors. Twin studies show strong concordance rates of between 80% and 90% for monozygotic twins. Family analyses show a significantly increased risk for the development of AGA in men with a father suffering from AGA.^[11,12] Conversely, the risk of AGA is significantly decreased in those men with a nonbalding father.

The current scientific data support the thesis that AGA has a polygenic trait. Significant associations have been reported with variant regions of the androgen receptor gene, which is located on the X-chromosome, using a candidate gene approach.^[13,14] More recently, two independent genome-wide association studies have identified a susceptibility locus at chromosome 20p11.^[15,16]

Women

There are few studies on the genetic base of AGA in women. Smith and Wells^[12] reported the frequency of female pattern hair loss with an incidence of 54% pattern hair loss in first-degree male relatives aged > 30 years and 21% in first-degree female relatives > 30 years. It is possible that early- and late-onset female AGA are genetically distinct entities. The role of androgens in female AGA is less certain than in men and other factors may be involved. For the purpose of this guideline the term 'androgenetic alopecia' is used, although the uncertainty of the role of androgens is recognized.

The European Consensus Group agreed not to differentiate between androgenic alopecia and AGA, but to define a subset of women with AGA and associated hormonal dysregulation.

Table 1. Diagnostic evaluation form for androgenetic alopecia
1. History
Age	___ years
Sex	□ Male
□ Female
First manifestation of hair loss	Age: ___
Course of hair loss	□ Acute
□ Chronic – Intermittent
□ Chronic – Persistent
Complaining of increased shedding of hair	□ Moderate
□ Severe
□ No
Complaining of increased thinning of hair	□ Diffuse
□ Localized
□ No
Itching	□ Yes □ No
Dandruff	□ Yes □ No
Trichodynia	□ Yes □ No
Family history of androgenetic alopecia	□ Yes
□ Mother/maternal side □ Father/paternal side
□ No
Concomitant diseases (chronic, autoimmune, recently diagnosed, with possibly chronologic relation to hair loss)	___________
Previous surgery	___________
Eating behaviour
Strictly vegetarian diet	□ Yes □ No
Crash diet or eating behaviour disorders	□ Yes □ No
Important weight loss > 5–10 kg	□ Yes □ No
Weight	___________
Height	___________
Drug history (e.g. pro-androgenic, antithyroid, anti-epiletics, β-blocker, chemotherapeutics, supplements)	Please provide details: ___________
Smoking	□ Yes □ No
Only in women
Menstrual cycle	□ Regular □ Irregular
Menopause	___________
Oligomenorrhoea	□ Yes □ No
Amenorrhoea	□ Yes □ No
Since when	___________
Hormonal contraception	□ Yes □ No
Hormonal replacement therapy	□ Yes □ No
Fertility treatment	□ Yes □ No
Specify drug and duration	___________
Succesful and unsuccessful pregnancies	___________
Excessive facial and/or body hair growth	□ Yes □ No
Skin changes (acne)	□ Yes □ No
Seborrhoea of scalp/skin	□ Yes □ No
In children and adolescents
Hair loss	□ Congenital □ Acquired
Signs of pubertal development	□ Yes □ No
If yes, at which age	___________
□ Mature □ Premature
2. Clinical examination
Hair density	□ Normal
□ Decreased
□ Pattern distribution
□ Alopecic patches
Scalp skin	□ Normal
□ Erythema
□ Scaling
□ Seborrhoea
□ Pustules
□ Signs of scarring
□ Others (e.g. psoriasis, pigmentation)
Eyebrows/eyelashes	□ Normal
□ Abnormal
Facial and body hair	□ Normal
□ Excessive hair growth/hirsutism
□ Decreased axillary hair
□ Decreased pubic hair
Signs of acne	□ Yes □ No
3. Laboratory
Iron, ferritin	□
TSH	□
Blood haemoglobin	□
TPHA/RPR if indicated by clinical DD	□
In women only, if hormonal dysregulation is suspected
FAI [total testosterone (nmol L⁻¹) × 100 SHBG (nmol L⁻¹)]	□
DHEAS	□
Prolactin	□
4. Hair examination tests
Pull test	□
(Video-) Dermoscopy/loupe	□
Hair shaft examination	□
Trichogram	□
Biopsy	□

Table 1. Diagnostic evaluation form for androgenetic alopecia

1. History

Age

___ years

Sex

□ Male

□ Female

First manifestation of hair loss

Age: ___

Course of hair loss

□ Acute

□ Chronic – Intermittent

□ Chronic – Persistent

Complaining of increased shedding of hair

□ Moderate

□ Severe

□ No

Complaining of increased thinning of hair

□ Diffuse

□ Localized

□ No

Itching

□ Yes □ No

Dandruff

□ Yes □ No

Trichodynia

□ Yes □ No

Family history of androgenetic alopecia

□ Yes

□ Mother/maternal side □ Father/paternal side

□ No

Concomitant diseases (chronic, autoimmune, recently diagnosed, with possibly chronologic relation to hair loss)

___________

Previous surgery

___________

Eating behaviour

Strictly vegetarian diet

□ Yes □ No

Crash diet or eating behaviour disorders

□ Yes □ No

Important weight loss > 5–10 kg

□ Yes □ No

Weight

___________

Height

___________

Drug history (e.g. pro-androgenic, antithyroid, anti-epiletics, β-blocker, chemotherapeutics, supplements)

Please provide details: ___________

Smoking

□ Yes □ No

Only in women

Menstrual cycle

□ Regular □ Irregular

Menopause

___________

Oligomenorrhoea

□ Yes □ No

Amenorrhoea

□ Yes □ No

Since when

___________

Hormonal contraception

□ Yes □ No

Hormonal replacement therapy

□ Yes □ No

Fertility treatment

□ Yes □ No

Specify drug and duration

___________

Succesful and unsuccessful pregnancies

___________

Excessive facial and/or body hair growth

□ Yes □ No

Skin changes (acne)

□ Yes □ No

Seborrhoea of scalp/skin

□ Yes □ No

In children and adolescents

Hair loss

□ Congenital □ Acquired

Signs of pubertal development

□ Yes □ No

If yes, at which age

___________

□ Mature □ Premature

2. Clinical examination

Hair density

□ Normal

□ Decreased

□ Pattern distribution

□ Alopecic patches

Scalp skin

□ Normal

□ Erythema

□ Scaling

□ Seborrhoea

□ Pustules

□ Signs of scarring

□ Others (e.g. psoriasis, pigmentation)

Eyebrows/eyelashes

□ Normal

□ Abnormal

Facial and body hair

□ Normal

□ Excessive hair growth/hirsutism

□ Decreased axillary hair

□ Decreased pubic hair

Signs of acne

□ Yes □ No

3. Laboratory

Iron, ferritin

□

TSH

□

Blood haemoglobin

□

TPHA/RPR if indicated by clinical DD

□

In women only, if hormonal dysregulation is suspected

FAI [total testosterone (nmol L⁻¹) × 100 SHBG (nmol L⁻¹)]

□

DHEAS

□

Prolactin

□

4. Hair examination tests

Pull test

□

(Video-) Dermoscopy/loupe

□

Hair shaft examination

□

Trichogram

□

Biopsy

□

S1 Guideline for Diagnostic Evaluation in Androgenetic Alopecia in Men, Women and Adolescents

Aetiology

Men

Women

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S1 Guideline for Diagnostic Evaluation in Androgenetic Alopecia in Men, Women and Adolescents

Aetiology

Men

Women

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