Treatment options for hair loss due to androgenetic alopecia in women (Part II)
Androgen-dependent treatments
Cyproterone acetate:Cyproterone acetate is a synthetic steroid with antiandrogenic and antigonadotropic properties, as well as weak progesterone activity. It competes with dihydrotestosterone for androgen receptor binding. Although there are conflicting results regarding its efficacy in FPHL, successful outcomes have been reported in women with hyperandrogenism and high ferritin levels. Cyproterone acetate is used in men to reduce hypersexuality and treat severe sexual aggression. Concomitant contraception is recommended for women of childbearing potential. It is also prescribed for severe hirsutism in women of reproductive age and for androgenetic alopecia in women.
In a retrospective review of two hundred and twenty-eight patients with hyperandrogenism, ethinyl estradiol and high-dose cyproterone acetate were shown to reduce the hirsutism score by 53% in 1 year and were effective in the treatment of acne and alopecia. While it is prescribed by physicians in Europe for the treatment of androgenetic alopecia in women, doctors in the USA do not prefer it for female pattern hair loss treatment due to potential toxicity and long-term side effects. In a study conducted on patients with FPHL and without hyperandrogenism, no significant difference in efficacy was found between spironolactone and cyproterone acetate, with new hair regrowth reported in 44% of patients. In a study comparing 2% minoxidil solution with cyproterone acetate, minoxidil was found to be more effective in women with no evidence of hyperandrogenism. Side effects include weight gain, menstrual irregularities, decreased libido, breast tenderness, and feminization of the male fetus. Cyproterone acetate exerts its effect by blocking the binding of dihydrotestosterone (DHT) to receptors. Possible side effects include breast tenderness, headache, and decreased libido.Spironolactone: It is commonly used in the treatment of female pattern hair loss (FPHL) and hirsutism. Spironolactone is a potassium-sparing diuretic. It is generally used to reduce fluid in the body without causing potassium loss. It is mostly used for the treatment of ascites cases due to cirrhosis. It is also used as an aid in the diagnosis of primary hyperaldosteronism cases. It is used in the treatment of polycystic ovary syndrome and hirsutism cases in women.
It acts as an androgen antagonist by competitively blocking androgen receptors and also inhibiting androgen production from the ovaries. It is used at doses of 100-200 mg/day. Since it also acts as an aldosterone antagonist, it has side effects distinct from other antiandrogens, such as postural hypotension and electrolyte disturbances. Menstrual irregularities, fatigue, urticaria, breast tenderness, and hematological disorders are other possible side effects. Regular monitoring of blood pressure and electrolyte levels is recommended during the first few months of treatment. Spironolactone should not be used in cases of moderate renal failure. Spironolactone is generally used to reduce fluid in the body without causing potassium loss.
In addition, it is used to treat potassium deficiency, high blood pressure (hypertension), swelling (edema), and a hormonal disorder called hyperaldosteronism.
Spironolactone acts as an anti-androgen in two ways. First, it slows down androgen production in the adrenal glands and ovaries. Second, it blocks the conversion of testosterone to dihydrotestosterone (DHT). Spironolactone is one of the most potent anti-androgen drugs. In topical applications, it is absorbed locally, so it is not absorbed systemically. Because it does not enter the systemic circulation, it is preferred in topical treatments.SPIRONOLACTONE HAIR LOTION
Rp
Spironolactone 1 g
Methylcellulose 0.25 %
Ethanol 95 % 40 ml
Propylene glycol 20 ml
Purified water qs 100 ml
Finasteride: Finasteride is a type 2 alpha-reductase enzyme inhibitor that prevents the conversion of testosterone to dihydrotestosterone. In male pattern hair loss, it reduces hair loss and stimulates hair growth at doses of 1 mg/day. Controlled studies in postmenopausal women have shown no efficacy at a dose of 1 mg/day. In an uncontrolled study in premenopausal women, a 62% improvement was observed with an oral contraceptive containing drospirenone and ethinyl estradiol at a dose of 2.5 mg/day. Numerous case reports and small-scale studies have demonstrated the efficacy of finasteride at 2.5–5 mg/day in pre- and postmenopausal women. Efficacy is independent of signs of hyperandrogenism.
Because it can cause feminization of a male fetus, it must be used with contraception in premenopausal women. A slight increase in estrogen levels may occur due to the conversion of testosterone to estradiol; therefore, it is not recommended in individuals with a personal or family history of breast cancer.MINOXIDIL 2% AND FINASTERIDE 0.1% SCALP LOTION
Rx
Minoxidil …………. 2 g
Finasteride ………… 100 mg
Propylene glycol … 20 ml
Ethanol 95% … qs 100 ml
Dutasteride: It is a type 1 and 2 5-alpha-reductase enzyme inhibitor. It inhibits the conversion of testosterone to dihydrotestosterone. In twenty-five postmenopausal women, improvement was observed with dutasteride at 0.25 mg/day in 60% in the first year and in 80% in the second year. Effective results were also achieved with a combination of 0.5 mg/day dutasteride and 2.5 mg/day finasteride. In a study where dutasteride was administered intradermally to the vertex via mesotherapy, photographic improvement was observed in 62.8% of patients using a solution consisting of a combination of dutasteride, biotin, pyridoxine, and D-panthenol.Flutamide: Flutamide is a nonsteroidal selective antiandrogen that inhibits receptor binding of androgens. Studies highlight its efficacy in female pattern hair loss at a dose of 250 mg/day. When compared to finasteride 5 mg/day and cyproterone acetate 50 mg/day, the use of flutamide at this dose was found to be the most effective, with a 21% improvement in the Ludwig score. Its only limiting aspect is that it causes dose-dependent hepatic dysfunction; liver function must be closely monitored. In a 35-year-old patient unresponsive to spironolactone treatment, a significant response in hair density was obtained when used together with topical minoxidil 5%.
Wishing you a good week…
To be continued…
References:
1- Türkderm 2014; 48: Special Issue 1: 31-5 İdil Ünal Androgenetic alopecia in women.
2- Standardisierte Rezepturen (NRF/SR)
Spec. Pharm. Ahmet Nezihi Pekcan
Pekcan Pharmacy – Konya
[email protected]
Tel: (332) 3520657http://www.majistralformul.com/
