Effective treatment of female androgenic alopecia with dutasteride

Journal of Drugs in Dermatology, Sept-Oct, 2005 by Malgorzata Olszewska, Lidia Rudnicka

Abstract

Dihydrotestosterone is the main molecule responsible for androgenic alopecia. Finasteride, which reduces transformation of testosterone into dihydrotestosterone and decreases dihydrotestosterone activity, is approved for treatment of androgenic alopecia in men. We describe the case of a 46-year-old woman with androgenic alopecia, non-responsive to minoxidil, who initially benefited from finasteride. Due to only limited improvement after finasteride and persisting profound psychological distress resulting from androgenic alopecia, another 5-reductase inhibitor, dutasteride, was introduced. Clinical evaluation and trichogram were applied for assessment of dutasteride efficacy in this patient. Additionally, mean hair diameter was monitored by means of computer dermoscopy. After 6 months of therapy, significant improvement was observed and after 9 months the clinical diagnosis of androgenic alopecia could no longer be made in this patient. No side effects were observed. In conclusion, theoretical data and our experience in this case show that dutasteride might develop into a true alternative in treatment of androgenic alopecia.

Introduction

It is universally accepted that dihydrotestosterone (DHT) is responsible for androgenic alopecia (AGA) in men and women. (1-3) DHT induces miniaturization of hair and hair follicles by accelerating the mitotic rate of the matrix, by shortening hair cycle and increasing telogen shedding, as well as by increasing the duration of the lag phase or ketogen. (1,2) Thus, attempts have been made to reduce DHT activity in patients with androgenic alopecia by applying inhibitors of the enzyme 5-reductase, which transforms testosterone into dihydrotestosterone (DHT). Finasteride, an inhibitor of 5-reductase type 2 isoenzyme is now widely used for treatment of AGA in men. Also, the use of finasteride for AGA in women is increasingly gaining interest. (1,2)

Dutasteride is another 5-reductase inhibitor. It has the capability of inhibiting both isoenzymes, type 1 and type 2 of 5-reductase, and induces an even more significant reduction of serum DHT. (1) This molecule, however, has not yet been used for management of AGA.

Case Report

We describe a 46-year-old woman, who suffered from gradually progressive, diffuse loss of hair over the vertex and slow recession of the frontal hairline from the age of 39. Trichogram results, summarized in Figure 1, showed the presence of 44% telogen hair with an anagen/telogen ratio of 0.84/1. Histopathology from two sites showed partly fibrous root sheath remnants below miniaturized follicles with no perifollicular infiltrates, which confirmed the diagnosis of AGA. Dermoscopy of the affected scalp also revealed characteristic features of AGA, including variable hair diameter and hair miniaturization with a mean diameter of hair below 0.04 mm at the vertex and the front line area, as compared to 0.08 mm at the occipital area. The method of hair diameter assessment is presented in Figure 2. Dermoscopy also showed that follicle density at the vertex was 150 per square centimeter, which is significantly below normal values ranging from 300 to 400.

All basic laboratory data, including serum levels of dehydroepiandrosterone sulfate, androstedione and free testosterone were within normal range. From the age of 43 the patient received cyproterone acetate and ethinyl estradiol for contraception. According to anamnesis the treatment had no effect on disease progression.

The patient received topical 2% minoxidil therapy twice daily for 4 months with no improvement. Also, no improvement could be observed after introduction of 5% minoxidil twice daily for the next 2 months. The disease progressed and at this point the diagnosis of AGA type II/III according to Ludwig classification (1) could be made. Due to the lack of response and based on our previous positive experience in other female patients (unpublished data), as well as available literature (6,7) finasteride at the dose of 1 mg per day was introduced. After 3 months of therapy slow improvement could be noticed. Clinical picture and patient's satisfaction were slightly improved. As shown in Figure 1, this improvement was accompanied by changes in trichogram. Despite treatment continuation for another 3 months, no further improvement could be observed thereafter. At this point, the diagnosis of AGA type I/II according to Ludwig classification could be made.

[FIGURE 1 OMITTED]

Despite some improvement as compared to values upon introduction of treatment, the patient still experienced profound anxieties and distress due to persistent AGA and awaited further improvement.

Due to the lack of further improvement, finasteride was discontinued and another 5-[alpha] reductase inhibitor, dutasteride, at the dose of 0.5 mg per day was introduced. The patient received no other treatment either for AGA or for any other condition, accept continuation of cyproterone acetate and ethinyl estradiol for contraceptive purposes.