Alopecia in women: identifying, diagnosing, treating

Hair loss in women is becoming increasingly common in clinical practice—but assessment remains complex. A clinical practice article in the New England Journal of Medicine clarifies the diagnostic criteria. Its author, dermatologist Dr. Elise A. Olsen, a professor at Duke University Medical Center, in Durham, N.C., directs a leading program in scalp disorders. She points out that female-pattern hair loss (FPHL) is “the most common cause of hair loss in women,” affecting up to 56% of patients over the age of 70.The article notes that diagnosis remains difficult, because FPHL can mimic telogen effluvium and distinguishing between them can be challenging, especially in the early stages. It can also mimic early scarring alopecia."Most patients arrive after several months, sometimes several years, of unresolved concern,” noted Dr. Olsen. However, as follicular miniaturization progresses, therapeutic margins become narrower, making early diagnosis essential.Identifying the clinical pattern is key: central thinning, widening of the parting and preserved frontal hairline. Two patterns predominate: central progression or a “Christmas tree” pattern. Trichoscopy shows variation in diameter and preserved ostia, a sign of a non-scarring process. This heterogeneity in caliber—sometimes more than 20% of miniaturized hair—is a major criterion. “The main characteristics are a pattern centred on the vertex and the preservation of follicular ostia,” Dr. Olsen said. In case of doubt about a scarring form, a targeted biopsy can remove the ambiguity: A lowered terminal/vellus ratio and a decrease in the anagen phase point to FPHL, while a disappearance of ostia and perifollicular fibrosis suggest scarring alopecia.No adrogen excessDr. Olsen points out that the majority of affected women have “no clinical or biological signs of androgen excess.” Androgen testing is therefore only indicated in cases of hirsutism, irregular cycles or severe acne. The beneficial tests are limited: complete blood count, ferritin, vitamin D, TSH and free T4. It is also essential to review current treatments: anti-estrogens, certain progestogens, and androgenic supplements can increase hair loss. In complex situations (postpartum, acute stress, systemic disease), concomitant telogen effluvium is not uncommon.Topical minoxidilDr. Olsen points out that treatments are more effective when started early. Minoxidil remains the first-line option: 2% solution twice daily or 5% foam once daily. In trials, more than half of patients show improvement after 48 weeks, with increased density and calibre. The 5% solution applied twice daily, although not approved for women, may offer superior efficacy, particularly in young patients or when miniaturization is marked. Initial shedding—a temporary hair loss related to the synchronization of the hair cycle—is common and should be explained. “This is a positive sign, not a worsening,” said Dr. Olsen. Adherence remains the main obstacle: delayed results, product texture, and daily application often complicate long-term maintenance.Low-dose oral minoxidilLow-dose oral minoxidil, prescribed off-label, is gaining ground when topical minoxidil is poorly tolerated or insufficient. A randomized study shows that a dosage of 1 mg per day is “at least as effective” as the 5% solution, with better adherence. Side-effects are generally mild: mild hypotension, reflex tachycardia, edema, or hypertrichosis, the latter affecting up to 15% of patients. In practice, doses vary between 0.625 mg and 2.5 mg per day. Gradual titration, particularly in patients with low blood pressure or taking antihypertensive drugs, reduces the risks. The combination of oral and topical minoxidil may also be considered in advanced cases.AntiandrogensAntiandrogens are indicated for women with signs of hyperandrogenism. Spironolactone remains the most commonly used, at doses of 50 to 200 mg per day. It is particularly useful in patients with PCOS or irregular cycles. More powerful molecules, such as bicalutamide or flutamide, carry risks to the liver, which limits their prolonged use. These treatments require reliable contraception and regular clinical monitoring. The response may be slow and is mainly manifested by stabilization of hair loss rather than clear regrowth.5-alpha-reductase inhibitors5-alpha-reductase inhibitors are particularly useful after menopause. Finasteride at 1 mg has not been shown to be effective in women. Doses of 2.5 to 5 mg give better results, but at the cost of a teratogenic risk. Dutasteride 0.5 mg, which acts on two enzyme isoforms, appears to be more effective but remains off-label. For some postmenopausal patients with marked FPHL, it may offer additional benefit. In all cases, “they should be prescribed to carefully selected patients,” emphasized Dr. Olsen.Adjuvant proceduresSeveral procedural approaches can complement drug therapy. Platelet-rich plasma improves diameter and density in several trials. Microneedling—micro-perforations designed to stimulate follicular regeneration—can enhance the effect of minoxidil, especially in highly miniaturized areas. Photobiomodulation devices, such as red light helmets, offer modest but reproducible gains. “Useful in combination therapy,” said Dr. Olsen, who points out that none of these approaches replaces basic treatments.The key challenge remains to act early and make gradual adjustments. Explaining the timeline for action, clarifying objectives, and consulting with the patient regularly helps to structure care. Standardized photographic assessment and documentation of treatments attempted facilitate followup. This approach, supported by the guidelines proposed by Dr. Olsen, helps reduce uncertainty and offer a clearer therapeutic pathway for patients for whom hair loss remains a real source of anxiety.This article has been translated from its original French and first appeared on our sister site Profession Santé.

Alopecia in women: identifying, diagnosing, treating

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