What ages hair?
Assaf Monselise, MD
, David E. Cohen, MD, MPH
, Rita Wanser
, Jerry Shapiro, MD
Department of Dermatology and Skin Science, University of British Columbia, BC, Canada
The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, NY, USA
Cicatricial Alopecia Research Foundation, Chairman of the Board, IL, USA
Private practice, Tel Aviv, Israel
Hair has always played an important role in the history of mankind.
Egyptian hieroglyphics are testimony of the paramount importance of
hair for this ancient civilization, not only because of the visual effect,
but also because of the erotic symbolism connected with hair. For the
ancient Romans hair was not only a question of fashion but was used
as a symbol of beauty, virility, class and intellect. In modern western
culture having a full head of hair is of ten associated with desirable
qualities such as youthfulness and vitality. Most pe ople experience
changes in hair and scalp health as they age. Subsequent hair loss may
cause signiﬁcant distress that deeply affects people’s life causing social
anxiety and interfering with their well being. Genetic and hormonal
changes are important factors in hair loss, but weathering and grooming
habits take a toll on our hair as well.
A recent advisory board comprising twelve experts in hair ﬁbers
and hair loss was formed to review hair loss in relation to heredity,
agin g and environmental factors emphasizing measures that m ay
slow alopecia. The following information is a summary of their discus-
sions on these topics.
Deﬁnition of a healthy scalp and hair
Although healthy scalp and hair are of prime importance, the general
public is no t kno wledgeable about these issues. Most people have little
awareness about how to appropriately care for their hair and scalp. Healthy
hair and healthy scalp typically complement each other, so a healthy scalp
is needed to give the appearance of healthy hair and vice versa. A healthy
scalp is generally deﬁned by a lack of disease or abnormalities; however a
person could be bald and perceived as having a healthy scalp.
Experts in the ﬁeld of dermatology (Rogaine®ScientiﬁcRoundtable,
2009) agree that the characteristics of healthy hair include thickness,
volume, lus ter and resilience of the ﬁber. The majority have agreed
that a healthy scalp would have normal follicular densi ty with no
scaling, itching, burning or erythema.
Many patients experiencing hair loss assume the problem is related
to the scalp if inﬂammation or ﬂaking is present at the time of hair loss.
They believe that treatment of the scalp would promote future hair
growth, although th is is frequently not the case.
Chronic scalp inﬂammation likely dim inishes hair health via a variety
of mechanisms that are not fully understood. Although research on the
effects of chronic scalp inﬂammation on hair health is limited, a plausible
mechanism involves cytokine-driven decrease in the anagen phase hair
lengthening as well as miniaturization of the hair follicle. The ideal envi-
ronment required for a healthy growth of hair still has to be identiﬁed,
yet changes in the environment surrounding the follicle like sebum
excretion, debris, and chronic inﬂammation could signiﬁcantly impact
the growth and health of hair. On the other hand, treatments targeted
at reducing inﬂammatory scalp conditions, such as dandruff and infec-
tion are harsh on the hair shaft and decrease shine and manageability.
Pattern Hair Loss or Age-related thinning
Pattern hair loss (PHL) has a multi-genetic background with half the
male population affected by the age of 50 years. Different patterns for hair
loss have been identiﬁed, including the Norwood-Hamilton pattern
(Figure 1), the Ludwig pattern (Figure 2) and the Christmas tree or frontal
accentuation pattern (Figure 3) Although the Norwood-Hamilton is tradi-
tionally used to describe PHL in men and th e Ludwig and Christmas tree
pattern for women, the different patterns are not gender restricted and
can be used interchangeably. According to available data 38% of women
over the age of 50 experience signiﬁcant hair thinning (Rogaine®Scientiﬁc
Roundtable, 2009). Women often regard hair loss a problem related to
men exclusively and do not recognize this problem until signiﬁcant hair
loss has occurred, thus delaying treatment with minoxidil.
In men, hormonal factors, namely dihydrotestosterone (DHT) levels,
play an important factor in the pathophysiology of PHL, with increased
5-alpha-reductase an d androgen receptors in the frontal scalp com-
pared to the occiput (Pri ce, 2003). High scalp DHT levels are associated
with follicu lar mi niaturization which is characteristic for PHL (Whiting,
2001), however follicular downsizing has been described for senescent
alopecia as well (Table 1)(Hordinsky et al., 2002). The pathophysiology
of follicular downsizing is not fully understood. It is described as an
alteration of the anagen (growth) and telogen (resting) phases of hair
growth with a diminished scalp vasculature as an adjustment for the
needs of the decrease in size follicles. In fact, the telogen phase during
which hair is shed changes as a person ages. In a child, the number of
hairs that are shed during this phase is much less compared with an
average adult, who typically loses 100 hairs each day. As a person
continues to age, the number of hairs that are shed increases, resulting
in thinning, which is common in the senior population. Conversely,
the anagen phase of hair growth is likely inﬂuenced by age and race
and appears to shorten as a person ages, however it is unclear when
International Journal of Women's Dermatology 1 (2015) 161–166
⁎ Corresponding Author.
E-mail address: firstname.lastname@example.org (A. Monselise).
2352-6475/© 2015 The Authors. Published by Elsevier Inc. on behalf of Women's Dermatologic Society. This is an open access article under th e CC BY-NC-ND license
Contents lists available at ScienceDirect
International Journal of Women's Dermatology
or what triggers a shortening of this phase. Additionally, people from
some ethnic backgrounds, such as African American women, appear to be
more susceptible to shortening of the anagen phase, as they often experi-
ence difﬁculty in growing and maintaining long hair as they get older.
A direct relationship appears to exist between the degree of scalp
inﬂammation and pattern hair loss especially in men (Jaworsky et al.,
1992), and treating this inﬂammation can reduce the loss of hair. In this
regard, minoxidil may exert anti-inﬂammatory/immunomodulatory
effects in the follicle environment (Fiedler and Buys, 1987, 1988). In
contrast, research in the area of female PHL suggests that sebum excre-
tion is unchanged in these patients (Birch et al., 2006). Most women
with PHL have normal serum androgen levels, suggesting genetic and
environmental factors are likely playing a role in alopecia.
Some people experience widespread thinning of their hair as they
get older. This condition is deﬁned as senescent alopecia or age-
related thinning, and is characterized by a scalp-wide reduction in the
number of hairs rather than classic pattern hair loss. Senescent alopecia
typically occurs between the ages of 50 and 80 years in a person without
a prior history of hair thinning and any underlying scalp diseases, and
can be superimposed on PHL. Indeed the distinction between age-
related thinning and PHL is confusing since the presence of follicular
miniaturization in age-related hair loss is an inconsistent ﬁnding. The
relation between senescent hair loss and androgens has yet to be deter-
mined. A drop in estrogen levels that occur during menopause could
contribute to hair thinning, which is commonly seen in older women.
Some areas of the scalp could be dependent on androgens for either
hair growth and/or hair loss, and this may explain, for example, the
association of Hamilton PHL, which is typical for men, in some women
with age-related hair loss. If low androgen plays a major role in
senescent alopecia, Estratest® (esteriﬁed estrogens combined with
methyltestosterone) would be the hormone replacement of choice in
women. This drug could also be combined with ﬁnasteride in women
with low dihydrotestosterone (DHT) levels. However, administration
of Estratest and dehydroepiandrosterone (DHEA) supplements has
been associated with hair loss in clinical practice, so determining the
appropriate dose and product for androgen replacement could be
challenging. The ideal androgen level for hair growth must be balanced
with the negative effects of androgen administration, such as hirsutism,
acne, and osteoporosis. Since minoxidil’s stimulatory effect impacts
many areas of the scalp, it would indeed help manage senescence and
hair loss related to aging alopecia.
Weathering & Grooming
Weathering is deﬁned as the cumulative effect of environmental fac-
tors on the physicochemical structure of the hair. Hair damage induced
by environmental factors including UV, humidity, wind and chemicals
in hair products and procedures, has a negative impact on the growth
and texture of the hair ﬁber. Grooming habits and weathering interplay
in the process of hair wearing and both can compound the natural
Fig. 1. Androgenetic Alopecia in Males. Hamilton-Norwood Classiﬁcation. (Reprinted with permission from Hair Loss and Hair Restoration. Authors: Shapiro J and Otberg N. CRC Press
Taylor and Francis 2015 Chapter 2 page 32.)
Fig. 2. Androgenetic Alopecia in Women. Ludwig Classiﬁcation.
162 A. Monselise et al. / International Journal of Women's Dermatology 1 (2015) 161–166
decrease in hair density related to age-related thinning/PHL. Typically in
Caucasians and Asians, when the inciting factor is weathering, the dam-
age occurs distally on the hair shaft. However, damage to the shaft fre-
quently occurs proximally in African Americans, caused by the harsh
chemicals applied on the scalp to relax the hair. The resilience of the
hair shaft to weathering is determined by its unique structure. Much
of the ﬁber’s strength is given by the cortex and overlying cuticle that
serves as a mechanical protective barrier. The latter constitutes about
10% of the ﬁber’s weight and is made of tiny scales that overlap one an-
other like shingles on a roof, with their exposed edges towards the tip of
the ﬁber. The cortex provides strength thanks to keratin which is rich in
disulﬁde bonds. Additionally, melanin which resides in the cortex
provides protection to the ﬁber against UV radiation. The pathogenesis
of photo damage involves interaction between iron, wa ter, and UV
light with the formation of free radicals. The latter are partially absorbed
by melanin which acts as a scavenger of free radicals. However, when an
overwhelming amount of free radicals is formed, melanin is degraded
and UV light then generates crosslinks between proteins, melting the
cortex and making the hair very brittle. Red headed and blond people
are more prone to photo-damage since their hair is rich in pheomelanin
which is less resistant than eumelanin. Likewise white or graying hair is
less protected from UV radiation.
The frictional properties of the cuticle determine how the hair feels
to touch, how it combs and styles. When the cuticular scales are smooth
light is reﬂected and the hair appears shiny and healthy. Typically, the
macroscopic appearance of a damaged ﬁber is characterized by splitting
of the ends, so called trichoptilosis. This happens mostly for longer ﬁbers
that have been exposed for lo nger periods to environmental fa ctors.
Observation of the hair by scanning electron microscopy reveals pro-
gressive damage to the ﬁber from root to tip, with slight scale lifting
proximally and gradual chipping and denudation of the cuticle, with
longitudinal ﬁssures and transverse breakage or trichoschisis near
trichorrhexis nodosa like nodes.
Grooming habits have an important impact on the wearing of the
hair ﬁber. Shampooing daily cleanses off the protective layer of sebum
that covers the hair, causing the shaft to dry out so it easily gets statically
charged and consequentially more prone to friction. Shampoos are am-
phiphilic molecules that have both a lipophilic side that binds sebum
and a hydrophilic part that binds water. They are divided into groups
based on their chemical structure. Those belonging to the anionic
group contain negatively charged molecules with stronger and deeper
cleansing properties, such as sodium laureth sulfate and sodium lauryl
sulfate. Sodium lauryl sulfate was used almost exclusively in shampoos
several years ago and is more irritating and damaging to the follicle com-
pared to sodium laureth sulfate. Currently, the majority of shampoos
contain sodium laureth sulfate due to its moisturizing properties
(Rogaine®Scientiﬁc Roundtab le, 2009 ). Shampoos categorized in other
chemical groups (cationic, non ionic and amphoteric) include products
that have milder cleansing properties, are less irritating and leave the
hair more manageable. Shampoos are often marketed based on the
type of hair that they are meant for. Those for oily hair have stronger
detergent properties while those for permed, permanently dyed,
bleached or dry hair, are milder in order to reduce sebum removal.
Baby shampoos are usually mild, less irritating and are suitable for
Permanent waving or relaxing of hair involves chemicals like ammo-
nium thioglycollate, sodium hydroxide and guanidine hydroxide, which
are extremely alkaline and cause breakage of disulphide cross-links
within the keratin, inducing swelling and softening of the ﬁber.
Reduced cysteine levels in relaxed hair is consistent with hair fragility
in comparison to normal unrelaxed hair Khumalo et al., nd.The
dama ged ﬁber characteristically breaks along the shaft, leaving the
root unaffected and is more often seen on the nape area which is
treated by the stylist and is thereby exposed to the product for longer
time. Bleaching products contain hydrogen peroxide or hydrogen
persulfate. These chemicals must traverse the cuticle in order to bleach
the melanin which lays in the cortex, causing irreversible oxidation of
keratin disulﬁde bonds with weakening the ﬁber.
Combing and brushing, especially when done tip to root on wet hair
can be harsh on the ﬁber with the development of trichoschisis. Wet
combing applies force on the hair close to the scalp, making it more
damaging than dry combing in which the force is pla ced on the en d
of the hair shaft (Rogaine®Scientiﬁc Roundtable, 2009). Using wide-
Fig. 3. Androgenetic Alopecia (AGA) in Women-Frontal Accentuation (Christmas Tree Pattern).
Deﬁning the characteristics of Senescent Alopecia
Scalp-wide reduction in the number of hairs
Occurs between the ages of 50 and 80 years
No prior history of hair thinning or underlying scalp disease
Presence of follicular miniaturization is inconsistent
Shortening of anagen
Decreased anagen/telogen ratio
Relation to androgens has yet to be determined.(low androgen levels could be a factor)
163A. Monselise et al. / International Journal of Women's Dermatology 1 (2015) 161–166
toothed combs and brushes with rounded tips is a good pro tective
measure when styling the hair. (Table 2)
In African Americans, straightened hair behaves similar to Caucasian
hair, so it is less difﬁcult to comb when it is dry compared with non-
straightened hair. The application of oil to African American hair prior
to shampooing would lubricate the hair shaft, making hair more
manageable, easier to comb, and less susceptible to damage by the
shampooing and drying process. Oils may also have antifungal proper-
ties, which could ward off scalp infe ctions. However, triglycerides in
these oils could be cleaved to free fatty acids that produce inﬂammation
in the hair follicle (Rogaine®Scientiﬁc Roundtable, 2009).
Using hair dryers and curling irons can “cook” the ha ir ﬁber. Obser-
vation with a magniﬁer reveals the classic picture of Bubble Hair
(Mirmirani, 2008)(Figure 4) that is given by micro cavities within the
shaft, which are formed by the expansion of moisture induced by the
high temperatures of these devices. Japanese or ionic hair straightening
with ceramic irons that reach temperatures as high as 210°C has been
related to widespread breakage of the hair shaft as a result of acquired
trichorrhexis nodosa (Mirmirani, 2010). Temp orary disruption of
hydrogen bonds in the cortex involved in this procedure, imparts the
desirable softness to the hair. Interestingly, trichorrhexis nodosa is
observed where the cuticle is lost and the cortex has been damaged.
Current Treatment Concepts
Minoxidil was the ﬁrst FDA approved medication for male-pattern
baldness and has been on the market for more than 20 years. Increased
scalp blood ﬂow resulting from local vasodilation has been proposed
as a possible mechanism of minoxidil's effect on hair growth however,
this mechanism has not been substantiated consi stently and not all
vasodilators produce hypertrichosis. Because minoxidil has stimulated
hair regrowth in several forms of alopecia, different speculations
regarding its mechanism of action have been forwarded. These include
immunomodulation (Fiedler and Buys, 1987, 1988), targeting speciﬁc
follicular p otassium channels (Davies et al., 2005 ) or induction of
PGE2 synthesis in the dermal papilla ﬁbroblasts (Michelet et al., 1997).
Traditionally, topical minoxidil has shown to be efﬁcacious for male
pattern hair loss (MPHL) involving the vertex, with an increase of 30% in
hair weight at 96 weeks of treatment compared to placebo (Price et al.,
1999). However, signiﬁcant clinical data has demonstrated minoxidil’s
efﬁcacy for frontal hair loss as well, which is consistent with histologic
(Whiting et al., 1999) and photographic evidence suggesting that folli-
cles in the vertex and frontal scalp have the same morphology. Indeed
it may take up to one year of treatment before signiﬁcant changes in
hair growth are detectable by consumers. Minoxidil solution has a
high safety proﬁle (Shapiro, 2003) with scalp irritation occurring in 7%
of patients which has been related to the vehicle (propylene glycol) or
minoxidil (Friedman et al., 2002). Minoxidil 5% foam is propylene glycol
free and is therefore recommended for patients who are suspected to be
sensitive to the vehicle. In the clinical trial of Minoxidil 5% foam (MTF) a
decrease in the incidence of irritation was observed on both the foam
vehicle a nd 5% MTF. Furthermore, the incidence of pruritus with 5%
MTF was 1.1% vs 6% seen in a separate trial of 5% Minoxidil topical solu-
tion (Olsen et al., 2007).
Many dermatologists recommend Minoxidil for age-related thinning
as this process inv olves a decrease in both hair density and the diameter
of the hair follicle (Ebling, 1988), which are successfully treated by
Non approved hair regrowth treatments
A plethora of products for hair loss is available on the market, some of
which are easily accessible through different web sites and others are
sold in salons (Table 3). Slogans and claims are provided to the public
of healthy hair seekers indicating the beneﬁcial effects of these products
as solid evidence for promoting hair growth. Hence people may be
provided with questionable information regarding their hair problem
and treatment options. Products for hair loss are sold as shampoos,
solutions, cle ansers, foams conditioners, and leave – in agents. An
array of natural and non-natural occurring ingredients is mixed into
these products (i.e. vitamins, adenosine, retinoic acid, herbal extracts,
minoxidil, ketoconazole, copper peptide, amino acids) as remedies for
hair loss. It is unknown whe ther some of these hair products may
indeed have beneﬁcial effects on the follicl es. Only Rogaine®
(containing minoxidi l) has established evide nce base d sc ience to
substantiate proven efﬁcacy.
Good grooming habits
Shampoo daily with mild shampoo which is less irritating to the shaft
Apply shampoo to soaked hair with ﬁngertips and rub gently
Avoid frequent perming
Avoid frequent application of permanent dyes
Avoid frequent bleaching
Comb hair root to tip when dry
Use wide-toothed combs and brushes with rounded tips
Avoid frequent use of hair dryers
Fig. 4. Bubble Hair-Deformed hair shafts due to heat exposure cau sed by dryers and
Efﬁcacy proven by clinical trials:
Minoxidil 5% solution (or minoxidil 5% foam if allergy occurs with the solution)
Finasteride (Propecia®) 1mg Tab Once daily (for MPHL)Price et al., 2006
Dutasteride (Avodart®) 2.5mg Tab Once daily (for FPHL)
Dutasteride (Avodart®) 0.5mg Tab Once daily (for MPHL) Stough, 2007; Eun et al.,
nd; Olsen et al., 2006
Non approved products with limited clinical data :
Finasteride 2.5mg Tab Once daily (for FPHL) Iorizzo et al., 2006
Hair products with Ketoconazole
Hair products with copper peptide
Hair products combining minoxidil and retinoic acid
Hair products with various vitamins, adenosine and herbal extracts
Estratest +/- ﬁnasteride (for senescent hair loss)
164 A. Monselise et al. / International Journal of Women's Dermatology 1 (2015) 161–166
Combinations of minoxidil and retinoic acid probably enhance
the penetration of the former but are unlikely beneﬁcial due to the
neutralizing effect of the latter on m inoxidil. Products that co ntain
both of these components are deﬁnitely not recommended by most
hair experts due to potential irritation and unproven efﬁcacy. Further-
more, application of enhancing products in combination with minoxidil
should be separated by at least 2 hours to permit the abso rption of
minoxidil in to the epidermis and prevent its potential deactivation.
The concept of “opening hair follicles” was developed as a marketing
strategy for so me hair care products with allegedly enha nced hair
growth capabilities. However hair follicles are not necessarily closed
therefore it is unclear what are the beneﬁts of such products. Nanosome
technology has been used to enhance th e penetration of some hair
products into the epidermis, but whether it is of beneﬁt for growing
hair is questionable (Rogaine®Scientiﬁc Roundtable, 2009). Claims
regarding acceleration of metabolism in the follicle or surrounding
circulation by topically applied vitamins and herbal extracts, as well as
their nourishing effects on the hair follicle and scalp by direct applica-
tion are unknown. Many patients take mega doses of vitamins, which
could cause more harm than beneﬁt. Indeed, consumption of Vitamin
A at doses higher than 5000IU per day may be a risk factor for hair loss.
Hair Fiber Protection
Limited data s upports that replaceme nt of amino acids via a
shampoo increases the tensile of the hair ﬁber, however this beneﬁtre-
mains unproven (Rogaine®Sci entiﬁcRoundtable,2009). Hair products
with sun-screeners are useful as they provide protection to the scalp
and hair form UV ra diation and slow the weathering process. When
sun-screens are compounded as leave-in conditioners this can provide
moisture to the ﬁber and improve the manageability of the hair. DHT
likely exists on the scalp surface as a component of sebum. It has been
suggested that removal of DHT with clea nsing products containing
ketaconazole can improve hair growth. Literature suggests that ketoco-
nazole has anti-DHT properties, and not only improves seborrhea but
also androgenetic thinning (Pierard-Franchimont et al., 1998; Inui and
Itami, 2007). While the anti-DHT properties has not been proven to
help pattern hair loss, nevertheless the a ssociation of ketoconazole
may contribute to a healthier scalp. Copper peptide is compounded in
some hair products and scientiﬁc evidence suggests its beneﬁcial effects
on hair grow th th rough stimulation of human dermal papilla cells
(Pyo et al., 2007), and as a potent activator of both telogen and anagen
follicles in mice (Trachy et al., 1991).
Overcoming the denial of hair loss and encouraging people to seek
medical attention earlier rather than later would be valuable in the
overall management of hair thinning/hair loss. When evident alopecia
has ensued, at least 50% of the scalp hair has already been lost. Certain
patient populations are more prone to aging and thinning of their hair,
particularly those who practice certain grooming procedures, whose
hair is grayi ng or fair colored and are inadvertent ly exposed to
weathering factors. Most peo ple do not realize that UV exposure has
negative effects not only on the skin but on the hair as well, especially
when it is devoid of melanin.
Confusion exists around the deﬁnition of senescent alopecia
(Kligman, 1988; Ebling, 1988). In-ofﬁce measurement of age-related
changes in hair density is problematic since an efﬁ
cient instrument or
rating scale has not been identiﬁed to measure and monitor diffuse
thinning of th e hair. The scales used for alopecia, such as the SALT
(severity of alopecia tool) score, are not highly applicable to the situa-
tion of senescent thinning. Establishing a “norm” volume of hair for a
patient would be important, as the differences of hair shafts prevents
comparisons between patients. Furthermore, normal hair density
should be deﬁn ed for each age bracket, so the severity of h air loss
could be determine d. Scalp biopsies with horizontal follicular counts
are the gold standard for conﬁrming a reduction in hair number
(Whiting, 1993) but are problematic in everyday practice. Weathering
and grooming habits pose a signiﬁcant problem in aging patients. Dif-
ferences between declines in hair quality due to weathering v ersus
aging should be clearly characterized to help guide treatment in these
two situations. Grey or chemically/physically treated hair is drier and
more easily weathered, so conditioning is n ecessary to reinforce the
cuticular sheath and protect it from damage. A distinction should be
made between scalp care and care of the hair shaft and proper educa-
tion of the pu blic should be instituted. The former requires regular
cleaning to remove debris and build-up that can negatively impact
hair growth. Before shampooing, untangling the hair is important and
emphasis should be directed at lathering the scalp rather than the hair
shaft in order to remove debris and build-up that can negatively impact
hair growth. The hair ﬁber is adequately cleaned as the shampoo is
rinsed off the scalp and out of the hair (Rogaine®ScientiﬁcRoundtable,
2009). The frequency of shampooing should be tailored according to the
oiliness of the scalp, as very oily scalps require daily shampooing. Some
experts a dvocate applying oil to the hair prior to sham pooing as a
protective measure. The oil would lubricate the hair, making it more
manageable and e asier to comb. In addition, the oil contains tri-
glycerides that are converted in the scalp epidermis to monoglycerides
and diglycerides, which have antifungal properties. However, some of
the triglycerides could be clea ved to free fatty acids that have a pro-
inﬂammatory effect on the hair follicle (Rogaine®ScientiﬁcRoundtable,
2009). Drying the hair should be done gently by patting with a towel,
rather than wrapping the hair. Comb ing done slowly when the hair
has dried out using a wide-tooth comb with rounded tips will eliminate
unnecessary tension and breakage of the hair. African American
patients compared to Caucasians and Asians, pose a particular challenge
for treatment of hair loss having unique hair density, texture, scalp
conditions, and styling techniques that could inﬂuence treatment
response. Additionally, African American women are more susceptible
to age-related thinning. This patient population, infrequently shampoo
their hair hence promoting the buildup of products on the scalp which
may negatively affect hair growth. Shampooing th e scalp more
frequently could help eliminate unwanted debris but would also wash
out the sebum and enhance dryness and irritation. Layering of condi-
tioning products may reduce hair breakage and dryness but on the
other hand impair the absorption of hair growth promoting agents
like minoxidil. Additiona lly, Minoxidil may aggravate sc alp and hair
dryness in these patients making compliance and adherence with treat-
ment difﬁcult. Application of Minoxidil foam over several days could
produce a slight scalp residue, which does not affect its efﬁcacy there-
fore avoiding the need of shampooing daily. Furthermore, this residue
could actually have a moisturizing effect since the Minoxidil foam con-
tains long-chain fatty acids found in conditioners. Rogaine®Scientiﬁc
Roundtable, 2009 Other measures t hat could improve ut ilization of
minoxidil and compliance of these patients would b e an over-the-
counter shampoo cont aining a low-l evel steroid that targets the
mild inﬂammation and i rritation of the scalp associated with mi-
noxidil. A combination of a mild shampoo and conditioner that is
rinsed out followed by a leave-in conditioner that is applied while
the hair is still wet could help as well. Indeed daily application of
conditioners to dry hair between shampoos would not interfere
with minoxidil (Rogaine®ScientiﬁcRoundtable,2009). The prevalence
and pathophysiology behind follicula r miniaturiz ation in senescent
alopecia merits further investigation to better understand the potential
beneﬁts of minoxidil for this type of hair loss. Identifying the threshold
of hair thinning at which minoxidil would be beneﬁcial for senescent
alopecia is important. Minoxidil has proven efﬁcacy for AGA in men
165A. Monselise et al. / International Journal of Women's Dermatology 1 (2015) 161–166
with frontal (Olsen, 1999). The public should be educated about
grooming habits and weathering factors tha t may aggravate AGA or
senescent hair loss. Recommendations for UV protection with a hat or
by application of a sunscreen pr oduct speciﬁc for the hair should
The advisors agreed that aging of hair is an inevitable process that is
determined by an interplay of many f actors including weathering,
grooming habi ts, UV exposure, hair color, androgenetic alopecia and
other age-related thining. Choice of hair care products is important to
the overall health of scalp and hair. Currently, there is no evidence
based data to suggest that hair care products are efﬁcacious for more
than healthier hair ﬁbers. Further study should be done to determine
if use of these products can provide healthier scalp con ditions, slow
the PHL process, due to androgenetic alopecia and/or age-related
thinning. Minoxidil foam and solution has proven efﬁcacy for AGA and
advisors agreed that their clinical evidence suggests this is a useful
treatment option for age-related thinning as well.
Birch MP, Lashen H, Agarwal S, Messenger AG. Female pattern hair loss, sebum excretion
and the end-organ response to androgens. Br J Dermatol 2006;154:85–9.
Davies GC, Thornton MJ, Jenner TJ, et al. Novel and established potassium channel openers
stimulate hair growth in vitro: implications for their modes of action in hair follicles.
J Invest Dermatol 2005;124:686–94.
Ebling FJ. The hair cycle and its regulation. Clin Dermatol 1988;6:67–73.
Eun HC, Kwon OS, Yeon JH, et al. Efﬁcacy, safety, and tolerability of dutasteride 0.5 mg
once daily in male patients with male pattern hair loss: a randomized, double-
blind, placebo-controlled, phase III study. J Am Acad Dermatol;63:252-8.
Fiedler VC, Buys CM. Immunohistochemical characterization of the cellular inﬁltrate in
severe alopecia areata before and after minoxidil treatment. Dermatologica 1987;
Fiedler VC, Buys CM. Direct T-cell effects of minoxidil. Clin Dermatol 1988;6:148–51.
Friedman ES, Friedman PM, Cohen DE, Washenik K. Allergic contact dermatitis to topical
minoxidil solution: etiology and treatment. J Am Acad Dermatol 2002;46:309–12.
Hordinsky M, Sawaya M, Roberts JL. Hair loss and hirsutism in the elderly. Clin Geriatr
Med 2002;18:121–33 vii.
Inui S, Itami S. Reversal of androgenetic alopecia by topical ketoconzole: relevance of anti-
androgenic activity. J Dermatol Sci 2007;45:66–8.
Iorizzo M, Vincenzi C, Voudouris S, Piraccini BM, Tosti A. Finasteride treatment of female
pattern hair loss. Arch Dermatol 2006;142:298–302.
Jaworsky C, Kligman AM, Murphy GF. Characterization of inﬂammatory in ﬁltrates in male
pattern alopecia: implications for pathogenesis. Br J Dermatol 1992;127:239–46.
Khumalo NP, Stone J, Gumedze F, M cGrath E, Ngwanya MR, de Berker D. 'Relaxers '
damage hair: evidence from amino acid analysis. J Am Acad Dermatol;62:402-8.
Kligman AM. The comparative histopathology of male-pattern baldness and senescent
baldness. Clin Dermatol 1988;6:108–18.
Michelet JF , Commo S, Billoni N, Mahe YF, Bernard BA. Activa tion of cytoprotectiv e prosta-
glandin synthase-1 by minoxidil as a possible explanation for its hair growth-stimulating
effect. J Invest Dermatol 1997;108:205–9.
Mirmirani P. What is your diagnosis? Bubble hair. Cutis 2008;82:176 84.
Mirmirani P. Ceramic ﬂat irons: improper use leading to acquired trichorrhexis nodosa.
J Am Acad Dermatol 2010;62:145–7.
Olsen EA. The midline part: an important physical clue to the clinical diagnosis of andro-
genetic alopecia in women. J Am Acad Dermatol 1999;40:106–9.
Olsen EA, Hordinsky M, Whiting D, et al. The importance of dual 5alpha-reductase inhibi-
tion in the treatment of male pattern hair loss: results of a randomized placebo-con-
trolled study of dutasteride versus ﬁn asteride. J Am A cad Dermatol 2006;55:
Olsen EA, Whiting D, Bergfeld W, et al. A multicenter, randomized, placebo-controlled, double-
blind clinical trial of a novel formulation of 5% minoxidil topical foam versus placebo in
the treatment of androgenetic alopecia in men. J Am Acad Dermatol 2007;57:767–74.
Pierard-Franchimont C, De Doncker P, Cauwenbergh G, Pierard GE. Ketoconazole
shampoo: effect of long-term use in androgenic alopecia. Dermatology 1998;196:474–7.
Price VH. Androgenetic alopecia in women. J Investig Dermatol Symp Proc 2003;8:24–7.
Price VH, Menefee E, Strauss PC. Changes in hair weight and hair count in men with
androgenetic alopecia, after application of 5% and 2% topical minoxidil, placebo, or
no treatment. J Am Acad Dermatol 1999;41:717–21.
Price VH, Menefee E, Sanchez M, Kaufman KD. Changes in hair weight in men with andro-
genetic alopecia after t reatment with
ﬁnasteride (1 mg daily): three- and 4-year
results. J Am Ac ad Dermatol 2006;55:71–4.
Pyo HK, Yoo HG, Won CH, et al. The effect of tripeptide-copper complex on human hair
growth in vitro. Arch Pharm Res 2007;30:834–9.
Rogaine®Scientiﬁc Roundtable. Short Hills NJ. April, 2009.
Shapiro J. Safety of topical minoxidil solution: a one-year, prospective, observational
study. J Cutan Med Surg 2003;7:322–9.
Stough D. Dutasteride improves male pattern hair loss in a randomized study in identical
twins. J Cosmet Dermatol 2007;6:9–13.
Trachy RE, Fors TD, Pickart L, Uno H. The hair follicle-stimulating properties of peptide
copper complexes. Results in C3H mice. Ann N Y Acad Sci 1991;642:468–9.
Whiting DA. Diagnostic and predictive value of horizontal sections of scalp biopsy speci-
mens in male pattern androgenetic alopecia. J Am Acad Dermatol 1993;28:755–63.
Whiting DA. Possible mechanisms of miniaturization during androgenetic alopecia or
pattern hair loss. J Am Acad Dermatol 2001;45:S81–6.
Whiting DA, Waldstreicher J, Sanchez M, Kaufman KD. Measuring reversal of hair minia-
turization in androgenetic alopecia by follicular counts in horizontal sections of serial
scalp biopsies: results of ﬁnasteride 1 mg treatment of men and postmenopausal
women. J Investig Dermatol Symp Proc 1999;4:282–4.
166 A. Monselise et al. / International Journal of Women's Dermatology 1 (2015) 161–166