Article

Hair loss among transgender and gender‐nonbinary patients: a cross‐sectional study

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

As facial, scalp, and body hair are closely linked to gender expression and perception, hair concerns represent important considerations in gender minority patients. Diagnosis and subsequent treatment of hair conditions in this population require an understanding of gender affirming hormones, which include both masculinizing hormone therapy (MHT, i.e. testosterone use) and feminizing hormone therapy (FHT, i.e. estrogen and antiandrogen use).¹ Testosterone has been found to induce androgenetic alopecia (AGA) in roughly two‐thirds of transmen, while estrogen/antiandrogens have been shown to increase scalp hair density in transwomen in limited case reports.2,3 In this cross‐sectional study, we sought to capture the frequency of scalp hair loss and its relation to gender affirming hormone use in gender minority patients. This article is protected by copyright. All rights reserved.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Stevenson et al. [31] report a transgender woman on estradiol 5 mg daily and spironolactone 150 mg daily who experienced both scalp hair regrowth as well as thickening of preexisting hair after 6 months of treatment. Other studies have reported little effect of feminizing hormonal therapy on scalp hair loss [17]. ...
... Marks et al. [17] MHT significantly worsened self-reported Hamilton-Norwood and Sinclair scores. FHT had no significant effect ...
... Over the first year after initiating testosterone therapy, hair growth rate, density, and diameter all increase progressively, but only hair diameter has been observed to reach values similar to cis-gendered males [36]. Masculinizing hormone therapy is associated with an increased risk of androgenic alopecia, which is often an undesirable side effect [17,19]. This has been seen in up to 45% of patients [17,19]. ...
Article
Full-text available
Transgender patients on masculinizing and feminizing hormonal therapy undergo myriad physical and psychologic changes. Dermatologists are uniquely qualified to guide patients in the gender-affirming process, especially as it relates to hair. Given the paucity of literature guiding dermatologists in this process, a systematic review was performed to better understand the physiologic changes of hair in patients on masculinizing and feminizing hormonal therapy as well as the variety of treatment options that exist to help transgender patients to attain their desired hair growth pattern. This review reports findings and treatment options supported by the performed literature review as well as treatment recommendations based on the authors’ own experiences treating this unique patient population.
... The questionnairebased study focused on FFA patients found a possible association with leave-on facial skin care products, including sunscreens (5,31). In a study of the main ingredients in sunscreen (such as oxybenzone), the authors found 87 out of 100 products tested contained at least one potential allergen identified in previous patch testing results of FFA patients (32). In a case series study in Brazil involving patch and photopatch testing of 63 FFA patients, 59% of subjects had at least one positive test (33). ...
Article
Full-text available
The primary forms of cicatricial (scarring) alopecia (PCA) are a group of inflammatory, irreversible hair loss disorders characterized by immune cell infiltrates targeting hair follicles (HFs). Lichen planopilaris (LPP), frontal fibrosing alopecia (FFA) and centrifugal cicatricial alopecia (CCCA) are among the main subtypes of PCAs. The pathogenesis of the different types of PCAs are poorly understood, and current treatment regimens yield inconsistent and unsatisfactory results. We performed high-throughput RNA-sequencing on scalp biopsies of a large cohort PCA patients to develop gene expression-based signatures, trained into machine-learning based predictive models and pathways associated with dysregulated gene expression. We performed morphological and cytokine analysis to define the immune cell populations found in PCA subtypes. We identified a common PCA gene signature that was shared between LPP, FFA, and CCCA which revealed a significant over-representation of mast cell genes, as well as downregulation of cholesterogenic pathways and upregulation of fibrosis and immune signaling genes. Immunohistological analyses revealed an increased presence of mast cells in PCAs lesions. Our gene expression analyses revealed common pathways associated with PCAs, with a strong association with mast cells. The indistinguishable differences in gene expression profiles and immune cell signatures between LPP, FFA and CCCA suggest that similar treatment regimens may be effective in treating these irreversible forms of hair loss.
... Approximately half of transgender men will eventually develop some degree of androgenic alopecia after long-term testosterone use [18,27,28]. For some, male pattern balding is a desired masculine trait. ...
Article
Full-text available
Purpose of Review The purpose of this review is to provide an up-to-date overview of gender-affirming hormone therapy, including the various hormone regimens available, the efficacy and potential risks of these treatments, and considerations for surveillance and long-term care. Recent Findings Recent studies reaffirm that hormone therapy has positive physical and psychological effects for many transgender individuals. The overall risks of treatment are low. Transgender women may have an increased risk of venous thromboembolism and breast cancer based on recent cohort studies, but these findings have yet to be confirmed with randomized controlled trials. Important long-term considerations include metabolic, cardiovascular, and skeletal health. Summary High-quality, long-term studies on the effectiveness and safety of various gender-affirming hormone treatment regimens are lacking, but the currently available evidence suggests that it is overall safe and effective with appropriate oversight.
Article
Androgenetic alopecia (AGA) management is a significant clinical and therapeutic challenge for transgender and gender diverse (TGD) patients. Although gender-affirming hormone therapies affect hair growth, there is little research about AGA in TGD populations. After reviewing the literature on approved treatments, off-label medication usages, and procedures for treating AGA, we present treatment options for AGA in TGD patients. First-line treatments for any TGD patient include topical minoxidil 5% applied to the scalp once or twice daily, finasteride 1 mg oral daily, and/or low-level laser light therapy. Spironolactone 200 mg daily is also first-line for transfeminine patients. Second-line options include daily oral minoxidil dosed at 1.25 or 2.5 mg for transfeminine and transmasculine patients, respectively. Topical finasteride 0.25% monotherapy or combination with minoxidil 2% solution are second-line options for transmasculine and transfeminine patients, respectively. Other second-line treatments for any TGD patient include oral dutasteride 0.5 mg daily, platelet-rich plasma, or hair restoration procedures. After 6-12 months of treatment, AGA severity and treatment progress should be assessed via non-sex-based scales, e.g. the Basic and Specific Classification or the Bouhanna scales. Dermatologists should coordinate care with the patient’s primary gender-affirming clinician(s) so that shared knowledge of all medications exists across the care team.
Article
Background: In gender minority patients, electrolysis and laser hair removal may be necessary to reduce facial and body hair in individuals seeking a more feminine appearance and/or modified gender expression. These procedures may also be required preoperatively for some gender-affirming surgeries. Aims: To identify (a) the frequency of unwanted facial and body hair, (b) the use of various hair removal methods, and (c) associated barriers to care in gender minority patients. Methods: An online-based patient survey was distributed via social media on Facebook® , YouTube® , and Instagram® in fall 2018. Respondents were at least 18 years old and self-identified as a gender minority. Results: In total, 991 responses were recorded with a completion rate of 77%. Considering excess hair, 84% of transwomen on feminizing hormone therapy (FHT: estrogen and anti-androgen therapy), 100% of transwomen not on FHT, and 100% of nonbinary individuals on FHT reported excess facial/body hair. Laser hair removal (18%) and electrolysis (17%) had similar rates of use in this cohort and were more commonly reported for nonsurgical gender-affirming purposes than preoperative preparation. Cost was the most frequently cited barrier to care. Conclusion: As the majority of transwomen and nonbinary people on feminizing hormone therapy had persistent excess facial/body hair, routine use of gender-affirming hormones is not sufficient to fully eliminate unwanted hair. There remains a critical need to advocate for more comprehensive insurance coverage for laser hair removal and electrolysis in gender minority patients.
Article
Full-text available
Response rates to the academic surveys used in quantitative research are decreasing and have been for several decades among both individuals and organizations. Given this trend, providing doctoral students an opportunity to complete their dissertations in a timely and cost effective manner may necessitate identifying more innovative and relevant ways to collect data while maintaining appropriate research standards and rigor. The case of a research study is presented which describes the data collection process used to survey a hard-to-reach population. It details the use of social media, in this case LinkedIn, to facilitate the distribution of the web-based survey. A roadmap to illustrate how this data collection process unfolded is presented, as well as several " lessons learned " during this journey. An explanation of the considerations that impacted the sampling design is provided. The goal of this case study is to provide researchers, including doctoral students, with realistic expectations and an awareness of the benefits and risks associated with the use of this method of data collection.
Article
Full-text available
Evidence of androgenetic alopecia, or male pattern baldness, can be distressing for transgender women. Here we present the case of a transgender woman with scalp hair regrowth after ∼6 months on oral estradiol and spironolactone therapy achieving testosterone levels within normal female range.
Article
Full-text available
Androgenetic alopecia (AGA) is characterized by a non-scarring progressive miniaturization of the hair follicle in predisposed men and women with a pattern distribution. Although AGA is a very prevalent condition, approved therapeutic options are limited. This article discusses the current treatment alternatives including their efficacy, safety profile, and quality of evidence. Finasteride and minoxidil for male androgenetic alopecia and minoxidil for female androgenetic alopecia still are the therapeutic options with the highest level evidence. The role of antiandrogens for female patients, the importance of adjuvant therapies, as well as new drugs and procedures are also addressed.
Article
Full-text available
Patterned hair loss is the most common cause of hair loss seen in both the sexes after puberty. Numerous classification systems have been proposed by various researchers for grading purposes. These systems vary from the simpler systems based on recession of the hairline to the more advanced multifactorial systems based on the morphological and dynamic parameters that affect the scalp and the hair itself. Most of these preexisting systems have certain limitations. Currently, the Hamilton-Norwood classification system for males and the Ludwig system for females are most commonly used to describe patterns of hair loss. In this article, we review the various classification systems for patterned hair loss in both the sexes. Relevant articles were identified through searches of MEDLINE and EMBASE. Search terms included but were not limited to androgenic alopecia classification, patterned hair loss classification, male pattern baldness classification, and female pattern hair loss classification. Further publications were identified from the reference lists of the reviewed articles.
Article
In the United States, an increasing number of individuals are identifying as transgender. Males at birth who identify as females are called male-to-female (MTF) transgender individuals or trans women, and females at birth who identify as males are called female-to-male (FTM) transgender individuals or trans men. The transgender patient population possess unique health concerns disparate from those of the general populace. Exogenous hormone therapy for transgender patients leads to changes in the distribution and pattern of hair growth. Exogenous testosterone can lead to male pattern hair loss and hirsutism, while estrogen therapy usually results in decreased facial and body hair growth and density. A thorough understanding of the hormonal treatments that may be used in transgender individuals as well the unique and complex biologic characteristics of the hair follicle is required for appropriate diagnosis, counseling and treatment of patients. The aim of this article is to provide a framework for understanding hair disorders in transgender individuals and effective treatment options.
Article
Background: Androgenic treatment of female-to-male transgender patients may result in androgenetic alopecia (AGA). Use of 5-alpha-reductase inhibitors are useful as oral treatment of AA in men. There are no previous studies of the use of finasteride in transgender men as treatment of AGA. Aim: To evaluate the effectiveness and safety of an oral 5α-reductase inhibitor (finasteride) for AA developed in transgender men. Methods: This single-centre retrospective study enrolled female-to-male transgender patients with a clinical diagnosis of AGA to receive 1 mg of an oral type II 5α-reductase inhibitor for at least 12 months. Results: In all, 10 patients were included in the study. All the patients received a clinical diagnosis of male-pattern AGA, with 90% classified as stage IV on the Norwood-Hamilton scale. Mean onset of AGA was 3.25 years after the introduction of androgenic treatment, and 70% of the patients had a family history of AGA. All the patients improved one grade on the Norwood-Hamilton scale after a mean of 5.5 months (range 4-6 months) since the start of finasteride treatment. Two patients stopped treatment for economic reasons and one stopped due to dyspepsia. No sexual or other adverse effects were observed. Patients were given periodic physical and analytical examinations by endocrinologists without any significant finding. Mean follow-up of patients was 16.2 months. Conclusion: AA in transgender men has a delayed onset, and is clinically and therapeutically similar to the common male-pattern-AGA in cis-gender men.
Article
Our knowledge concerning the effects of testosterone (T) therapy on the skin of trans men (female-to-male transsexuals) is scarce. The aim of this study was to evaluate the short- and long-term clinical effects of T treatment on the skin of trans men. We conducted a prospective intervention study in 20 hormone naive trans men and a cross-sectional study in 50 trans men with an average of 10 years on T therapy. Acne lesions were assessed using the Gradual Acne Grading Scale, hair patterns using the Ferriman and Gallwey classification (F&G), and androgenetic alopecia using the Norwood Hamilton Scale. T treatment increased facial and body hair growth. The F&G score increased progressively from a median value of 0.5 at baseline to a value of 12 after 12 months of T administration. After long-term T treatment, all but one trans man achieved an F&G score indicative of hirsutism in women, with a median value of 24. Only one trans man acquired mild frontotemporal hair loss during the first year of T treatment, whereas 32.7% of trans men had mild frontotemporal hair loss and 31% had moderate to severe androgenetic alopecia after long-term T therapy. The presence and severity of acne increased during the first year of T therapy, and peaked at 6 months. After long-term T treatment, most participants had no or mild acne lesions (93.9%). Dermatological outcome was not demonstrably related to individual serum T or dihydrotestosterone levels. T treatment increased facial and body hair in a time-dependent manner. The prevalence and severity of acne in the majority of trans men peaked 6 months after beginning T therapy. Severe skin problems were absent after short- and long-term T treatment. Wierckx K, Van de Peer F, Verhaeghe E, Dedecker D, Van Caenegem, E, Toye K, Kaufman JM, and T'Sjoen G. Short- and long-term clinical skin effects of testosterone treatment in trans men. J Sex Med **;**:**-**.