Androgenic Alopecia - Hormonal Etiology

Hormonal Etiology

Researchers assert the initial programming of pilosebaceous units begins in utero. The physiology is primarily androgenic, with dihydrotestosterone (DHT) the major contributor at the dermal papillae. Below normal values of SHBG, FSH, testosterone and epitestosterone are present in men with premature androgenic alopecia compared to normal controls. Although follicles were previously thought permanently gone in areas of complete hair loss, they are more likely dormant, as recent studies have shown the scalp contains the stem cell progenitors from which the follicles arose.

Transgenic studies have shown that growth and dormancy of hair follicles are related to the activity of IGF at the dermal papillae, which is affected by DHT. Androgens are important in male sexual development around birth and at puberty. They regulate sebaceous glands, apocrine hair growth and libido. With increasing age, androgens stimulate hair growth on the face, but suppress it at the temples and scalp vertex, a condition that has been referred to as the 'androgen paradox'.

These observations have led to study at the level of the mesenchymal dermal papillae. Type 1 and 2 5α reductase enzymes are present at pilosebaceous units in papillae of individual hair follicles. They catalyze formation of the androgens testosterone and DHT, which in turn regulate hair growth. Androgens have different effects at different follicles: they stimulate IGF-1 at facial hair, leading to growth, but stimulate TGF β1, TGF β2, dickkopf1 and IL-6 at the scalp, leading to catagenic miniaturization. Hair follicles in anaphase express four different caspases. Tumor necrosis factor was found to inhibit elongation of hair follicles in vitro with abnormal morphology and cell death in the bulb matrix.

Studies look at serum levels of IGF-1 show it to be increased with vertex balding. Earlier work looking at in vitro administration of IGF had no effect on hair follicles when insulin was present, but when absent, caused follicle growth. The effects on hair of IGF-I were found greater than IGF-II. Later work also showed IGF-1 signalling controls the hair growth cycle and differentiation of hair shafts, possibly having an anti-apoptotic effect during the catagen phase. In situ hybridization in adult human skin have shown morphogenic and mitogenic actions of IGF-1. Mutations of the gene encoding IGF-1 result in shortened and morphologically bizarre hair growth and alopecia. IGF-1 is modulated by IGF binding protein, which is produced in the dermal papilla.

DHT inhibits IGF-1 at the dermal papillae. Extracellular histones inhibit hair shaft elongation and promote regression of hair follicles by decreasing IGF and alkaline phosphatase in transgenic mice. Silencing P-cadherin, a hair follicle protein at adherens junctions, decreases IGF-1, and increases TGF beta 2, although neutralizing TGF decreased catagenesis caused by loss of cadherin, suggesting additional molecular targets for therapy. P-cadherin mutants have short, sparse hair.

At the occipital scalp, androgens enhance inducible nitric oxide synthase (iNOS), which catalyzes production of nitric oxide from L-arginine. The induction of nitric oxide synthase usually occurs in an oxidative environment, where high levels of nitric oxide produced interact with superoxide, leading to peroxynitrite formation and cell toxicity. iNOS has been suggested to play a role in host immunity by participating in anti-microbial and anti-tumor activities as part of the oxidative burst of macrophages. The gene coding for nitric oxide synthase is on human chromosome 17.

There is also crosstalk between androgens and the Wnt-Beta-catenin signaling pathway that leads to hair loss. At the level of the somatic stem cell, androgens promote differentiation of facial hair dermal papillae, but inhibit it at the scalp. Other research suggests the enzyme prostaglandin D2 synthase and its product prostaglandin D2 (PGD2) in hair follicles as contributive.

Men with androgenic alopecia typically have higher 5-alpha-reductase, lower total testosterone, higher unbound/free testosterone and higher free androgens, including DHT. 5-alpha-reductase converts free testosterone into DHT, and is highest in the scalp and prostate. DHT is most commonly formed at the tissue level by 5α-reduction of testosterone. The genetic corollary that codes for this enzyme has been discovered.

Prolactin has also been suggested to have different effects on the hair follicle across gender. It seasonally modulates and can delay hair growth in animal models. In vitro models show it inhibits hair follicle growth. In vivo it can inhibit facial hair growth in humans. Researchers have suggested it works through paracrine action.