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The Contribution of Endogenous and Exogenous Factors to Female Alopecia: A Study of Identical Twins

Gatherwright, James M.D.; Liu, Mengyuan T. B.S.; Gliniak, Christy M.S.; Totonchi, Ali M.D.; Guyuron, Bahman M.D.

Plastic and Reconstructive Surgery: December 2012 - Volume 130 - Issue 6 - p 1219–1226
doi: 10.1097/PRS.0b013e31826d104f
Reconstructive: Head and Neck: Original Articles
Press Release

Background: In this study, the authors investigated the potential contribution of environmental factors and testosterone levels on androgenic alopecia in women.

Methods: Ninety-eight identical female twins were recruited from 2009 to 2011. Subjects were asked to complete a comprehensive questionnaire, provide a sputum sample for testosterone analysis, and pose for standardized digital photography. Frontal, temporal, and vertex hair loss were assessed from the photographs using Adobe Photoshop. Hair loss measures were then correlated with survey responses and testosterone levels between twin pairs. Two independent, blinded observers also rated the photographs for hair thinning.

Results: Factors associated with increased frontal hair loss included multiple marriages (p = 0.043); longer sleep duration (p = 0.011); higher severity of stress (p = 0.034); positive smoking history (p = 0.021); higher income (p = 0.023); absence of hat use (p = 0.017); and history of diabetes mellitus (p = 0.023), polycystic ovarian syndrome (p = 0.002), and hypertension (p = 0.001). Factors associated with increased temporal hair loss included divorce or separation (p = 0.034), multiple marriages (p = 0.040), more children (p = 0.005), longer sleep duration (p = 0.006), and history of diabetes mellitus (p = 0.008) and hypertension (p = 0.027). Lack of sun protection (p = 0.020), consuming less caffeine (p = 0.040), history of skin disease (p = 0.048), and lack of exercise (p = 0.012) were associated with increased vertex hair loss. Higher testosterone levels were associated with increased temporal and vertex hair loss patterns (p < 0.039). Increased stress, increased smoking, having more children, and having a history of hypertension and cancer were all associated with increased hair thinning (p < 0.05).

Conclusion: This study implicates several environmental risk factors in the pathophysiology of female alopecia.

Cleveland, Ohio

From the Department of Plastic Surgery, University Hospitals Case Medical Center, and Case Western Reserve University School of Medicine.

Received for publication May 8, 2012; accepted June 4, 2012.

Disclosure:The authors have no financial interest to declare in relation to the content of this article.

Bahman Guyuron, M.D.; 29017 Cedar Road, Cleveland, Ohio 44124,

©2012American Society of Plastic Surgeons