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

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

Plastic and Reconstructive Surgery: May 2013 - Volume 131 - Issue 5 - p 794e–801e
doi: 10.1097/PRS.0b013e3182865ca9
Cosmetic: Original Articles

Background: The purpose of this study was to investigate the potential contribution of environmental factors and testosterone on male alopecia.

Methods: Ninety-two identical male twins were recruited from 2009 to 2011. A comprehensive questionnaire was completed followed by the acquisition of sputum samples for testosterone analysis and standardized digital photography. Frontal, temporal, and vertex hair loss was assessed from these photographs. Hair loss was then correlated with survey responses and testosterone levels between twin pairs. Two independent, blinded observers also rated the photographs for hair thinning.

Results: Increased smoking duration (p < 0.001) and the presence of dandruff (p = 0.028) were significantly associated with increased frontal hair loss. Increased exercise duration (p = 0.002), consumption of more than four alcoholic drinks per week (p = 0.042), and increased money spent on hair loss products (p = 0.050) were all associated with increased temporal hair loss. Daily hat use (p = 0.050), higher body mass index (p = 0.012), and higher testosterone levels (p = 0.040) were associated with decreased temporal hair loss. Factors that were significantly associated with increased vertex hair loss included abstinence from alcohol consumption (p = 0.030), consumption of more than four alcoholic drinks per week (p = 0.004), increased smoking duration (p = 0.047), increased exercise duration (p = 0.050), and increased stress duration (p = 0.010). Lower body mass index, more children, increased caffeine consumption, history of skin disease, and abstinence from alcohol were significantly associated with increased hair thinning scores (p < 0.05).

Conclusion: This study offers substantial evidence that exogenous factors may have a clinically significant impact on hair loss.


Cleveland, Ohio; and Dallas, Texas

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

Received for publication May 8, 2012; accepted November 20, 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,

©2013American Society of Plastic Surgeons