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Thinning Temples in Women Mr Greg Williams explores the common causes for hair thinning in the temple area in women When a woman’s hair thins or recedes in the temples there is a self-perception, often negatively re-enforced by society, that her hairline is less feminine. This is because men have ‘M’ shaped hairlines, while rounded hairlines are considered normal for females.1 This can cause embarrassment, loss of self-confidence and even depression.2,3 Making an accurate diagnosis early is critical as some conditions are progressive and treating the cause can stop further hair loss. Most women, as they enter menopause, will experience a deterioration in their hair quality. This is part of a constellation of distressing symptoms that women are prepared by society to deal with. However, hair loss in women under 40 is less expected and is a cause of great concern.4 Not being able to pull back their hair in ponytails because of hair thinning in the temple area, and having to choose hairstyles that cover the area can
Figure 1: Congenital masculine hairline in a woman
be very upsetting. The degree of temple hair recession can be described in different ways, therefore, it is important to understand what is of concern to the patient so that expectations can be set against what is achievable.
Consulting women with thinning temples Hairs grow naturally on the scalp in groupings called follicular units that have one, two, three, four (and occasionally more) hairs emerging from a single orifice. The number of hairs per square centimetre is therefore determined by the number of follicular units per square centimetre, and the number of hairs per follicular unit.5 However, there are other factors that impact the appearance of hair density. These include hair diameter, hair curl, hair colour (as well as the contrast between hair colour and scalp skin colour), hair length, and exit angle of the hair from the
Figure 2: Temporal triangular alopecia. Image courtesy of Dr William Rassman
Figure 3: Frontal fibrosing alopecia
scalp surface. Consider, when a woman says that the hair around her temples is thinning, what does she mean? Does she mean that the diameter of the hairs is decreasing or that the number of hairs is less? Or both? Or does she mean that the area of deterioration is getting bigger? Like any medical condition, a thorough history is required including onset and rate of progression of the problem, any medical conditions, any medications being taken (prescription or recreational), and any vitamin/herbal/homeopathic supplements being used. An enquiry into eating habits and dietary composition, including protein intake, will also provide insight into the patient’s lifestyle.6,7 Telogen effluvium is the name for hair shedding that typically occurs three to four months after a stressful event.8 This can be physical stress like an illness, trauma or surgery, emotional distress or a negative psychological event. Asking specifically if any of these sorts of things happened in the previous months can reveal a possible contributing factor. It is likely that the hair loss associated with COVID-19 is due to telogen effluvium.9 Whilst we know that hair growth in women is affected by hormonal changes, the exact nature of which hormones are most important is not known. Noting the menarche, menstrual frequency, duration and severity, use of contraception and type, as well as any pregnancies and associated periods of breastfeeding is important.10 Taking a history in a woman with female pattern hair loss (FPHL) is far more time consuming than taking a history in a man with male pattern hair loss (MPHL). This is because there are so many more factors that can affect hair growth and hair loss in women. Whilst the epigenetic factors that affect the onset and severity of MPHL are poorly understood, they are even less well understood in women. However, there are specific conditions that should be ruled out when examining a woman who complains of hair loss in the temples and further specific questions that should be asked. Often the patient will have done some research on the internet and will present with a good idea of what is causing their hair loss. Many things that cause hair loss such as telogen effluvium, including medications, and dietary deficiencies (protein, iron, zinc, vitamin D) will present with global hair loss or hair deterioration rather than patterned hair loss affecting the temples symmetrically.
Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021
