الفهرس 
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Abstract
Women presenting with diffuse hair loss considered to be very common and a challenging problem for dermatologists. The condition has several causes mainly telogen effluvium (the commonest cause) then female pattern hair loss (FPHL) (the 2nd common cause). The problem arises in differentiating between these two causes. Also, the early stages of FPHL may be easily missed. FPHL begins at any age following puberty and it is widely accepted that the prevalence increases postmenopausal with a possible hormonal effect (Chartier, Hoss and Grant, 2002).
Although the follicular changes that lead to alopecia are similar between men and women, clinical presentation and response to antiandrogen therapy are different. So, the term ’’FPHL’’ became the preferred term for this form of hair loss. This terminology helps to distinguish the different features of the condition in women versus men and shows the lack of clear hormonal contribution in many cases (Mesinkovska and Bergfeld, 2013).
In FPHL there is a reduction in the duration of the anagen phase and a miniaturization of the dermal papilla (thinning of the hair). Thick pigmented hairs are gradually replaced by miniaturized hairs. Moreover, there is a delay between the end of the telogen phase and the beginning of the new anagen phase. This resting phase, during which the hair follicle remains empty, is known as the kenogen phase (Cotsarelis and Millar, 2001).
A high percentage of women with FPHL without any overt clinical signs of hyperandroginism and had no biochemical evidence of androgen excess because FPHL is multifactorial with genetic and environmental influence (Ellis and Harrap, 2001).
FPHL has several clinical patterns and Ludwig grading system commonly and easily used to describe severity of hair loss into three grades: grade I, grade II and grade III (Camacho-Martínez, 2009).
Diagnosis of FPHL is mainly clinical and scalp biopsy usually not needed. Nowadays, there are multiple non invasive techniques involving trichoscopy which has been widely used as a diagnostic as well as a prognostic tool to measure anisotrichosis (>20% HDD) in cases of FPHL. Trichoscopy can thus also be used as a tool to diagnose FPHL in early cases which can be missed easily (Rudnicka et al., 2008).
Women with hair loss are more likely to have a lowered self-esteem and lowered quality of life than men. Thus, the patient should be adequately counseled about the need for detailed evaluation, availability of effective medical treatment and the need for long term indefinite treatment to maintain response (Blumeyer et al., 2011).
Until recently, the only FDA-approved medication for women was 2% minoxidil solution, while both the 2% and 5% solutions are available for men. Recently, FDA approved the use of 5% minoxidil foam in treatment of FPHL (Gupta and Foley, 2014).
Minoxidil appears to prolong the duration of anagen phase and its angiogenic effects reverse miniaturization of hair follicles. Minoxidil has been showen to increase the proliferation of dermal papilla cells of human hair follicles. Lastly, it is possible that minoxidil plays an immunomodulatory role as demonstrated by invitro studies that showed that minoxidil has a suppressive effect on normal human T- lymphocytes (Blume-Peytavi et al., 2011).
There are three different vehicles commonly used: ethanol, propylene glycol (PG) and water.A previous study showed maximum penetration of topical minoxidil after the initial 12 h obtained by the formulation with the most PG percentage. That was interpreted by a physical change in the membrane (SC) induced by PG led to a change in the transport mechanism (Tata et al., 1994).
The study emphasized important points:
• Majority of patients were in the age group of 17-55 years. Positive family history was 56.66% of all patients participated in the study. Ludwig pattern was the most common pattern (86%) and grade IIwas the most common grade (50%) followed by grade III (35%) then grade I (15%).
• Direct correlation between Ludwig classification grade and age of presentation, so an increase in patient age associated with increase in Ludwig grading and vice versa. Also, there was a direct correlation between Ludwig grading and duration of hair loss, but there was no correlation between Ludwig grading and number of affected family members.
• Both minoxidil 5% with and without PG were superior to placebo in promoting hair growth in patients with FPHL. There was a slight advantage of minoxidil with PG over minoxidil without PG regarding Ludwig grading and trichoscopic findings, but it was not statistically significant.
• The highest prevalence of drug related adverse effects of a dermatological nature (eg, pruritis, dandruff, scalling..) showed with group C (Placebo) followed by group A (Minoxidil 5% with PG) while group B had the least side effects. The most frequent side effect was itching affecting 40% of placebo group, 25% of group A and 15% of group B. group A (Minoxidil 5% with PG) was the only group that showed hypertrichosis (20%).
In conclusion, both minoxidil 5% with PG and minoxidil 5% without PG are effective in promoting hair growth in patients with FPHL with no significant difference.