Hair loss: a harbinger of the morbidities to come!

Sir,

Hair loss has been traditionally associated with benign prostatic hyperplasia (and clinical prostate cancer), coronary heart disease, hyperinsulinemia, insulin-resistance-associated disorders, such as obesity, hypertension, and dyslipidemia. Considerable amount of negative psychosocial effects are also linked with male pattern hairloss (MPH) such as decreased self-esteem, dissatisfaction with body image or appearance, self-consciousness, perception of aging, and often emotional stress.

MPH has been believed to confer high risk for coronary artery disease than those who are not bald. A dermatologic review noted that those developing MPH before their 30s may have a higher risk for coronary artery disease than other men. This subset of people is known to have early-onset androgenetic alopecia (AGA) with elevated dihydrotestosterone–testosteroneratios.[1] Early onset AGA is a risk factor for an early onset of severe coronary heart disease. This finding was proved in a study that showed that early AGA increased one's risk of the requirement of a coronary revascularization procedure.[2] The converse was studied in a study which concluded that women with markers of insulin resistance (higher waist and neck circumferences, abdominal obesity measured by waist-to-hip ratio, higher mean insulin concentration, and urinary albumin-to-creatinine ratio) had significantly increased risk for female AGA.[3] The female counterpart of AGA is also known to increase the prevalence of the metabolic syndrome, and warrants routine screening for the underlying clinical abnormalities. In a study, hypertension and the use of antihypertensive drugs were common among men with AGA (61% vs. 45% and 50% vs. 26%, respectively). The rates of diabetes and hyperinsulinemia (21% vs. 12% and 61% vs. 49%) were also higher among men with AGA when compared with those with normal hair status.[4]

Coronary Artery Disease (CAD) patients are known to have significantly higher scores for baldness (receding frontal hairline, a critical bald area, and total or subtotal hair loss) as well as higher risk for blood pressure and smoking habit.

Apart from MPH, a study linked thoracic hairiness and earlobe crease to CAD and showed that the three factors were about 40% more prevalent in cases (admitted for the first non-fatal myocardial infarction) when compared with controls (no CAD). Also in men under the age of 50 years, hair graying was associated with myocardial infarction.[5]

The Framingham study showed that the amount of progression of baldness was associated with coronary heart disease occurrence, coronary heart disease mortality, and all-cause mortality. Rapid hair loss may be a marker for coronary heart disease. Another study analyzed frontal balding and vertex balding and showed that the latter had a higher risk of CAD. Also vertex baldness was more strongly associated with CAD risk among men with hypertension or high cholesterol levels compared with men with no hair loss.[6]

The pattern of hair loss thus is a red-flag for clinicians to gauge the gravity of one's risk for various diseases especially CAD and metabolic syndrome and awareness of such associations may help to either prevent or better manage the associated complications.