|Year : 2013 | Volume
| Issue : 2 | Page : 63-66
Androgenetic alopecia as an early marker for hypertension
Fatma M El-Esawy, Sherine H Abd El-Rahman
Department of Dermatology and Andrology, Faculty of Medicine, Benha University, Qalubiya, Egypt
|Date of Submission||04-Oct-2013|
|Date of Acceptance||11-Nov-2013|
|Date of Web Publication||31-Dec-2013|
Sherine H Abd El-Rahman
Department of Dermatology and Andrology, Faculty of Medicine, Benha University, Qalubiya
Source of Support: None, Conflict of Interest: None
Background and objectives
The relationship between androgenetic alopecia (AGA) and cardiovascular diseases has been studied by some authors in the past, although the results of epidemiological studies have been variable. The objective of this study was to determine the prevalence of hypertension and aldosterone level in male patients with AGA.
Patients and methods
Sixty men were enrolled in this case-control study, 30 with a diagnosis of AGA and 30 control participants who consulted for other skin conditions. They were recruited from the outpatient clinic of the Dermatology and Andrology of Benha University Hospital. Data were collected included, age, AGA score with Ebling score (I-V), serum aldosterone and serum testosterone level, blood pressure or history of hypertension, smoking, family history of AGA, and treatment.
Patients with AGA showed significantly higher aldosterone levels and blood pressure values (P < 0.05) versus controls. However, there was no statistically significant difference between patients and controls in the serum testosterone level.
Blood pressure screening of patients with AGA will enable earlier diagnosis of an unknown hypertension and initiation of appropriate treatment. Moreover, determination of aldosterone levels can enable early detection of individuals at risk and initiation of preventive treatment before cardiovascular disease becomes established.
Keywords: androgenetic alopecia, aldosterone, hypertension
|How to cite this article:|
El-Esawy FM, El-Rahman SH. Androgenetic alopecia as an early marker for hypertension. Egypt J Dermatol Venerol 2013;33:63-6
| Introduction|| |
Androgenetic alopecia (AGA) is the most common dermatological condition resulting in hair loss affecting both men and women. In the case of men, up to 30% older than 30 years of age and more than 50% older than 50 years of age are affected  . In the Asian population, the frequency of AGA in male and female patients is lower compared with Europeans. There is no information on the prevalence of the disease in African men and women  .
AGA is characterized by a marked decrease in hair follicle size, which could be related to the loss of hair follicle stem or progenitor cells  . Research has established that two essential etiological factors for AGA are a genetic predisposition and the presence of androgens  .
Aldosterone is essential to life because it regulates sodium and potassium levels, helping to maintain both blood pressure and body fluids. High levels of aldosterone can cause high blood pressure, muscle cramps, and weakness  .
Over the past few decades, various authors have investigated the relationship between male AGA and various cardiovascular risk factors. Many controversies exist in terms of the presence of an association between AGA and those cardiovascular risk factors  .
| Patients and methods|| |
This is a case-control study that was carried out on 30 male patients with a diagnosis of AGA and 30 control participants who consulted for other skin conditions. They were recruited from the outpatient clinic of the Dermatology and Andrology of Benha University Hospital. The Ebling classification was used to assess the degree of hair loss and BMI was calculated by dividing the weight in kilograms by the square of the height. The exclusion criteria for patients were as follows: other types of alopecia, hormone replacement therapy with testosterone or corticosteroids, a known cause for hyperaldosteronism, and a history of cancer. The exclusion criteria for the controls were the same as for the patients, in addition to the presence of AGA.
All patients, before any procedure, were subjected to a thorough assessment of history and signed a written informed consent that was approved by the Ethics Committee of Human Research Benha University. We recorded blood pressure (average of two readings taken 10 min apart), and serum levels of aldosterone and free testosterone were determined in all participants using direct ELISA kits manufactured by diagnostics Biochem Canada Inc (1020 Hargrive Road, London). Hypertension is defined according to the JNC 7 classification  .
The clinical and laboratory data were recorded on an 'investigation report form'. These data were tabulated, coded, and then analyzed using the computer program Statistical package for social science (SPSS, version 19; SPSS Inc., Chicago, Illinois, USA).
| Results|| |
The present study included 60 male patients. Patients with AGA (30 patients) showed no difference in the mean value in terms of age and BMI versus the 30 control participants [Table 1].
[Table 2] shows the degree of hair loss in AGA patients according to the Ebling classification. The majority (46.7%) had grade V.
|Table 2: Percentage of patients according to the grade of androgenetic alopecia |
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The mean blood pressure (SBP) values were significantly higher in patients with AGA (128 vs. 120 mmHg; P = 0.012), although there was no difference in diastolic blood pressure (DBP) (P = 0.13) [Figure 1] and [Table 3].
|Table 3: Comparison between patients and controls in systolic and diastolic blood pressure (mmHg) |
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For the laboratory investigations, patients with AGA had significantly higher levels of aldosterone (1075.4 vs. 841.4 pg/ml; P = 0.029) [Figure 2], whereas no statistically significant difference was observed in serum levels of free testosterone (21 vs. 21.2 pg/ml; P = 0.92) versus controls, respectively [Table 4].
|Table 4: Serum aldosterone and free testosterone level (pg/ml) in patients and controls |
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[Table 5] shows a positive correlation between SBP and DBP and aldosterone levels in patients with AGA. However, there was a statistically insignificant difference (P > 0.05) in aldosterone levels irrespective of the presence of hypertension. In addition, we observed that aldosterone values were high in hypertensive patients with AGA, whereas they were lower in hypertensive controls.
|Table 5: Serum aldosterone in relationship with systolic and diastolic blood pressure |
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| Discussion|| |
Male AGA is the most prevalent form of alopecia and is largely determined by genetic factors and the peripheral action of androgens  .
Aldosterone is produced by the adrenal glands, which manages the body's balance of sodium, water, and potassium. When the body produces too much aldosterone, it retains sodium and loses potassium, a condition known as aldosteronism or hyperaldosteronism  .
Ahouansou et al.  reported an elevated prevalence of hypertension among men with AGA, and it has been proposed that both phenomena may be explained by the presence of hyperaldosteronism. Another study  reported that chronic elevation of circulatory levels of aldosterone led to increased anxiety. This explained why some patients with AGA may occasionally show heightened anxiety levels.
In our study, there was no correlation between BMI and AGA. This observation was supported by Arias-Santiagos et al.'s , studies. In contrast, Gonzαlez-Gonzαlez et al.  found a positive correlation between obesity and AGA and he also observed that obese patients had a more frequent family history of AGA than non obese controls. Furthermore, Diane  reported that obesity is one of the factors related to causing AGA.
The mean SBP values were significantly higher (P < 0.05) in patients with AGA, although there were no differences in DBP. This was in agreement with many authors , . Ahouansou et al.  offered an explanation for this association; androgen involved in the pathogenesis of AGA binds to vascular receptors and favors the increase in BP because the two blood pressure medications have been used to increase hair growth, such as minoxidil and spironolactone  . Although the Framingham Heart Study did not find baldness to be associated with an increased risk of heart disease, men younger than 55 years of age who had very rapid onset and progressive AGA were found to be slightly more prone to developing coronary heart disease  . However, a study published in 2007  did not find a statistically significant difference in SBP and DBP levels in patients younger than 35 years of age.
We observed that aldosterone values were significantly higher (P < 0.05) among hypertensive cases and that they were lower in hypertensive controls. Our result was similar to those of Arias-Santiagos et al. , ; however, they concluded that the increase in aldosterone values in these patients might contribute to other mechanisms in the development of AGA. Serge et al.  also observed that overexpression of a mineralocorticoid receptor targeting the skin in a double transgenic mouse model induced the development of alopecia. Similarly, a study published in 2001  unmasked the association between increased aldosterone levels and insulin resistance, which confirmed Matilainen et al.'s  observation that excess circulating insulin could lead to vasoconstriction and nutritional deficiency in the follicles of the scalp, thus exacerbating the effect of dihydrotestosterone on follicular miniaturization.
There was no statistically significant difference between AGA patients and controls in free testosterone levels. This was in agreement with Arias-Santiagos et al.  as they found no correlation between the presence of AGA and levels of free testosterone. In addition, Arias-Santiagos et al.  attributed this phenomenon to the fact that the pathogenesis of AGA is characterized by an increase in peripheral sensitivity to the androgens responsible for follicular miniaturization with no changes in serum levels of total testosterone.
Our results show a positive correlation between SBP and DBP and aldosterone levels in patients with AGA; there was no statistically significant difference in aldosterone levels between normotensive and hypertensive AGA patients. Our results are in agreement with those of the Arias-Santiagos et al.  study in women with early-onset AGA. This positive correlation was verified by the fact that aldosterone causes sodium retention, which then causes water retention. This combination increases blood pressure and blood volume  . Other authors  suggested that in such cases, the use of aldosterone antagonists could have a double beneficial effect, namely, control of blood pressure and a halt in the progression of alopecia.
Aldosterone causes an increase in the levels of ROS, EGFβ, and TGFβ, which modulate fibrinolytic effects and inflammatory responses  , which may be responsible, along with other factors, in causing perifollicular fibrosis and inflammation in AGA.
| Conclusion|| |
Hyperaldosteronism plays a role in the pathogenesis of AGA and hypertension; thus, the use of aldosterone antagonists may lead to a dual effect. Blood pressure screening in patients with AGA would be valuable to facilitate the early diagnosis of unknown hypertension and to initiate an appropriate treatment.
| Acknowledgements|| |
Conflicts of interest
| References|| |
|1.||Rogers NE, Avram MR. Medical treatment for male & female pattern of hair loss. J Am Acad Dermatol 2008; 59 :547-566. |
|2.||Blume-Peytavi U, Blumeyer A, Tosti A, Finner A, Marmol V, Trakatelli M, et al. European Consensus Group. S1 guideline for diagnostic evaluation in androgenetic alopecia in men, women and adolescents. Br J Dermatol 2011; 164 :5-15. |
|3.||Garza LA, Yang CC, Zhao T, Blatt HB, Lee M., He H, et al. Bald scalp in men with androgenetic alopecia retains hair follicle stem cells but lacks CD200-rich and CD34-positive hair follicle progenitor cells. J Clin Invest 2011; 121 :613-622. |
|4.||Heilmann S, Nyholt DR, Brockschmidt FF, Hillmer AM, Herold C, Maan Consortium, et al. No genetic support for a contribution of prostaglandins to the aetiology of androgenetic alopecia. Br J Dermatol 2013; 169 :222-224, Available at: http://www.ncbi.nlm.nih.gov/pubmed/23448296. [Accessed 28 February 2013] |
|5.||Funder JW. Genetics of primary aldosteronism. Science 2011; 133 :685-686. |
|6.||Yi SM, Son SW, Lee KG, Kim SH, Lee SK, Cho ER, et al. Gender specific association of androgenetic alopecia with metabolic syndrome in middle aged Korean population. Br J Dermatol 2012; 167 :306-313. |
|7.||JNC 7. Guidelines for hypertension. Available at: http://www.nhlbi.nih.gov/guidelines/hypertension. [Accessed 30 May 2003] |
|8.||Obterg N, Finner AM, Shaprio J. Androgenetic alopecia. Endocrinal Metab Clin North Am 2007; 36 :379-398. |
|9.||Fujita T. Aldosterone is salt sensitive hypertension and metabolic syndrome. J Mol Med 2008; 86 :729-734. |
|10.||Ahouansou S, Le Toumelin P, Crickx B, Descamps V, et al. Association of androgenetic alopecia & hypertension. Eur J Dermatol 2007; 17 :220-223. |
|11.||Sonita B, Touyz RM. Magnesium transport in hypertension. Pathophysiology 2007; 14 :205-211. |
|12.||Arias-Santiagos S, Gutierrrez-Salmeron MT, Castellote-Caballero L, Naranjo-Sintes R. Elevated aldosterone levels in patients with androgenetic alopecia. Br J Dermatol 2009; 161 :1196-1198. |
|13.||Arias-Santiagos S, Gutierrrez-Salmeron MT, Castellote-Caballero L, Naranjo-Sintes R Hypertension and aldosterone levels in women with early onset androgenetic alopecia. Br J Dermatol 2010; 162 :786-789. |
|14.||González-González JG, Mancillas-Adame LG, Fernández-Reyes M, Gómez-Flores M, Lavalle-González FJ, Ocampo-Candiani J, Villarreal-Pérez JZ. Androgenic alopecia and insulin resistance in young men. Clin Endocrinol 2009; 71 :494-499. |
|15.||Diane R. The basic of balding: Androgenetic alopecia. Available at: http://www.everydayhealth.com/skin-and-beauty/androgenic-alopecia.aspx. [Accessed 23 June 2010] |
|16.||Hirsso P, Laakso M, Matllainen V, Hiltunen L, Rajala U, Jokelainen J, et al. Association of insulin resistance linked diseases & hear loss in elderly men. Finnish population-based study. Cent Eur J Public health 2006; 14 :78-81. |
|17.||Serge A, Phillipe T, Béatrice C, Vincent D. Association of androgenetic alopecia and hypertension. Eur J Dermatol 2007; 17 :220-222. |
|18.||Parvin M, Mohammadreza M, Masood E, Mona M. Androgenetic alopecia and coronary artery disease in women. Dermatol Online J 2005; 11 :2. |
|19.||Hirsso P, Rajala U, Hiltunen L, Jokelainen J, Keinänen-Kiukaanniemi S, Näyhä S, et al. Obesity and low-grade inflammation among young Finnish men with early-onset alopecia. Dermatology 2007; 214 :125-129. |
|20.||Adult Treatment Panel III. Executive Summary on the Third Report of the National Cholesterol Education Program (NECP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001; 285 :2486-2497. |
|21.||Matilainen V, Koskela P, Keinänen-Kiukaanniemi S. Early androgenetic alopecia as a marker of insulin resistance. Lancet 2000; 356 :1165-1166. |
|22.||Arias-Santiagos S, Arrabal-Polo MA, Buendia-Eisman A, Arrabal-Martín M, Gutiérrez-Salmerón MT, Girón-Prieto MS, et al. Androgenetic alopecia as an early marker of benign prostatic hyperplasia. J Am AcadDermatol. 2012; 66 :401-408. |
|23.||Gross ND, Kempton JB, Trune RR. Spironolactone blocks glucocorticoid-mediated hearing preservation in autoimmune mice. Laryngoscope 2002; 112 :298-303. |
|24.||Schjoedt KJ, Andersen S, Rossing P, Tarnow L, Parving HH. Aldosterone escape during blockade of the renin-angiotensin aldosterone system in diabetic nephropathy is associated with enhanced decline in glomerular filtration rate. Diabetologia 2004; 47 :1936-1939. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]