CASE REPORT
A 59-year-old post-menopausal Hispanic female with no
significant past medical history presented with a complaint
of a three-year history of gradual “thinning” of
her hair over the central and frontal scalp. The hair loss was
refractory to over-the-counter vitamin supplementation and
minoxidil foam. Recently, the hair loss had become more cosmetically
displeasing and concerning. On examination, the
patient had diffuse thinning of the entire part-width with maintenance
of the frontal and temporal hairline (i.e., Ludwig Scale
I–II) without evidence of inflammation or scarring (Figure 1).
A review of systems was non-contributory and the patient
specifically denied any recent changes in medication, known
exposures or stressors, changes in dietary habits, or signs
of virilization (e.g., acne, hirsutism, clitoral enlargement, or
deepening of voice). She also denied any family history of hair
loss. Extensive laboratory analyses including thyroid studies
(thyroid-stimulating hormone, triiodothyronine (T3), and
thyroxine (T4)), free and bound testosterone, dehydroepiandrosterone
(DHEA) sulfate, complete blood count (CBC) with
differential, iron studies (e.g., total iron binding capacity, iron
and ferritin), folate, vitamin B-12 and a complete metabolic
panel (CMP) were unremarkable. Rapid plasma reagin (RPR)
and anti-nuclear antibody (ANA) tests were also within normal
limits. A diagnosis of androgenetic alopecia (AGA; femalepattern)
was made based upon the patient history, physical
examination with detailed clinical assessments and extensive
laboratory analyses. The patient requested a novel therapy as
she was unsatisfied with previous topical therapies and was
hesitant to begin any systemic therapies such as finasteride,
spironolactone, or contraceptives.
Bimatoprost 0.03% solution (Latisse, Allergan) was injected
(30 g needle on a 1 cc syringe) with perpendicular injections
depositing 0.1 ml aliquots 1 cm apart across a chosen target
area of the anterior part-width on the frontal scalp weekly for
12 weeks and then twice weekly for an additional four weeks
(Figure 2). Injection was chosen over topical application in anticipation
of increased medication absorption and more direct
medication delivery to the target site. Each injection had the total
weekly concentration of bimatoprost that would be used as
determined per package insert for eyelash growth to limit the
number of injection sessions per week, as typical application of
bimatoprost for hypotrichosis is nightly application to the skin
of the upper eyelid margin with the accompanying applicator.
No significant improvement in hair density or hair darkening
was noted in the treatment target area after four months of
therapy (Figure 3). A decision to begin alternative combination
therapy with oral spironolactone, topical minoxidil foam and
vitamin B complex injection supplementation was made given
the clinical response was not as robust as anticipated. Of note,
there was no evidence or patient report of local injection site
reactions and the treatments were well tolerated without any
evidence of adverse events.
