Thinning Temples 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 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 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.

Typical FPHL described by the Ludwig Classification involves the central scalp, rather than the temples, and often the hairline is preserved. Examination of the scalp and hairs under magnification with a folliscope will frequently make the diagnosis obvious, but sometimes a biopsy is required so that a histological diagnosis can be made.

The below are some common reasons why women might present with hair loss and thinning hair around the temples.

Congenital hereditary temple recessions

Some women will have been born with an ‘M’ shape to their hairline or will always have had a lower hair density in their temples. In these women a small degree of localised or global hair loss might accentuate the problem so a question to ask is what their hairline looked like when they were a teenager (Figure 1).¹¹

Temporal triangular alopecia (TTA)

This will have been present form birth and, as the name implies, is a triangular area of hair loss which is usually unilateral but can occasionally be bilateral (Figure 2). The degree of thinning is variable, but the area involved can be completely bald.¹²

Polycystic ovarian syndrome (PCOS)

This is the most common cause of hair loss in young women and other signs of hyperandrogenism such as acne, hirsutism and irregular periods, so this should be asked about.¹³ In young women with hair loss, the presence of these other symptoms/signs should alert the clinician to the possibility of PCOS, which would require further investigation to make the diagnosis.

Male hormone producing tumours

Whilst rare, a woman who has rapid onset of a male-shaped hairline should be appropriately investigated. This would be similar to what happens in female transgender patients who start on male hormones – their male phenotype is unmasked. Similar to the differing distribution of facial and body hair that occurs in trans men, the degree and extent of MPHL in women exposed to high levels of male hormones is unpredictable.¹⁴

It is important to understand what is of concern to the patient so that expectations can be set against what is achievable

Alopecia areata

This autoimmune non-scarring alopecia can involve isolated patches of hair loss which, rarely, might involve the temples. This condition should be easily diagnosed as the hair loss usually presents in a round shape, is very likely to be unilateral, and often has a rapid onset.¹⁵

Frontal fibrosing alopecia (FFA)

This is an autoimmune scarring alopecia where the hair follicles are destroyed. Often the entire hairline recedes and there may be associated eyebrow loss, as well as affecting the hair on the temples (Figure 3). It is thought to be a separate entity from lichen planopilaris (LPP), which affects the scalp more globally but might be first noticed by the patient as thinning hair on the temples.¹⁶

Trichotillomania

Compulsive hair pulling is sometimes subconscious and a patient might not be aware of the habit, but broken hairs are almost always visible on examination with a folliscope.¹⁷

Traction alopecia

This is common in women with Afro-textured hair who have worn their hair in tight braids for long periods of time. It can also occur in any racial background where the hair is pulled tight, or weaves and extensions are used habitually (Figure 4). If diagnosed early, it can be reversible.¹⁸

Genetically-predetermined temple hair loss

This is the most common cause of thinning hair around the temples in women approaching middle age. A typical history is that the hair in the temples which once was thick and dense has become fine and sparse, resembling baby hairs that neither grow long nor quickly. It may be part of generalised female pattern hair loss, but the extent of the temple hair loss does not correlate with the severity of hair loss in the central scalp.¹⁹

Treatment

Treatment of hair thinning around the temples is obviously tailored to the diagnosis. Dermatological conditions need specific treatments which often involve topical, injected or systemic steroids or other anti-inflammatory drugs.

Hyperandrogenism is treated with antiandrogens and hair-friendly forms of contraception.^20,21 Trichotillomania and traction alopecia are addressed by stopping the hair-pulling habits. For genetically-predetermined thinning temples, it is worth trying topical minoxidil 2% liquid twice a day or 5% foam once a day, but it has to be used consistently for at least six months before the benefit can be judged.²² The additional benefit might just be preventing further loss. Minoxidil can also be used in oral form off-licence, as can other medications that have antiandrogen properties such as spironolactone and finasteride.^23,24,25

There is a whole industry in hair makeup from coloured hairsprays and microfibres, to hair coloured scalp creams. Scalp micropigmentation can reduce the contrast of pale skin and darker-coloured hair (Figure 5) but needs to be done with caution in women with lighter hair colours because of the risks of blended pigment colours changing over time. Microneedling intended to cause micro-trauma to the skin and stimulate repair might be beneficial, as might be low level light therapy (laser combs, bands and caps) and platelet-rich plasma injections.^26,27

As long as there is no contraindication, hair transplant surgery is the most reliable way of restoring good quality hair coverage in women with thinning temples (Figure 6).

Understanding hair loss

A better understanding of the causes and treatment options that are available can be very reassuring for women presenting with hair loss concerns. There are a wide range of options from cosmetic camouflage to topical and systemic medications, including non-invasive, minimally-invasive non-surgical treatments and hair transplant surgery. The first step to supporting your patients, if you are not experienced in treating hair loss, is to seek a well-qualified trichologist or a hair specialist dermatologist to make the diagnosis and suggest appropriate treatment. Then, if surgical hair restoration is desired, a consultation with a reputable hair transplant surgeon can start the journey to resolving the problem.