|Year : 2021 | Volume
| Issue : 2 | Page : 70-75
The association between androgenic alopecia severity and the development of metabolic syndrome in Saudi Arabia: A case-control study
Almuntsrbellah M Almudimeegh1, Khalid A Alekrish2, Rakan A Bahammam2, Ibrahim A Alhedaithi2, Khalid A Al Dakheel2
1 Department of Dermatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 College of Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Submission||05-Dec-2020|
|Date of Acceptance||31-May-2021|
|Date of Web Publication||29-Mar-2022|
Dr. Khalid A Alekrish
P.O. Box 56810, Riyadh 11564
Source of Support: None, Conflict of Interest: None
Background: Androgenic alopecia (AGA) is a common type of chronic progressive hair loss that affects both males and females. AGA was shown to be associated with metabolic syndrome (MS) in many studies; the correlation between the AGA grade and MS, however, is still debatable. Purpose: The objective of the study was to assess the severity of AGA in a sample of patients suffering from this condition and its association with MS. Methods: This case–control study included 319 patients attending a dermatology clinic at a tertiary care hospital. Anthropometrics, blood pressure, lipid profile, and fasting blood sugar were collected from patients' records. Patients with AGA were allocated to the case group and were stratified based on severity using the Ludwig hair loss scale for females and the Norwood scale for males. The control group was composed of patients free of any hair condition. Data were analyzed using version 25 of SPSS. Results: MS was seen in 26.4% and 10.2% in cases and controls, respectively (P < 0.05). In terms of severity, MS was found in 21.6% of Grade I, 30.5% of Grade II, and 42.9% of Grade III patients. Although the findings showed no statistical significance (P > 0.05), the burden of MS was associated with the severity of AGA. Conclusion: Our findings suggest an association between MS and AGA and that burden of MS is associated with the severity of AGA, although the analysis showed no statistical significance. Based on our results, we think that early screening for MS might be beneficial to patients with AGA, as this will encourage early lifestyle modification to hopefully prevent future complications.
Keywords: Androgenic alopecia, diabetes, hair loss, metabolic syndrome, obesity
|How to cite this article:|
Almudimeegh AM, Alekrish KA, Bahammam RA, Alhedaithi IA, Al Dakheel KA. The association between androgenic alopecia severity and the development of metabolic syndrome in Saudi Arabia: A case-control study. J Dermatol Dermatol Surg 2021;25:70-5
|How to cite this URL:|
Almudimeegh AM, Alekrish KA, Bahammam RA, Alhedaithi IA, Al Dakheel KA. The association between androgenic alopecia severity and the development of metabolic syndrome in Saudi Arabia: A case-control study. J Dermatol Dermatol Surg [serial online] 2021 [cited 2022 May 19];25:70-5. Available from: https://www.jddsjournal.org/text.asp?2021/25/2/70/341198
| Introduction|| |
Androgenic alopecia (AGA) is a common type of chronic progressive hair loss that affects both males and females, and although it is a benign condition, it can have a significant psychosocial impact on patients. Androgens – in particular dihydrotestosterone (DHT) – have a substantial effect on the development of AGA. Various studies have reported the concurrency of cardiovascular disease (CVD), metabolic syndrome (MS), benign prostate hyperplasia (BPH), and prostate cancer with AGA.,, It is believed that the association between AGA and CVD is heavily dependent on DHT. DHT, a metabolite of testosterone, is five times more potent than testosterone at androgen receptors. In AGA, DHT was found to be a leading cause of hair follicle miniaturization. Meanwhile, in CVD, the increased rate of proliferation and thickening of the vascular smooth muscle was the main effect of DHT. Dharam Kumar et al. reported that patients with AGA have a higher prevalence of dyslipidemia, hypertension, and higher values of waist circumference. It was also found that patients with higher severity of AGA have a more severe form of MS.
In India, a case–control study was conducted to assess the presence of MS and insulin resistance (IR) in patients with AGA; the study included 100 male patients with AGA and 100 male control participants. They found a statistically significant association between AGA and MS and between AGA and IR. They recommended assessing MS and IR in all young patients with Stage III AGA and above. Another study in the same country was carried out with a sample of 85 cases and an equivalent number of controls; they had similar results, in which the association between AGA and MS was significant, but the study was limited by sample size.
A case–control study was to identify whether early-onset AGA is a marker for early atherosclerosis was carried out in Turkey with 51 male participants with early-onset AGA and 17 male controls. According to the Hamilton Norwood scale, they classified their cases into three groups in terms of severity. MS was found in 25 cases and two controls. They concluded that early-onset AGA appeared to be a marker for early atherosclerosis. The study was limited by the relatively small sample size.
A cross-sectional study was carried out in Egypt to evaluate the incidence of BPH and MS in 400 participants with AGA. They found a significant difference between patients with AGA and those without the condition. Differences included waist circumference, body mass index (BMI), fibrinogen level, fasting blood sugar (FBS), cholesterol, C-reactive protein, erythrocyte sedimentation rate, and glycosylated hemoglobin. Of those with AGA, 51% were found to meet the criteria for MS, while 28% comprised those without AGA.
To the extent of our knowledge, there have been no studies in Saudi Arabia that have evaluated the association between AGA and its severity with MS. Therefore, the aim of the present study was to assess the severity of AGA in a sample of patients suffering from this condition and its association with MS. The results observed in the study may help address whether to perform an MS screening for patients with more severe AGA. It can also raise awareness in susceptible individuals that early lifestyle changes can reduce the risk of MS in the long term.
| Methods|| |
Institutional Review Board approval was obtained for this observational, analytical, retrospective, case–control study. The estimation of the sample size needed was based on the prevalence rate of MS in a similar study, in which MS was seen in 53% of patients with AGA and 17% of controls, with a confidence interval and power of 95%. The sample size needed was calculated to be 48 in each group.
All the patients attending a weekly dermatology clinic at a tertiary care hospital, from January 2019 to August 2020, were included in the study, for a total of 319 patients.
The eSIHI patient record system was accessed to obtain the patients' age, gender, nationality, dermatologic diagnosis, anthropometrics, blood pressure, lipid profile, and FBS. Patients who had any of the above data missing were excluded from the study.
The case group included patients who were diagnosed with AGA. They were divided into two groups based on gender and were then stratified based on severity. We used the Ludwig grading system for females and the Norwood grading system for males. The control group was composed of the patients who were free of any hair condition. The MS diagnosis was based on the 2005 update of the NCEP ATP III criteria (anthropometrics, blood pressure, high-density lipoprotein [HDL], and FBS), however, because of data limitations, we used the patients' BMI with a value equal to or greater than 30 instead of waist circumference.
Data were entered in Microsoft Excel and analyzed using Statistical Product and Service Solutions (SPSS) version 25 International Business Machines Corporation (IBM), Armonk, New York, USA. Descriptive statistics were computed for quantitative and qualitative variables in terms of mean ± standard deviation or frequency (%). Association of MS was observed with AGA by odds ratio with (95% CI), and significance was obtained using Chi-square test. Confounders were also assessed. Quantitative variables were compared by applying an independent t-test correlation between different clinical parameters and lipid profile. The significance level was set as ≤ 0.05.
| Results|| |
In this case–control study, a total of 319 participants were included. Among them, 182 (57.1%) patients were diagnosed with AGA, and 137 (42.9%) subjects were healthy controls.
The mean age of all patients was 39.3 ± 13.25 years. A significant difference was observed between the mean age of cases and controls (P < 0.0001). The largest portion of study participants (27.3%, n = 87) were of ages 26–35, followed by those 36–45 years of age (25.7% n = 82). In the AGA group, most of the patients (26.4%, n = 48) were of age 36–45 years. In both groups, the majority of the participants were females (97.3% vs. 78.1%; P = 0.0001). In the AGA group, the prevalence of high systolic blood pressure (SBP), obesity, impaired FBS levels, and abnormal lipid profile were significantly higher in comparison to the control group (P ≤ 0.05). No significant difference was observed regarding nationality, high diastolic blood pressure, overall hypertension, low HDL, and pattern of medication consumption with respect to both groups with P > 0.05. Patients with AGA were more likely to have a greater number of fulfilled MS criteria when compared to controls; 11% (n = 20) of cases and 2.2%(n = 3) of controls had four or more fulfilled criteria (P < 0.05). The number of medications used was also associated with AGA, where 72% (n = 131) of patients with AGA had a history of using three or more drugs similar to controls (63.5%, n = 87) who were using multiple drugs [Table 1].
|Table 1: Distribution of patients demographic and clinical characteristics|
Click here to view
The findings showed that there was a significant difference in SBP, FBS, hemoglobulin A1c, triglycerides (TGs), and BMI between both cases and controls with a P ≤ 0.05 [Table 2].
The association of AGA with MS is shown in [Table 3]; in the AGA group, MS was seen in 26.4% of patients; in the control group, only 10.2% of participants had MS. Association between exposure and disease was found to be statistically significant with a P = 0.0001 and (odds ratio [OR]: 3.15; [95% confidence intervals (CI): 1.65–5.99]). It also showed that the frequency of MS increases in cases compared to controls; this indicates that there is a significant association between AGA and MS.
|Table 3: Association of metabolic syndrome in cases (with androgenic alopecia) and controls (without androgenic alopecia) according to possible confounders|
Click here to view
A stratified approach was used to observe the association of MS in both groups with dominant associated factors. This study explored the significant confounders that affect exposure and disease. Older age (P = 0.024 and OR: 8.89; [95% CI: 1.01–78.18]), female gender (P = 0.0001 and OR: 4.60; [95% CI: 2.08–10.18]), Saudi nationality (P = 0.0001 and OR: 3.87; [95% CI: 1.79-8.38]), hypertension (P = 0.023 and OR: 2.46; [95% CI: 1.12–5.4]), obesity (P = 0.020 and OR: 2.78; [95% CI: 1.16–6.67]), impaired glucose level (P value: 0.005 and OR: 4.41; [95% CI: 1.51–12.87]), and use of multiple medicines (P = 0.0001 and OR: 3.85; [95% CI: 1.62–9.16]) were the factors determined through this study.
In [Table 4], the comparison between the severity of AGA and MS concerning gender is depicted. In male patients, all five patients are in Grades III and IV of severity; among them, none was found to have MS. In female patients, the majority were in Grades I and II of AGA, 97/177 (54.8%) and 59/177 (33.3%), respectively. The prevalence of MS in female patients was 21.6%, 30.5%, and 42.9% in Grades I, II, and III of AGA, respectively. The burden of MS is associated with the severity of AGA, although the findings showed no statistical significance (P > 0.05).
|Table 4: Comparison of severity of androgenic alopecia with metabolic syndrome according to gender|
Click here to view
| Discussion|| |
In our study, we included 182 patients as cases and 137 as controls. Along with the association between AGA and MS, we also assessed the effect of the severity of AGA on this association.
The average age of our sample was 42.7 and 37.8 years for cases and controls, respectively. We noticed a predominance of female patients and Saudi nationality, which is to be expected given the location, in which the study was carried out. Our analysis showed a statistically significant association between AGA and increased age, female gender, elevated SBP, obesity, hypertriglyceridemia, and impaired FBS. MS was seen in 26.4% of patients with AGA, while only 10.2% of controls were noted to have the syndrome. The analysis also showed a statistically significant association between AGA and the number of satisfied MS criteria, further solidifying the association between the two conditions.
Using Ludwig and Norwood grading systems for females and males, respectively, we assessed the association between the grade of AGA and MS. Because of the limited number of males visiting the dermatology hair clinic, we could not assess the association by gender. In females, however, the prevalence of MS was 21.6%, 30.5%, and 42.9% in grades I, II, and III, respectively. It was clear from the data that the burden of MS was associated with the severity of AGA even though there was no statistical significance.
Comparing our study to similar studies, it was found that SBP values are higher in cases when compared to controls (P < 0.05); similar results were reported by Dharam Kumar et al. and Bakry et al., Furthermore, cases were found to have significantly higher values of TGs when compared to controls; comparable results were reported by several studies.,, It was also found that AGA patients have a statistically significant higher blood glucose level, and this aligns with previous studies.,, BMI was found to be significantly higher among cases when compared to controls; again, similar results were reported by Bakry et al. and Agamia et al., There was no statistically significant difference between cases and controls regarding HDL levels, which upholds results from several previous studies.,,,
This study had several limitations. Even though BMI was included in the analysis, it was not possible to obtain waist circumference. In addition, the study participants were mostly females because the overwhelming majority seeking treatment for AGA in our hospital were females. Finally, this is the study of a single center; therefore, further studies from multiple centers are recommended. As for the strengths of our study, we had a larger sample size compared to several other similar studies.,,, We also assessed the association between the grades of AGA and MS.
| Conclusion|| |
Our findings suggest an association between MS and AGA. Our findings also suggest that the burden of MS is associated with the severity of AGA, although the analysis showed no statistical significance. Based on the results of our study, we think that early screening for MS might be beneficial in patients with AGA, as this will encourage early lifestyle modification and hopefully lessen – or altogether prevent – future complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Krupa Shankar D, Chakravarthi M, Shilpakar R. Male androgenetic alopecia: Population-based study in 1,005 subjects. Int J Trichology 2009;1:131-3.
Ertas R, Orscelik O, Kartal D, Dogan A, Ertas SK, Aydogdu EG, et al.
Androgenetic alopecia as an indicator of metabolic syndrome and cardiovascular risk. Blood Press 2016;25:141-8.
Dharam Kumar K, Kishan Kumar Y, Neladimmanahally V. Association of androgenetic alopecia with metabolic syndrome: A case–control study on 100 patients in a tertiary care hospital in South India. Indian J Endocrinol Metab 2018;22:196.
Yassa M, Saliou M, De Rycke Y, Hemery C, Henni M, Bachaud JM, et al.
Male pattern baldness and the risk of prostate cancer. Ann Oncol 2011;22:1824-7.
Kaufman KD. Androgen metabolism as it affects hair growth in androgenetic alopecia. Dermatol Clin 1996;14:697-711.
Death AK, McGrath KC, Sader MA, Nakhla S, Jessup W, Handelsman DJ, et al
. Dihydrotestosterone promotes vascular cell adhesion molecule-1 expression in male human endothelial cells via a nuclear factor-κB-dependent pathway. Endocrinology 2004;145:1889-97.
Bakry OA, Shoeib MA, El Shafiee MK, Hassan A. Androgenetic alopecia, metabolic syndrome, and insulin resistance: Is there any association? A case-control study. Indian Dermatol Online J 2014;5:276-81.
] [Full text]
Gopinath H, Upadya GM. Metabolic syndrome in androgenic alopecia. Indian J Dermatol Venereol Leprol 2016;82:404-8.
] [Full text]
Norwood OT. Male pattern baldness: Classification and incidence. South Med J 1975;68:1359-65.
Agamia NF, Abou Youssif T, El-Hadidy A, El-Abd A. Benign prostatic hyperplasia, metabolic syndrome and androgenic alopecia: Is there a possible relationship? Arab J Urol 2016;14:157-62.
Ludwig E. Classification of the types of androgenetic alopecia (common baldness) occurring in the female sex. Br J Dermatol 1977;97:247-54.
Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH, Franklin BA, et al.
Diagnosis and management of the metabolic syndrome: An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation 2005;112:2735-52.
Acibucu F, Kayatas M, Candan F. The association of insulin resistance and metabolic syndrome in early androgenetic alopecia. Singapore Med J 2010;51:931-6.
Behrangi E, Azizian Z, Ardestani FS, Najafi Z, Vakili SH. Association of androgenic alopecia with metabolic syndrome. Ann Med Health Sci Res. 2018;8:91-3.
Thakare SA, Singh A. Early-onset male androgenetic alopecia and metabolic syndrome: Are they associated? Int J Recent Surg Med Sci 2016;2:5-9.
Arias-Santiago S, Gutiérrez-Salmerón MT, Castellote-Caballero L, Buendía-Eisman A, Naranjo-Sintes R. Male androgenetic alopecia and cardiovascular risk factors: A case-control study. Actas Dermosifiliogr 2010;101:248-56.
El Sayed MH, Abdallah MA, Aly DG, Khater NH. Association of metabolic syndrome with female pattern hair loss in women: A case-control study. Int J Dermatol 2016;55:1131-7.
[Table 1], [Table 2], [Table 3], [Table 4]