JMIR Publications

ABSTRACT

Background:

Androgenetic alopecia (AGA), the predominant cause of hair loss (1)(2), is a non-scarring alopecia with a genetic predisposition. AGA manifests through the miniaturization of large terminal follicles into smaller versions due to dihydrotestosterone's (DHT) impact on scalp hair androgen receptors. Characteristically, men experience hair thinning in the vertex and frontotemporal regions, while women tend to see it along the crown (3). Aldosterone plays a crucial role in maintaining electrolyte balance and blood pressure regulation, which is pivotal for survival. An excess of aldosterone can manifest in a spectrum of symptoms ranging from muscular weakness and cramping to an increase in blood pressure. Intriguingly, recent studies have disclosed the existence of mineralocorticoid receptors in the dermal strata of mice, which when stimulated, lead to hair loss. The discovery of these receptors highlights a novel dermatological dimension to the hormone's activity, pointing to a broader systemic impact that extends to influence hair follicle function (4)(5). Numerous studies have suggested a relationship between AGA and increased cardiovascular risk, particularly concerning cardiovascular diseases (CVD) and metabolic syndrome (MtS) (6-9). The evidence points to a substantial link, emphasizing AGA as a potential marker for these conditions. However, despite the prevalence of these findings, research exploring the connection between AGA and specific ailments such as hypertension (HTN) and hyperaldosteronism remains comparatively limited and controversial (9)(10). In exploring the relationship between AGA and cardiovascular morbidity, Mansouri, P. et al. identified a significant relationship between AGA in females and both coronary artery disease (CAD) and a history of myocardial infarction (MI) (6). As for the relationship between AGA and MtS, a study conducted by Dharam Kumar, et al. demonstrated a notable correlation between the severity of AGA and the presence of MtS (7). Conversely, subsequent recent studies in China and Saudi Arabia had failed to replicate these findings, indicating no significant associations between AGA and MtS (8)(9). While research into association of AGA with HTN and hyperaldosteronism is relatively nascent, emerging studies provide insightful data. A case-control study from Spain found that women with early-onset AGA had significantly higher systolic and diastolic blood pressure, as well as elevated aldosterone levels, when compared to non-alopecic controls (5). Similarly, a research conducted in Egypt observed that men with AGA exhibited significantly higher systolic blood pressure and aldosterone concentrations; however, unlike the Spanish study, diastolic blood pressure readings did not differ significantly from those without AGA (10).

Objective:

Given the paucity of researches on AGA's association with HTN and hyperaldosteronism particularly within the Saudi Arabian, our study endeavors to elucidate this association. We hypothesize that AGA may serve as an early indicator of hypertensive and hyperaldosteronism states.

Methods:

This case-control study was conducted at the Department of Dermatology, Qassim University Medical City, from September 2023 to January 2024. The study protocol was approved by the Local Ethical Committee of Qassim University with reference number: (23-42-08) and was performed according to the guidelines of Declaration of Helsinki. All participants were informed about the purpose of the study, and their permission on the forms of written consent was obtained. The study comprised 20 male patients diagnosed with AGA and 20 age and sex-matched healthy controls. Participants were included based on the following criteria: males aged 18-65 years with clinically established diagnosis of AGA. Exclusion criteria encompassed any history usage of hormonal medications (e.g., testosterone, corticosteroids), diagnosed states of hyperaldosteronism and pre-existing cardiovascular disease including HTN. Controls were matched in age and selected from individuals presenting with other dermatological conditions, excluding those meeting any patient group exclusion criteria. Data were extracted from electronic medical records and official reports, with confidentiality maintained strictly by investigator access only. Data Collection: All participants underwent detailed medical history and physical examination including vital signs checking. Weight, height and Body Mass Index (BMI) were obtained. Blood pressure readings and serum aldosterone levels were obtained during morning sessions. For AGA assessment, the Ludwig scale was employed. Statistical Analysis: Data were systematically entered into a Microsoft Excel database and subsequently analyzed with SPSS software (version 26). Descriptive statistics, including mean and standard deviation for continuous variables, along with frequencies and percentages for categorical variables, were calculated. The chi-square test and independent samples t-test were applied for comparative analyses of categorical and continuous variables, respectively. One-way ANOVA was utilized for comparisons across multiple groups. A P-value threshold of less than 0.05 was predetermined to signify statistical significance

Results:

Demographic Characteristics Demographic and clinical data of both patients and healthy controls are presented on [Table 1]. The age of the participants ranged from 20 to 62 years, with Body Mass Index (BMI) scores spanning from 17 to 43. Notably, only five participants reported a history of smoking, whereas the majority, comprising thirty-five individuals, did not. Additionally, comorbidities were present in seven participants, in contrast to thirty-three who reported none. Descriptive Statistics The blood pressure (Systolic/Diastolic measures), and Aldosterone levels in patients group appeared to be slightly lower than for participants in the control group. Detailed statistical values and comparisons are provided on [Table 2]. Inferential Statistics Series of statistical analyses were performed to explore the association between androgenetic alopecia, hypertension, and hyperaldosteronism. Initially, three independent sample t-tests were conducted to assess the differences in blood pressure and aldosterone levels relative to the presence of androgenetic alopecia. These analyses yielded no significant differences, with results for aldosterone levels (t(38) = -0.3, p = 0.766), systolic blood pressure (t(37) = -1.34, p = 0.188), and diastolic blood pressure (t(37) = -1.31, p = 0.180) as shown on [Table 3]. Subsequent to the t-tests, point-biserial Pearson correlation analyses were implemented to further investigate the relationships between androgenetic alopecia and both hypertension and hyperaldosteronism. Although these correlations did not reach statistical significance, they illuminated a negative association, suggesting a potential inverse relationship between androgenetic alopecia and these conditions [Table 4]. In light of these findings, additional analyses were conducted to explore the potential influence of age, familial history of androgenetic alopecia, and smoking history on the relationships with androgenetic alopecia and hyperaldosteronism. Androgenetic alopecia An independent sample t-test was conducted to compare ages between control and case groups, revealing no significant age difference (t(38) = 1.08, p = 0.287). Additionally, a chi-square test of association indicated that smoking history does not significantly correlate with androgenetic alopecia (χ2(1) = 0.229, p = 0.633). Conversely, a significant association was found between family history of androgenetic alopecia and the likelihood of developing the condition (χ2(1) = 4.912, p = 0.027). Notably, 32.5% of participants with androgenetic alopecia reported a family history, compared to 17.5% in the control group [Tables 5 and 6] [Figure1]. Hyperaldosteronism A multiple linear regression test was conducted to evaluate the relationship between age, family history of androgenetic alopecia, smoking history, and hyperaldosteronism. The analysis revealed that the model as a whole was not significant in predicting hyperaldosteronism: F(3, 36) = .582, p = 631. In addition, none of these factors were significant in predicting one’s hyperaldosteronism, as shown in (Table 7). Degree of Androgenetic Alopecia (Norwood Scale) To investigate the impact of the severity of androgenetic alopecia (AGA) on physiological measures, one-way ANOVA tests were utilized to analyze differences in blood pressure and aldosterone levels among AGA patients categorized according to the Norwood scale. The analysis encompassed systolic and diastolic blood pressure, as well as aldosterone levels. The results, detailed on [Table 8.1 and 8.2] , indicated no statistically significant differences across the different degrees of AGA severity.

Conclusions:

In this case-control study, we rigorously evaluated the association between AGA and two health conditions—hypertension and hyperaldosteronism. Contrary to previous studies that posited potential correlations (5)(10), our findings reveal no significant disparities in systolic and diastolic blood pressure or aldosterone levels between AGA patients and healthy control. This evidence suggests that AGA may not serve as a reliable clinical predictor for hypertension or hyperaldosteronism. Our results align with those from similar studies conducted by Danesh-Shakiba et al. (11) in Iran and by Ozbas Gok et al. (12) in Turkey, which also reported no significant association between AGA and health conditions. In contrast, a study from Egypt reported by El Esawy et al. (10), sharing similar objective, and similar study design settings (case-control, male-only participants), indicated a positive association. These results divergence may stem from regional or genetic variations that were not controlled in the study settings. Additionally, our findings depart from research such as that by Arias-Santiago et al. (5), and Mansouri et al. (6), which documented higher rates of hypertension among female AGA sufferers across various regions. Such inconsistencies highlight a potential gender-specific prevalence that underscores the influence of other non-AGA-related factors on hypertension and hyperaldosteronism, as suggested by research from Akasaka et al. (13), Connelly et al. (14), and others (15-22). These studies imply that factors specific to male physiology may diminish the impact of AGA on the investigated conditions. Further, our analysis considers the role of geographical variability in health outcomes, as discussed by Dummer et al. (23) and Volinn et al. (24), who emphasized how environmental factors and healthcare accessibility influence health status. Studies by Kershaw et al. (25) and Reddy et al. (20) corroborate this, demonstrating that geographic variation affects both the prevalence and management of hypertension. Given the comprehensive analysis and corroborative findings from diverse studies, it is prudent for healthcare practitioners, particularly in Saudi Arabia and similar regions, to reassess the predictive significance of AGA concerning hypertension and hyperaldosteronism. The lack of a significant association in our study challenges the traditional view of AGA as an indicator of these conditions. Future research should thus broaden its demographic and regional scope within Saudi Arabia to further explore this relationship, emphasizing the need for larger sample sizes to strengthen the reliability of the data. This nuanced understanding of AGA's diagnostic value, especially in gender-specific and geographic contexts, offers a refined perspective that can influence clinical approaches and health policy decisions, promoting more tailored and effective healthcare strategies. Conclusion This study contributes to a growing body of evidence suggesting that androgenetic alopecia should not be considered as a marker for hypertension or hyperaldosteronism. Our findings are particularly relevant to the medical community, indicating that the presence of AGA alone should not lead healthcare providers to anticipate these conditions in patients. Moving forward, research should focus on elucidating the complex interplay of genetic, environmental, and regional factors that influence these associations, which may inform more tailored and effective clinical assessments.