Hair follicles and associated glands as androgen targets.

The growth of hair, except that on the scalp, and the secretion of sebum are, in general, under the major influence of androgens. However, the responses of the hair follicles and their associated glands vary greatly between sites and between individuals. On the face, trunk and extremities the most important role of testosterone is to increase the period of activity, the anagen phase, of the hair follicle, though it also increases the rate of growth, thickness, extent of medullation and pigmentation of the hair. These effects involve high levels of hormone and its conversion to 5 alpha-dihydrotestosterone in the target organ. In contrast, the lower pubic triangle develops luxuriantly even in absence of 5 alpha-reductase. In the sebaceous glands, cell replication and lipid synthesis do not seem to be identically controlled, since they respond differently to inhibitors. The response of the sebaceous glands to androgens involves the interaction at the target site of pituitary factors, for which growth hormone, prolactin, and melanocyte stimulating hormone are all putative candidates. The most important scientific and clinical question is whether, in any particular circumstances, the degree of response of the hair follicles or sebaceous glands is determined by the level of available androgen or by the sensitivity of the target organ. While it is true that some patients with hirsutism or acne have above normal levels of plasma androgens or below normal levels of SHBG, a substantial proportion are normal in all respects. Moreover, the rates of hair growth on the extremities or of sebum excretion on the forehead do not seem to be correlated either positively with plasma androgens or negatively with SHBG, though they each have been shown to be correlated with circulating 5 alpha-dihydrotestosterone. The conclusion must be that, although male-type hair growth and high sebaceous secretion may be caused by, or at least accompanied by, high levels of free testosterone, the critical factor is more likely to be the peripheral response.