10.5826/dpc.1304a285
Introduction: Both Androgenetic alopecia (AGA) and age-related macular degeneration (AMD) shared the microinflammatory milieu and increased oxidative stress as important criteria in pathogenesis. &nbsp;
Objectives: To assess the monocyte/High density lipoprotein (HDL) ratio (MHR) in patients with AGA and its correlation to AMD in these patients, if any.
Methods: 40 patients with AGA aged 40 years or more of both sexes and 40 control subjects participated in this case-control study. General, dermatological, and ophthalmologic examination, MHR evaluation and optical coherence tomography (OCT) were performed.
Results: The mean MHR was significantly higher in AGA patients (6.98 ± 2.21) than controls (3.82 ± 0.68) (p&lt;0.001). AMD was significantly higher in patients than control (p &lt;0.001). 80% of patients were diagnosed with AMD vs 20% of control subjects. Presence of AMD in AGA was significantly related to the degree of severity of AGA in male patients (P= 0.02). MHR was significantly higher in AGA patients found to have AMD (9.37 ± 1.1 and 7.01 ± 1.42 in wet and dry type respectively) than those without AMD (P&lt;0.001). The best cutoff value of MHR in prediction of wet type among patients of AGA is ≥8.2337 with overall accuracy 80%. While the best cutoff value of MHR in prediction of dry type among AGA patients is ≥4.1408 to &lt;8.2337 with overall accuracy 86.7%.
Conclusion: AMD may develop more frequently in those with AGA, and this may correspond with the disease's severity. MHR seems to be a missing link between both conditions.
text/xml
2160-9381
3441
en
Amira Osama  Abdel-Ghaffar
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
pattern hair loss
Age-Related Macular Degeneration in Patients with Androgenetic Alopecia: Could the Monocyte/HDL Ratio Be the Link?
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-10-31
2023-04-16
2023-10-31
2024-01-16
e2023285
Dermatol Pract Concept
Introduction: Both Androgenetic alopecia (AGA) and age-related macular degeneration (AMD) shared the microinflammatory milieu and increased oxidative stress as important criteria in pathogenesis. &nbsp;
Objectives: To assess the monocyte/High density lipoprotein (HDL) ratio (MHR) in patients with AGA and its correlation to AMD in these patients, if any.
Methods: 40 patients with AGA aged 40 years or more of both sexes and 40 control subjects participated in this case-control study. General, dermatological, and ophthalmologic examination, MHR evaluation and optical coherence tomography (OCT) were performed.
Results: The mean MHR was significantly higher in AGA patients (6.98 ± 2.21) than controls (3.82 ± 0.68) (p&lt;0.001). AMD was significantly higher in patients than control (p &lt;0.001). 80% of patients were diagnosed with AMD vs 20% of control subjects. Presence of AMD in AGA was significantly related to the degree of severity of AGA in male patients (P= 0.02). MHR was significantly higher in AGA patients found to have AMD (9.37 ± 1.1 and 7.01 ± 1.42 in wet and dry type respectively) than those without AMD (P&lt;0.001). The best cutoff value of MHR in prediction of wet type among patients of AGA is ≥8.2337 with overall accuracy 80%. While the best cutoff value of MHR in prediction of dry type among AGA patients is ≥4.1408 to &lt;8.2337 with overall accuracy 86.7%.
Conclusion: AMD may develop more frequently in those with AGA, and this may correspond with the disease's severity. MHR seems to be a missing link between both conditions.
Amira Osama  Abdel-Ghaffar
2023/10/31
10.5826/dpc.1304a285
e2023285
Department of Clinical and Chemical Pathology, Faculty of Medicine, Benha University, Benha, Egypt
2160-9381
pattern hair loss
en
e2023285
Shin YK, Lee GW, Kang SW, Kim SJ, Kim AY. Macular Abnormalities Associated With 5α-Reductase Inhibitor. JAMA Ophthalmol. 2020;138(7):732-739. DOI: 10.1001/jamaophthalmol.2020.1279. PMID: 32379286. PMCID: PMC7206535.
Age-Related Macular Degeneration in Patients with Androgenetic Alopecia: Could the Monocyte/HDL Ratio Be the Link?
https://dpcj.org/index.php/dpc/article/download/3441/2384
Age-Related Macular Degeneration in Patients with
 Androgenetic Alopecia: Could the Monocyte/HDL
               Ratio Be the Link?
        Ghada Mohamed Shams1, Ahmed Abdel-Wahab Saleh1, Ahmed Mohamed Saeed2,
                  Safa Nabil El-Damaty1, Amira Osama Abdel-Ghaffar3


1 Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Benha University, Benha, Egypt
2 Department of Ophthalmology, Faculty of Medicine, Benha University, Benha, Egypt
3 Department of Clinical and Chemical Pathology, Faculty of Medicine, Benha University, Benha, Egypt



Key words: androgenetic alopecia, age-related macular degeneration, monocyte/HDL ratio, pattern hair loss
Citation: Shams GM, Saleh AA, Saeed AM, El-Damaty SN, Abdel-Ghaffar AO. Age-Related Macular Degeneration in Patients with
Androgenetic Alopecia: Could the Monocyte/HDL Ratio Be the Link? Dermatol Pract Concept. 2023;13(4):e2023285.
DOI: https://doi.org/10.5826/dpc.1304a285
Accepted: July 27, 2023; Published: October 2023
Copyright: ©2023 Shams et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Ghada Mohamed Shams, MD, Department of Dermatology, Venerology and Andrology, Faculty of Medicine,
Benha University, Egypt. Email: ghadashams84@gmail.com, ghada.abdelrazik@fmed.bu.edu.eg




  ABSTRACT             Introduction: Both Androgenetic alopecia (AGA) and age-related macular degeneration (AMD)
                       shared the microinflammatory milieu and increased oxidative stress as important criteria in their
                       pathogenesis. The monocyte/high density lipoprotein (HDL) ratio (MHR) seems to be an easy-to-­
                       calculate prognostic marker of microinflammation.
                       Objectives: To assess MHR in patients with AGA and its correlation to AMD in these patients, if any.
                       Methods: Forty patients with AGA aged 40 years or more of both sexes and 40 control subjects par-
                       ticipated in this case-control study. General, dermatological, and ophthalmologic examination, MHR
                       evaluation and optical coherence tomography (OCT) were performed.
                       Results: The mean MHR was significantly higher in AGA patients (6.98 ± 2.21) than in controls
                       (3.82 ± 0.68) (P < 0.001). AMD was significantly higher in patients than controls (P < 0.001). Eighty
                       percent of AGA patients were diagnosed with AMD versus 20% of control subjects. The presence of
                       AMD in AGA was significantly related to the degree of severity of AGA in male patients (P = 0.02).
                       The MHR was significantly higher in AGA patients found to have AMD (9.37 ± 1.1 and 7.01 ± 1.42
                       in the wet and dry type respectively) than those without AMD (P < 0.001).




Original Article | Dermatol Pract Concept. 2023;13(4):e2023285                                                                      1
                      Conclusions: AMD may develop more frequently in those with AGA. The MHR seems to be a missing
                      link between both conditions, and could be utilized as a potential biomarker for predicting AMD in
                      AGA patients.




Introduction                                                        Methods
As the name implies, androgenetic alopecia (AGA) is that            This case control study involved 80 individuals of both gen-
kind of hair loss characterized by “miniaturization” of hair        ders, within two equal groups (40 each). The first group
follicle and caused mainly by an end-organ hyperresponsive-         (N = 40) were patients suffering from clinically-diagnosed
ness to circulating androgens, predetermined by hereditary          and trichoscopically-confirmed AGA with a mean age of
factors [1]. It is the most prevalent cause of hair loss- despite   58.75 ± 9.8 years. Forty apparently healthy AGA- free indi-
different clinical patterns- in both genders [2].                   viduals were included in the second group as control subjects
    Also known as pattern hair loss (PHL), AGA strictly fol-        with a mean age 55.65 ± 12.2 years. Both groups were age
lows distinctive patterns in both sexes. Male pattern hair loss     (P = 0.381) and gender (P = 0.752) matched.
(MPHL) is more noticeable in the vertex and frontotemporal             Patients were picked out from those attending the outpa-
regions, whereas female pattern hair loss (FPHL) often pre-         tient clinic of Dermatology, Venereology, and Andrology in
serves the frontal hairline [3].                                    Benha University Hospitals, Egypt, in the period between May
    Apart from the cosmetic implication, there is growing           2021 and December 2021, after obtaining an ethical approval
evidence that AGA may be a part of a systemic microin-              from the Local Ethics Committee (MS:4-5-2021) in line with
flammation milieu [4]. Research revealed that AGA patients          the Helsinki Declaration fundamentals. Signing an informed
tend to have an atherogenic lipid profile [5].                      consent, age ≥40 years, and abstinence from systemic med-
    Known to release the most abundant pro-inflammatory             ications namely steroids or antihyperlipidemic drugs for 6
and pro-oxidant cytokines involved in inflammation cascades,        months prior to the study were prerequisites for participation.
monocytes and macrophages have been largely investigated               Subjects with any dermatological diseases other than
as the main cells in microinflammation [6]. Furthermore,            AGA and lactating or pregnant females were rolled out from
high-density lipoproteins (HDL) were found to protect en-           the study. subjects with any history of blood disease, sys-
dothelial cells from the harmful effects of low-density lipo-       temic inflammatory or infectious disease, or cancer were also
proteins (LDL) and to inhibit the oxidation of LDL particles.       excluded.
As a result, HDL was considered to have antioxidant and                After obtaining a thorough medical history, subjects
anti-inflammatory properties [7]. Based on these facts, the         were generally examined, including for vital signs, and the
monocyte count to HDL cholesterol level ratio (MHR) has             body mass index (BMI) was measured for each participant
been identified as a simple-to- calculate prognostic indicator      using the weight (Kg)/ height2 (m2) formula. The Hamilton-­
of the amount of inflammation and oxidative stress [7].             Norwood classification was used to grade MPHL, while the
    The MHR has also been investigated in the course of re-         Ludwig scale was utilized in FPHL.
vealing a clear pathogenesis for age- related macular degener-
ation (AMD), a major factor contributing to visual loss in the      Ophthalmologic Examination
geriatric population [8]. AMD development has been linked           Slit lamp biomicroscopy using a 90D lens and indi-
to several factors, among which are lipid rich deposits (known      rect ophthalmoscopy were performed by an experienced
as drusen) beneath the retinal pigmented epithelium (RPE)           ophthalmologist.
and neovascularization [9]. In fact, AMD can be classified             For detection of AMD, optical coherence tomography
into two distinctive types: dry AMD, which is nonexudative          (OCT) was performed on the macular area to measure foveal
or atrophic, and wet AMD, which is exudative or neovascular.        thickness, at its central, thickest, and thinnest points both
The wet type seems to be linked to more severe visual loss [10].    peri- and parafoveal (Figure 1) using the 3D TOPCON®
    We attempted to find out whether MHR might imply a              OCT (TOPCON Company).
potential connection between AGA and AMD, and the asso-                Before taking the image, mydriatic eye drops were used
ciation between both conditions, if any.                            to dilate the subjects eyes. Throughout the whole OCT




2                                                                       Original Article | Dermatol Pract Concept. 2023;13(4):e2023285
                Figure 1. Diagrammatic representation of the different regions of the macula assessed by Optical Coherence
                Tomography.



scanning procedure, patients were told to focus on the intrin-         abnormally-distributed, and the comparison between two
sic fixation target. Manual adjusting was done if the patient          studied groups. The plotting sensitivity (TP) on the Y axis
fixation was not satisfactory, and the image center was not            versus specificity (FP) on the X axis at various cut off levels
on the fovea. The OCT scans were carried out by an expe-               resulted in the creation of the Receiver Operating Charac-
rienced trained ophthalmic technician under the supervision            teristic curve (ROC). The diagnostic effectiveness of the test
of one of the authors.                                                 is indicated by the area under the ROC curve. Areas with
    The data obtained was evaluated by a qualified retina              performances around 100% are the best for the test, while
specialist for the determination of macular thickness and in-          areas with performances above 50% are considered accept-
tegrity to detect the presence or absence of drusen, foveal,           able. The ROC curve also enables performance comparison
parafoveal, and perifoveal thickness measurements in both              between two tests.
eyes (left and right) in order to identify the type of macular
degeneration (wet or dry).
                                                                       Results
Laboratory Investigations                                              Eighty individuals participated in this case-control study, 40
Estimation of monocyte count and HDL level in venous                   of them with mean age of 58.75 ± 9.8 years suffering from
blood samples was performed for each participant. The                  AGA (the AGA group) and 40 other individuals who were
monocyte/HDL ratio (MHR) was calculated thereafter.                    apparently healthy with a mean age group 55.65 ± 12.2 years
                                                                       (serving as a control group). No significant difference was
Statistical Analysis                                                   found between the studied groups regarding age (P = 0.381),
The IBM SPSS software programme version 20.0 was                       gender (P = 0.752), smoking (P = 0.288), comorbid hyperten-
used to analyse the data after adding it to the software.              sion (P = 0.311) or occupation (P = 0.206). Family history
The qualitative data were described in terms of numbers                of AGA was positive in 100% of AGA patients and 45%
and percentages. To confirm that the distribution was nor-             of control subjects. Clinical and anthropometric data of the
mal, the Kolmogorov test was applied. Quantitative data                studied subjects are clarified in Table 1.
were described using the range (minimum and maximum),                      Male alopecia was graded by the Hamilton grade
mean, standard deviation, median, and interquartile range              (22 patients): grade III and V each was present in 6 patients
(IQR) values. P < 0.05 was used as the statistical signif-             (27.3%), grade IV and VI each was present in 4 patients
icance criterion. The tests employed were the chi-square               (18.2%), while 2 patients (9.1%) had grade VII.
test for categorical variables, the student t-test for quan-               Female alopecia was graded by the Ludwig grade
titative variables that were normally-distributed, the                 (18 ­
                                                                           patients): 10 patients (55.6%) had grade III and
Mann Whitney test for quantitative variables that were                 8 ­patients (44.4%) had grade II.



Original Article | Dermatol Pract Concept. 2023;13(4):e2023285                                                                      3
                                 Table 1. Demographic data of the studied groups.
                                                             Groups                                              Test
                                          AGA group                    Control group
           Parameter                      N = 40 (%)                    N = 40 (%)                      t/χ2                  P
 Age (year):
 Mean ± SD                                58.75 ± 9.8                   55.65 ± 12.2                  0.886               0.381
 Gender:
 Female                                    18 (45%)                       20 (50%)                      0.1               0.752
 Male                                      22 (55%)                       20 (50%)
 Smoking:
 No                                        26 (65%)                       24 (80%)                    1.129               0.288
 Yes                                       14 (35%)                       16 (20%)
 Occupation:
 Outdoor                                   24 (60%)                       16 (40%)                      1.6               0.206
 Indoor                                    16 (40%)                       24 (60%)
 Family history:
 Irrelevant                                 0 (0%)                        22 (55%)                    15.172                  <0.001
 Relevant                                 40 (100%)                       18 (45%)
 Hypertension                              16 (40%)                       10 (25%)                    1.026               0.311
 Weight (kg)                             90.47 ± 16.73                  84.15 ± 12.39                 1.357               0.183
 Height (cm)                             169.5 ± 8.26                   166.25 ± 5.68                  1.45               0.156
             2
 BMI (kg/m )                             31.42 ± 4.84                   30.55 ± 4.97                  0.562               0.578
AGA = Aandrogenetic alopecia; BMI = body mass index; SD = standard deviation.




        Table 2. Monocyte counts, HDL levels and their ratio (MHR) among the studied groups.
                                                               Groups                                             Test
                                              AGA group                   Control group
             Parameter                        Mean ± SD                    Mean ± SD                       t                   P
 HDL (mg/dl)                                  42.85 ± 5.58                  53.65 ± 4.86                4.192             <0.001
 Monocytes (per µl)                          293.0 ± 87.31                204.0 ± 37.33                 -6.531            <0.001
 MHR                                           6.98 ± 2.21                      3.82 ± 0.68             6.101             <0.001
AGA = Aandrogenetic alopecia; HDL = high density lipoprotein; MHR = monocyte/ HDL ratio.




    All AGA patients (male and female) had a progressive           wet-type) versus 20% of the control group (all of them
course. The age of disease onset ranged from 25 to 35 years        were with wet-type). The presence of AGA increases the
(mean 28.8 ± 2.91 years).                                          risk of AMD by 32-folds when compared with the control
    On one hand, monocyte count was significantly higher in        group and increases the risk of wet-type AMD by 10-folds
AGA patients versus control subjects (P < 0.001), and on the       (­Table 3). Supplementary tables show the significant differ-
other hand, serum HDL was significantly lower (P < 0.001).         ences between the OCT findings in both AGA group and
Consequently, the MHR was significantly higher in AGA pa-          control subjects (Tables S1 and S2).
tients vs. control subjects (P < 0.001) (Table 2).                     A significant difference was found in the monocyte count,
    In AGA patients, the MHR correlated significantly and          HDL levels and consequently the MHR between patients
positively with age (r = 0.761, P < 0.001), BMI (r = 0.688,        diagnosed with AMD and those without within the AGA
P < 0.001), Hamilton grade (r = 0.809, P < 0.001) and Lud-         group, with the highest significant difference noted among
wig grade (r = 0.502, P < 0.001). No significant difference        AGA patients diagnosed with wet-type AMD (Table 4).
was found in MHR values between male (7.74 ± 1.76) and             There was also a significant association between weight –
female (6.44 ± 2.35) patients (P = 0.06) (Figure 2).               and BMI- on one hand and presence and type of AMD on
    Eighty percent of AGA patients met the OCT diagnostic          the other hand, with significantly higher values within the
criteria for AMD (22 patients with dry-type, and 10 with           wet-type AMD patients (Table 4).



4                                                                       Original Article | Dermatol Pract Concept. 2023;13(4):e2023285
Figure 2. (A-D) Scatter dot graphs showing significant positive correlations between monocyte/HDL ratio (MHR) and Age (A), Body mass
index (BMI, B), The Ludwig grade (C), The Hamilton grade in patients with androgenetic alopecia (D).




        Table 3. Presence of age-related macular degeneration (AMD) among the studied groups.
                                                                 Groups                                          Test
                                            AGA group                        Control group
          Parameter                         N = 40 (%)                        N = 4 0 (%)                 χ2                P
 Type of AMD:
 Dry                                          22 (55%)                          0 (0%)                 18.113            <0.001
 Wet                                          10 (25%)                          8 (20%)
 Normal                                        8 (20%)                         32 (80%)
 COR (95% CI)                                                    32 (3.4 – 75.35) (AMD)                                  <0.001
 COR (95% CI)                                               10 (0.9 – 27.69) (wet AMD)                                       0.056
AGA = Androgenetic alopecia; AMD = age-related macular degeneration; CI = confidence interval; COR = crude odds ratio.




    Furthermore, the presence and type of AMD were signifi-            association was detected between presence and type of AMD
cantly related to the grade of AGA in males (P = 0.02), with           and gender (P = 0.955).
patients diagnosed with wet-type AMD having the highest                   Finally, ROC curve analyses were performed. In the
grades of AGA (66.7% of them were grade VI and 33.3%                   prediction of AGA, the best cutoff value of the MHR was
were grade VII). On the other hand, no significant associ-             ≥ 4.041 with an area under the curve of 0.907, sensitivity
ation was found with the severity of AGA in females as as-             85%, specificity 80%, positive predictive value (PPV) 81%,
sessed by Ludwig scale (P = 0.058). The age of onset of AGA            negative predictive value (NPV) 84.2% and an overall ac-
was not related to the presence or type of AMD in affected             curacy of 82.5%. The best cutoff value of the MHR in the
patients (P = 0.556).                                                  prediction of wet-type AMD among AGA patients was ≥
    significant relation was found between the presence and            8.2337 with an area under the curve of 0.933, sensitivity
type of AMD on one hand and age (P < 0.001), smoking                   80%, specificity 80%, PPV 57.1%, NPV 92.3% and an over-
(P = 0.009), or occupation (P = 0.024) on the other hand.              all accuracy of 80%. While in prediction of dry-type AMD
Wet-type AMD was found to be associated with older age,                among AGA patients, the best cutoff of MHR is ≥4.1408 to
smoking and outdoor occupation. Whereas no significant                 < 8.2337 with area under curve 0.955, sensitivity 90.9%,



Original Article | Dermatol Pract Concept. 2023;13(4):e2023285                                                                       5
    Table 4. Relation between presence and type of age-related macular degeneration (AMD) with
    monocyte/HDL ratio (MHR), weight, height, and body mass index (BMI) among androgenetic
                                      alopecic (AGA) patients.
                                                                AMD                                                     Test
                                        No                      Dry                        Wet
                                       N=8                     N = 22                     N = 10
          Parameter                 Mean ± SD                Mean ± SD                 Mean ± SD                 F               P
 Monocytes (per µl)                190.0 ± 18.26           290.91 ± 70.21             380.0 ± 26.65           10.587            0.001
 Tukey-HSD                            P1 0.03*                 P2 0.04                  P3 <0.001
 HDL (mg/dl)                        49.0 ± 1.41             41.64 ± 5.75               40.6 ± 3.91              4.12            0.035
 Tukey-HSD                            P1 0.046                 P2 0.917                  P3 0.048
 MHR                                3.88 ± 1.42              7.01 ± 1.42                9.37 ± 1.1            21.809           <0.001
 Tukey- HSD                          P1 <0.001                P2 0.007*                 P3 <0.001
 Weight                            74.88 ± 9.98             85.64 ± 8.21             113.56 ± 10.59           23.284           <0.001
 Tukey HSD                            P1 0.139                P2 <0.001                 P3 <0.001
 Height                            170.5 ± 9.98             167.45 ± 7.38              173.2 ± 9.12             0.856           0.442
 BMI                               25.68 ± 0.54             30.61 ± 3.14               37.82 ± 0.69           28.885           <0.001
 Tukey HSD                            P1 0.008                P2 <0.001                 P3 <0.001
AMD = age-related macular degeneration; BMI = body mass index; F = One way ANOVA test; HSD = highest significant difference;
P1 = difference between normal and dry AMD; P2 = difference between dry-type AMD and wet-type AMD; P3 = difference between wet AMD
and normal SD standard deviation.




Figure 3. (A-C) Receiver operator characteristics (ROC) curve showing performance of monocytes/HDL ratio (MHR) in the prediction of:
Androgenetic alopecia (A), wet-type age-related macular degeneration (B), Dry-type age-related macular degeneration (C).




specificity 7%, PPV 90.9%, NPV 75% and overall accuracy             To date, no data has been published investigating the MHR
86.7% (Figure 3).                                                   as an easy-to-calculate prognostic marker in patients with
                                                                    AGA. The MHR as an indicator of inflammation, depends

Conclusions                                                         on the pro-inflammatory action of monocytes vs. the anti-
                                                                    inflammatory effect of HDL. Monocyte activation and dif-
The unclear etiopathogenesis is a common feature of both            ferentiation into lipid-laden macrophages play a key role
AGA and AMD. Sharing other characteristics, including               in the enhancement of immunological responses in patients
microinflammatory milieu and increased oxidative stress,            with a chronic inflammatory status [11]. On the other hand,
makes the potential connection between both diseases likely.        HDL was found to counteract the migration of macrophages
    In this case-control study, the MHR was significantly           and deprive them from lipids, thereby reversing the process
higher in AGA patients versus control subjects (P < 0.001).         of lipid deposition in the vessel wall [12]. The MHR had



6                                                                         Original Article | Dermatol Pract Concept. 2023;13(4):e2023285
been investigated as an indicator of systemic inflammation        analysis of the present work data, presence of AGA increases
in cardiovascular disease [7]. It is now thought that minia-      the risk of AMD by 32-folds when compared with control
turization of hair follicles in AGA is a result of an indolent,   subjects (Table 3). The MHR was found to be significantly
painless, silent inflammatory process, given the term "micro-     higher in AGA patients diagnosed with AMD vs. those who
inflammation" to be differentiated from the usual inflam-         were not (P < 0.001). In fact, the MHR has been investigated
matory process [4]. Dyslipidemia in AGA patients has been         as a biomarker of systemic inflammation in AMD [20].
studied in multiplicity of research, with proved decreased            In line with the results of the current work, Kucuk and
HDL levels in AGA patients in most controlled studies [5].        colleagues linked the significantly higher values of MHR to
However, the exact explanation of this finding is yet to be       the wet-type AMD [20]. According to reports, monocytes
identified. A compromised microvasculature of the dermal          are crucial in the development of the lipid-rich drusen [21]
papillae of bald scalp was suggested as a possible contrib-       and neovascularization [22] (a key step in development of
uting mechanism to follicle miniaturization, a mechanism          wet-type AMD), while elevated HDL levels were proven to
similar to atherosclerosis in cardiovascular disease (CVD)        be protective against development of neovascularization in
linking both conditions [13] and supporting the growing ev-       AMD [23]. Consequently, MHR represents an indicator of
idence of an atherogenic lipid profile in AGA patients [5].       the pro/anti-inflammatory balance status in such patients.
    Numerous studies investigated the MHR as a prognostic         Given that the composition and pathogenesis of cholesterol-
marker in various conditions. Bolayir and colleagues found        rich subretinal drusen deposits resemble that of atheroscle-
the MHR to be significantly higher in acute stroke patients       rotic plaques [24], the atherogenic lipid profile increasingly
than healthy individuals and reported the ratio as a signifi-     reported in AGA patients [5], and the increased comorbid
cant mortality variable in such patients [14]. According to       cardiovascular risk in AGA patients [13], a link among these
Karatas et al, the MHR in diabetic nephropathy patients was       conditions could be suggested.
considerably greater than in normoalbuminuric diabetic pa-            The association between sex hormones and development
tients and healthy controls [15]. Furthermore, a significantly    of soft drusen, hence AMD had been investigated earlier in
higher MHR was recorded in vitiligo patients in comparison        multiple research articles [25,26]. Shin and colleagues sug-
to vitiligo-free controls and was significantly correlated with   gested increased incidence of macular abnormalities with
the severity of the disease as evaluated by the vitiligo extent   the use of antiandrogens and stated that the mechanism is
tensity index (VETI) score [16]. Moreover, a study by Acik-       not yet well-understood [26], However, they did reported
goz and colleagues detected a significant correlation between     hair loss in their patients, therefore further investigations
the MHR and vascular involvement in patients with Beh-            are needed to clarify whether the macular abnormalities are
cet disease, suggesting endothelial dysfunction as a possible     associated with the use of anti-androgens, or with hair loss.
mechanism [17]. The MHR was also suggested as an indica-              Owing to the results of the present research, the AGA
tor of the systemic inflammatory process in psoriatic patients    male patients diagnosed with wet-type AMD were found
that correlates with severity of psoriasis as evaluated by The    to have more severe AGA, making the association between
Psoriasis Area and Severity Index (PASI) [18].                    both conditions more plausible. The relatively small size of
    In the present work, the MHR correlated positively with       the included patient samples limits the generalizability of the
severity of AGA as assessed by the Hamilton grade (r = 0.809,     findings of the present work.
P < 0.001) and the Ludwig grade (r = 0.502, P < 0.001). Con-          Taken together, the findings of this research suggest that
sequently, the ratio may be utilized as a biomarker for AGA       AGA could be associated with increased risk of AMD, the
severity in both genders.                                         wet-type in particular. We assert that the MHR could repre-
    We also reported a significant positive relation between      sent a potential link between the two diseases and could be a
the MHR and BMI. This is hardly distinguishable from the          target for future research.
findings of Usta and colleagues as they reported significantly
higher MHR values in obese versus. lean subjects when they
were studying Polycystic Ovary Syndrome (PCO) patients [11].
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