What is the appropriate workup and treatment plan for a patient presenting with hair loss?

Hair Fall Workup

Begin with a focused history targeting pattern, duration, triggers, and family history, followed by scalp examination to classify the alopecia as diffuse, patterned, focal, or scarring—this classification drives all subsequent diagnostic and treatment decisions 1, 2.

Clinical History: Key Elements

Obtain these specific details:

• Pattern and distribution: Diffuse thinning vs. focal patches vs. patterned (frontal/vertex in men, central widening in women)
• Timeline: Acute (weeks) suggests telogen effluvium; gradual (years) suggests androgenetic alopecia
• Triggers: Recent stressors, surgery, childbirth, weight loss, new medications, or illness within 3-6 months
• Associated symptoms: Scalp pruritus, scaling, or pain (suggests inflammatory/infectious causes)
• Family history: Androgenetic alopecia is typically genetic
• Styling practices: Tight hairstyles, chemical treatments, heat styling (traction alopecia)
• Systemic symptoms: Fatigue, weight changes, cold intolerance (thyroid), irregular menses (hormonal) 1, 2

Physical Examination: Systematic Approach

Scalp inspection determines the diagnostic pathway:

• Hair pull test: Gently pull 40-60 hairs; >6 hairs suggests active shedding (telogen effluvium)
• Scalp examination: Look for erythema, scaling, follicular plugging, or scarring
• Pattern recognition:
  • Diffuse thinning = telogen/anagen effluvium
  • Patterned (male: frontal/vertex; female: central widening) = androgenetic alopecia
  • Focal patches with smooth scalp = alopecia areata
  • Focal with scaling/inflammation = tinea capitis or scarring alopecia
  • Marginal/temporal thinning = traction alopecia 1, 3

Laboratory Workup: Targeted Testing

Order these baseline tests for most patients with unexplained hair loss:

• Thyroid-stimulating hormone (TSH): Screens for hypo/hyperthyroidism
• Complete blood count (CBC): Detects anemia
• Ferritin: Iron deficiency is common, especially in premenopausal women (target >40-70 ng/mL for optimal hair growth)
• Consider adding (based on clinical suspicion):
  • Vitamin D, zinc (nutritional deficiencies)
  • Testosterone, DHEA-S (women with hirsutism or irregular menses)
  • ANA, RPR (if scarring alopecia suspected)
  • Fungal culture/KOH prep (if tinea capitis suspected) 1, 4, 3

Scalp biopsy is reserved for:

• Uncertain diagnosis after history/exam
• Suspected scarring alopecia (requires two 4-mm punch biopsies: one for horizontal sectioning, one for vertical) 4, 3

Treatment Algorithm by Diagnosis

Androgenetic Alopecia (Most Common)

First-line treatment is topical minoxidil: 5% foam once daily for women, 5% solution/foam twice daily for men 5, 1, 6.

• For men: Add oral finasteride 1 mg daily (FDA-approved, more effective than minoxidil alone) 1
• Low-dose oral minoxidil (LDOM) is emerging as an alternative:
  • Starting dose: 0.625-1.25 mg daily for women; 2.5-5 mg daily for men
  • Titrate based on response and tolerability
  • Baseline evaluation: Blood pressure, heart rate, ECG if cardiac history, renal/hepatic function
  • Monitoring: BP/HR at 1-3 months, then every 6-12 months
  • Contraindications: Pheochromocytoma, severe renal impairment, recent MI
  • Common side effect: Hypertrichosis (facial/body hair growth) 5, 7

Telogen Effluvium (Diffuse Shedding)

• Identify and eliminate trigger (stress, medication, nutritional deficiency, illness)
• Correct deficiencies: Iron supplementation if ferritin <40-70 ng/mL, thyroid replacement if hypothyroid
• Reassurance: Self-limited, regrowth typically occurs within 6-12 months after trigger removal
• Consider adjunctive minoxidil to accelerate regrowth 1, 3

Alopecia Areata (Focal Patches)

• Mild-moderate (<50% scalp involvement):

  • Intralesional triamcinolone 5-10 mg/mL every 4-6 weeks (first-line)
  • Topical/oral minoxidil as adjunct
  • Observation is reasonable given potential for spontaneous regrowth 8

• Severe (≥50% scalp involvement):

  • FDA-approved JAK inhibitors: Baricitinib, ritlecitinib, or deuruxolitinib
  • Selection based on age, comorbidities, insurance coverage
  • Alternative: Topical immunotherapy (diphencyprone), systemic immunosuppressants 8

Tinea Capitis

• Oral antifungals required (topicals insufficient):
  • Griseofulvin or terbinafine for 6-12 weeks
  • Confirm with KOH prep or fungal culture 1, 3

Traction Alopecia

• Eliminate tension: Avoid tight hairstyles, braids, extensions, chemical treatments
• Topical minoxidil may help if caught early (before scarring develops) 1

Follow-Up Protocol

Schedule visits at 3,6, and 12 months with standardized photography (same lighting, angles) to objectively assess response 9. This approach achieves >90% patient adherence and maintains treatment motivation.

Critical Pitfalls to Avoid

• Don't overlook nutritional deficiencies: Ferritin <40-70 ng/mL impairs hair growth even if not anemic
• Don't delay treatment for androgenetic alopecia: Earlier intervention preserves more follicles
• Don't prescribe finasteride to women of childbearing potential: Teratogenic risk
• Don't miss scarring alopecia: Permanent follicle destruction if untreated; requires biopsy and aggressive immunosuppression
• Don't forget psychosocial impact: Hair loss significantly affects quality of life, anxiety, and depression—acknowledge patient distress and set realistic expectations 1, 4