What is the workup for a patient presenting with shedding hair?

Workup for Hair Shedding

The comprehensive workup for a patient presenting with shedding hair should include a detailed history, physical examination, laboratory testing, and in some cases, specialized diagnostic procedures such as trichoscopy, pull test, and scalp biopsy to determine the specific cause of hair loss.

Initial Assessment

History

• Duration and pattern of hair loss (sudden vs. gradual onset)
• Distribution of hair loss (diffuse, patchy, or localized)
• Family history of hair disorders
• Medical conditions (thyroid disease, autoimmune disorders)
• Medications (chemotherapy, anticoagulants, retinoids)
• Recent physiological or emotional stressors
• Hair care practices and styling methods
• Nutritional status and recent dietary changes

Physical Examination

• Scalp examination for signs of inflammation, scaling, or scarring
• Hair shaft examination for structural abnormalities
• Assessment of hair density and distribution
• Evaluation of other body hair
• Examination of nails for associated changes (particularly important in alopecia areata) 1
• Complete skin examination for associated dermatologic conditions

Diagnostic Tests

Non-invasive Tests

1. Pull Test: Gently tugging on a cluster of hairs to assess fragility and shedding 1
2. Trichoscopy: Using a specialized magnifying device to examine the scalp and hair follicles in detail 1
3. Hair Count: Counting the number of hairs in a specific area before and after treatment 1
4. Global Photography: Taking standardized photographs for visual comparison over time 2
5. Daily Hair Counts: Having patients count shed hairs daily 3
6. Standardized Wash Test: Collecting and counting hairs shed during washing 3

Laboratory Tests

Based on clinical suspicion:

• Complete blood count
• Ferritin and iron studies
• Thyroid function tests (TSH, free T4)
• Vitamin D levels
• Zinc levels
• Hormonal panel (testosterone, DHEAS, androstenedione) if androgenetic alopecia is suspected
• Autoimmune markers if alopecia areata is suspected

Invasive Tests

• Scalp Biopsy: Recommended when the diagnosis remains unclear after history, physical examination, and laboratory tests, or when scarring alopecia is suspected 3

Differential Diagnosis

Non-scarring Alopecias

1. Androgenetic Alopecia: Pattern hair loss, gradual thinning
2. Telogen Effluvium: Diffuse shedding often triggered by stress, illness, or medications
3. Alopecia Areata: Patchy hair loss with characteristic "exclamation mark" hairs 1
4. Anagen Effluvium: Abnormal diffuse loss during growth phase, often due to chemotherapy 4
5. Trichotillomania: Self-induced hair pulling

Scarring Alopecias

• Various inflammatory conditions leading to permanent hair loss
• Require prompt dermatology referral and biopsy

Management Approach

Management depends on the specific diagnosis:

• Androgenetic Alopecia: Topical minoxidil (5% for men, 2% for women), with results typically taking 3-6 months 5
• Alopecia Areata:
  • Limited patches: Intralesional corticosteroids (first-line) 2
  • Extensive involvement: Contact immunotherapy with agents like diphenylcyclopropenone 1, 2
• Telogen Effluvium: Address underlying cause, typically self-resolves once trigger is removed 4
• Nutritional Deficiencies: Appropriate supplementation based on laboratory findings

Special Considerations

• The psychological impact of hair loss can be significant and should be addressed 2
• Patient support groups may be beneficial 2
• For extensive hair loss, wigs or hairpieces may provide immediate cosmetic improvement 2
• Referral to dermatology is appropriate for:
  • Diagnostically challenging cases
  • Scarring alopecia
  • Hair loss unresponsive to initial therapy
  • Need for specialized treatments

Monitoring Response

• Follow-up visits to assess response to treatment
• Repeat photography to document changes
• Consideration of quality of life measures
• Adjustment of treatment based on response

Remember that early diagnosis and appropriate treatment are crucial for managing hair loss effectively and minimizing psychological distress 6.