What are the causes and treatments of sudden hair loss in females?

Causes of Sudden Hair Fall in Females

The most common causes of sudden hair loss in females are telogen effluvium, androgenetic alopecia, alopecia areata, nutritional deficiencies, and thyroid disorders, with telogen effluvium being the most frequent cause of acute diffuse shedding. 1, 2

Common Causes of Sudden Hair Loss

1. Telogen Effluvium

• Characterized by diffuse hair shedding 2-3 months after a triggering event
• Common triggers:
  • Physiological or emotional stress
  • Childbirth
  • Major surgery
  • Severe illness or infection
  • Rapid weight loss
  • Medication changes
  • Nutritional deficiencies
• Usually self-limited once the precipitating cause is removed 1, 3

2. Androgenetic Alopecia (Female Pattern Hair Loss)

• Most common cause of chronic hair loss in women 4
• Characterized by:
  • Gradual thinning at the part line
  • Widening of the central part
  • Preservation of the frontal hairline
• Associated with increased risk of cardiovascular and metabolic disease 4
• Treatment: FDA-approved topical minoxidil 5% (high strength of evidence) 1

3. Alopecia Areata

• Presents as well-defined patches of complete hair loss
• Characteristic "exclamation mark" hairs at the periphery of patches
• May progress to total scalp hair loss (alopecia totalis) or complete body hair loss (alopecia universalis)
• Spontaneous remission occurs in up to 80% of patients with limited patchy hair loss of short duration 5
• Treatment: intralesional corticosteroids for limited patches (strength of recommendation B) 5, 1

4. Nutritional and Hormonal Factors

• Iron deficiency (low ferritin)
• Thyroid disorders (hypothyroidism or hyperthyroidism)
• Vitamin D deficiency
• Hormonal changes (pregnancy, menopause, PCOS)
• Laboratory testing recommended: CBC, ferritin, thyroid stimulating hormone, vitamin D levels 1

5. Other Causes

• Trichotillomania (compulsive hair pulling)
• Tinea capitis (fungal infection)
• Frontal fibrosing alopecia (scarring alopecia affecting hairline)
• Traction alopecia (from tight hairstyles)
• Anagen effluvium (from chemotherapy or toxins)
• Systemic diseases (lupus erythematosus, syphilis) 5, 1, 3

Diagnostic Approach

1. Hair Pull Test: Positive if more than 6 hairs extracted, indicating active shedding 1

2. Dermoscopy: Non-invasive tool to reveal specific features:

   • Yellow dots
   • Black dots
   • Exclamation mark hairs (alopecia areata)
   • Hair shaft diameter variation 1

3. Laboratory Testing:

   • Complete blood count
   • Ferritin levels
   • Thyroid stimulating hormone
   • Vitamin D levels
   • Additional tests based on clinical presentation 1

4. Scalp Biopsy: Necessary when physical examination findings are inconclusive or suggest scarring alopecia 1

Treatment Recommendations

For Telogen Effluvium:

• Identify and address underlying cause
• Reassurance about self-limited nature (typically resolves within 6-12 months after trigger removal)
• Nutritional support if deficiencies identified 1, 3

For Androgenetic Alopecia:

• Topical minoxidil 5% (first-line treatment, FDA-approved) 1, 2
• Consider oral minoxidil in selected cases 1

For Alopecia Areata:

• Limited patches: Intralesional corticosteroid injections 5, 1, 6
• Extensive disease: Consider systemic treatments (corticosteroids, methotrexate, cyclosporine) 6
• Topical corticosteroids (limited evidence of efficacy) 5

For Nutritional Deficiencies:

• Iron supplementation if ferritin is low
• Vitamin D supplementation if deficient
• Thyroid hormone replacement if hypothyroid 1

Important Caveats and Pitfalls

• Misdiagnosis: Several conditions can mimic each other; accurate diagnosis is crucial for appropriate treatment 5
• Psychological Impact: Hair loss can be devastating to women and may require psychological support 7, 2
• Treatment Expectations: Many treatments induce hair growth but may not alter the underlying disease course 5
• Spontaneous Remission: High rate of spontaneous remission in some conditions (like limited alopecia areata) makes treatment efficacy assessment difficult 5
• Chronic Disease: Prognosis is poorer for extensive or long-standing hair loss 5
• Follow-up: Regular monitoring is essential to assess treatment response and adjust management 1

Treatment Outcomes

• Telogen effluvium: Generally good prognosis with removal of trigger
• Alopecia areata: Recovery rates vary by severity (68% for <25% hair loss, only 8% for >50% hair loss) 1
• Androgenetic alopecia: Requires ongoing treatment to maintain results
• Documentation with photographs and hair density measurements helps track progress 1