What is the initial workup and treatment approach for female hair loss?

Initial Workup and Treatment Approach for Female Hair Loss

The initial workup for female hair loss should include a complete blood count, serum ferritin, thyroid function tests, and assessment of androgen levels, followed by first-line treatment with topical minoxidil 5% for female pattern hair loss. 1, 2

Diagnostic Approach

Initial Assessment

• Thorough history focusing on:
  • Duration and progression of hair loss
  • Pattern of hair loss (diffuse, patterned, or focal)
  • Family history of hair loss
  • Recent stressors, illnesses, or surgeries
  • Medication use
  • Hormonal changes (pregnancy, menopause)
  • Hair care practices (tight hairstyles, chemical treatments)

Physical Examination

• Evaluate scalp for:
  • Pattern of hair loss (frontal/parietal thinning vs. patchy)
  • Presence of scarring
  • Scalp inflammation or scaling
  • Hair shaft abnormalities
• Document with standardized photographs for baseline comparison 1

Laboratory Testing

• Essential initial tests:

  • Complete blood count
  • Serum ferritin (target >70 μg/dL for optimal hair growth) 1
  • Thyroid function tests (TSH, free T4)
  • Vitamin D levels (maintain >30 ng/mL) 1
  • Zinc levels (if suspected deficiency) 1

• Additional tests for suspected hyperandrogenism:

  • Total and free testosterone
  • DHEAS (dehydroepiandrosterone sulfate)
  • Androstenedione
  • Prolactin
  • Sex hormone-binding globulin 2

Specialized Diagnostic Tools

• Dermoscopy: To evaluate hair shaft diameter variation, perifollicular inflammation
• Hair pull test: To assess active shedding
• Scalp biopsy: When diagnosis is unclear or scarring alopecia is suspected 3

Treatment Approach Based on Diagnosis

Female Pattern Hair Loss (Androgenetic Alopecia)

1. First-line treatment:

   • Topical minoxidil 5% twice daily 1, 2
   • Allow 6-12 months for visible results
   • Continue indefinitely to maintain results

2. Second-line treatments:

   • For women with hyperandrogenism:
     • Spironolactone 25-200 mg daily
     • Low-dose oral minoxidil 0.25 mg with spironolactone 25 mg daily 1
   • Consider finasteride 2.5 mg daily for postmenopausal women 4

3. Adjunctive therapies:

   • Low-level laser therapy (3 times weekly) 1
   • Platelet-rich plasma therapy (3 monthly sessions initially, then maintenance every 6 months) 1
   • Nutritional supplements if deficiencies are identified 1, 5

Telogen Effluvium

• Identify and address underlying trigger:
  • Stress management
  • Nutritional optimization
  • Medication adjustment if drug-induced
• Reassurance about self-limited nature (typically resolves within 6-12 months) 6
• Consider topical minoxidil to expedite recovery

Alopecia Areata

• For limited patchy loss:
  • Intralesional corticosteroid injections (triamcinolone acetonide 5-10 mg/mL) 7
  • Monthly injections until response
• For extensive involvement:
  • Consider oral corticosteroids in tapering course 7
  • Referral to dermatology for advanced therapies

Follow-up and Monitoring

• Evaluate treatment response at 3,6, and 12 months with standardized photographs 1
• Adjust treatment if minimal improvement after 6 months
• Continue successful treatments indefinitely for maintenance

Common Pitfalls to Avoid

1. Delayed diagnosis: Female pattern hair loss is often dismissed as normal aging
2. Inadequate laboratory evaluation: Missing treatable causes like iron deficiency or thyroid disorders
3. Unrealistic expectations: Patients should understand that treatments prevent progression rather than restore all lost hair
4. Premature discontinuation: Treatments require 6-12 months for visible results and must be continued for maintenance
5. Overlooking psychological impact: Hair loss significantly affects quality of life and may require psychological support 6

Remember that female hair loss is often multifactorial, and addressing all contributing factors (hormonal, nutritional, and environmental) provides the best outcomes. Early intervention is crucial as treatments are more effective at preventing progression than stimulating regrowth of miniaturized follicles 2.