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

Workup and Treatment for Thinning Hair

The appropriate workup for thinning hair should include assessment for specific hair loss patterns, nutritional deficiencies, hormonal imbalances, and scalp conditions, followed by targeted treatment based on the diagnosis, with topical minoxidil 5% being the first-line treatment for androgenetic alopecia. 1

Initial Diagnostic Approach

Pattern Recognition

• Determine the pattern of hair loss:
  • Diffuse thinning (telogen effluvium)
  • Patterned loss (androgenetic alopecia)
  • Patchy loss (alopecia areata)
  • Scarring alopecia

Key History Elements

• Duration and progression of hair loss
• Family history of hair loss
• Recent stressors (physical or emotional)
• Medication use (chemotherapy, anticoagulants, retinoids)
• Hormonal changes (pregnancy, menopause)
• Hair care practices (tight hairstyles, chemical treatments)
• Systemic symptoms suggesting underlying disease

Physical Examination

• Scalp examination:
  • Presence of inflammation or scaling
  • Hair shaft abnormalities
  • Scarring
• Hair pull test: Gently pull 50-60 hairs to assess for excessive shedding
• Dermoscopy: Evaluate hair shaft diameter variation, follicular openings

Laboratory Evaluation

Based on clinical suspicion:

• Complete blood count
• Thyroid function tests (TSH, free T4)
• Iron studies (ferritin, iron, TIBC)
• Vitamin D level (maintain at least 30 ng/mL) 1
• Zinc level (supplement if below 70 μg/dL) 1
• Hormonal panel if androgenic features present:
  • Total and free testosterone
  • DHEAS
  • Prolactin

Treatment Based on Diagnosis

Androgenetic Alopecia

1. First-line treatment:

   • Topical minoxidil 5% twice daily (allow 6-12 months for visible results) 1, 2
   • For men: Oral finasteride 1mg daily 1
   • For women: Consider low-dose oral minoxidil 0.25mg + spironolactone 25mg daily 1

2. Adjunctive treatments:

   • Platelet-rich plasma (PRP) therapy: 3-5 sessions at 4-6 week intervals 1
   • Low-level laser therapy: 3 times weekly 1
   • Nutrafol or similar supplements (for early or mild thinning) 1

Alopecia Areata

1. Limited patchy hair loss:

   • Intralesional corticosteroid injections (triamcinolone acetonide 5-10 mg/mL) monthly until response 3, 1
   • Topical high-potency corticosteroids under occlusion 3

2. Extensive hair loss:

   • Consider oral corticosteroids in tapering course 1
   • Referral to dermatology for advanced therapies 1

Telogen Effluvium

• Identify and address underlying cause (stress, nutritional deficiency, medication)
• Typically self-limiting within 6 months once trigger is removed 4
• Supportive care and reassurance

Monitoring Treatment Response

• Baseline photos before starting treatment
• Follow-up photos at 3,6, and 12 months 1
• Initial assessment at 3 months
• Critical evaluation point at 6 months (significant improvement should be visible) 1
• Comprehensive evaluation at 12 months to determine continuation or modification of treatment 1

Hair Care Recommendations

• Use sulfate-free shampoos and conditioners with hydrating ingredients 1
• Minimize heat styling and use thermal protectants 1
• Protect hair from environmental factors with UV protection 1
• Avoid tight hairstyles that can cause traction alopecia 4

Important Caveats

• Temporary increased shedding may occur during the first 2 weeks of minoxidil treatment 2
• Treatment must be continued indefinitely to maintain results 2
• Women should use 2% minoxidil rather than 5% to minimize risk of unwanted facial hair growth 2
• Psychological impact of hair loss should be addressed, as it can cause significant emotional distress 4
• Referral to dermatology is appropriate for diagnostically challenging cases or those not responding to initial therapy 5