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

Hair Loss Workup and Treatment

The recommended workup for hair loss should include a thorough clinical examination to determine the type of alopecia (scarring vs. non-scarring), pattern of hair loss, and laboratory testing based on suspected underlying causes, followed by targeted treatment specific to the diagnosis.

Initial Assessment

Clinical Examination

• Hair and scalp examination:
  • Pattern of hair loss (diffuse, patchy, or patterned)
  • Presence of inflammation, scaling, or scarring
  • Presence of "exclamation mark" hairs (in alopecia areata)
  • Hair shaft abnormalities
  • Signs of scalp infection

Key Diagnostic Features

• Non-scarring alopecias:

  • Androgenetic alopecia: Gradual thinning at vertex/crown in men, diffuse thinning over mid-frontal scalp in women
  • Alopecia areata: Well-defined round/oval patches of hair loss
  • Telogen effluvium: Diffuse shedding 2-3 months after triggering event
  • Anagen effluvium: Rapid hair loss after chemotherapy or toxic exposure

• Scarring alopecias:

  • Permanent follicular destruction with inflammation
  • Requires prompt dermatology referral for biopsy

Laboratory Investigations

Based on clinical suspicion, consider:

1. Complete blood count: To evaluate for anemia, infection
2. Ferritin and iron studies: Iron deficiency is associated with hair loss
3. Thyroid function tests: Hypothyroidism can cause hair loss
4. Vitamin D levels: Deficiency linked to alopecia
5. Zinc levels: Deficiency associated with hair loss
6. Hormonal panel: For suspected hormonal causes (DHEAS, testosterone, SHBG)
7. Fungal culture: If tinea capitis is suspected
8. Scalp biopsy: For scarring alopecia or unclear diagnosis

Treatment by Type of Hair Loss

Androgenetic Alopecia

1. First-line treatment:

   • Men: Topical minoxidil 5% twice daily 1, 2
   • Women: Topical minoxidil 2-5% twice daily 1

2. Second-line options:

   • Men: Oral finasteride 1mg daily 1
   • Women: Consider spironolactone or cyproterone acetate 3

3. Combination therapies:

   • Minoxidil + finasteride shows higher efficacy (81% improvement vs. 41% with minoxidil alone) 1
   • Platelet-rich plasma (PRP) + minoxidil for enhanced results 1

Alopecia Areata

1. Limited patchy hair loss:

   • Intralesional corticosteroids (triamcinolone acetonide 5-10 mg/mL) 4
   • Monthly injections until response (62% achieve full regrowth with <5 patches) 4

2. Extensive patchy hair loss or alopecia totalis/universalis:

   • Contact immunotherapy (DPCP) is the best-documented treatment 4
   • Response rates <50% for extensive patchy hair loss, lower for alopecia totalis/universalis 4

3. No treatment is a legitimate option, as spontaneous remission occurs in up to 80% of patients with limited patchy hair loss of short duration (<1 year) 4

Telogen Effluvium

• Identify and remove the triggering factor (stress, medications, nutritional deficiencies)
• Reassurance about self-limited nature (typically resolves within 6-12 months)
• Treat underlying causes (iron supplementation for deficiency, etc.)

Tinea Capitis

• Oral antifungal therapy (not topical) based on fungal culture results
• Adjunctive antifungal shampoo

Follow-up and Monitoring

• Baseline photos before starting treatment 1
• Initial assessment at 3 months 1
• Critical evaluation at 6 months 1
• Comprehensive assessment at 12 months to determine continuation 1

Important Considerations

• Set realistic expectations: Maintenance of existing hair and modest regrowth is a successful outcome; complete hair restoration is unlikely 1
• Treatment duration: Visible improvement typically begins at 2-4 months, with optimal results at 6-12 months 1, 2
• Contraindications: Minoxidil and finasteride should be avoided during pregnancy and breastfeeding 1, 2
• Side effects: Minoxidil may cause scalp irritation; finasteride may cause sexual dysfunction in men 1, 2

Supportive Measures

• Hair care practices: Use sulfate-free shampoos, limit heat styling, protect from environmental damage 1
• Nutritional support: Address deficiencies in iron, zinc, vitamin D 1, 5
• Psychological support: Hair loss can significantly impact quality of life and mental health 6, 7
• Wigs and hairpieces: For extensive hair loss, especially in women 4

By following this structured approach to diagnosis and treatment, most cases of hair loss can be effectively managed with significant improvement in patient outcomes and quality of life.