What are the initial management steps for hair shedding?

Initial Management of Hair Shedding

For patients presenting with hair shedding, the initial management should include a comprehensive diagnostic workup followed by targeted treatment based on the identified cause, with correction of nutritional deficiencies being a primary intervention for many cases of telogen effluvium. 1, 2

Diagnostic Assessment

Essential Initial Evaluation

• Detailed history:

  • Timing and pattern of hair loss
  • Recent triggering events (childbirth, surgery, high fever, stress)
  • Medications
  • Nutritional status
  • Family history of hair loss

• Physical examination:

  • Pull test (to assess fragility and active shedding)
  • Trichoscopy (examination of scalp and hair follicles)
  • Hair count (measuring number of hairs in specific areas)

• Laboratory testing:

  • Complete blood count
  • Serum ferritin (iron stores)
  • Thyroid function (T3, T4, TSH)
  • Vitamin D levels
  • Zinc levels 1, 3

Initial Management Based on Diagnosis

Telogen Effluvium (Most Common Cause)

1. Identify and correct triggering factors:

   • Nutritional deficiencies (particularly iron deficiency)
   • Thyroid disorders
   • Stress
   • Postpartum hormonal changes
   • Medications

2. Nutritional correction:

   • Iron supplementation if ferritin is low (major cause in women)
   • L-lysine supplementation (essential amino acid often deficient) 2
   • Correction of other identified deficiencies (vitamin D, zinc)

3. Patient education and reassurance:

   • Explain that telogen effluvium is self-limiting (typically resolves in 3-6 months if trigger is removed)
   • Clarify that it represents excessive shedding, not permanent hair loss
   • Set realistic expectations about recovery timeline 4, 3

Female Pattern Hair Loss

1. Topical minoxidil:

   • 2-5% solution twice daily as first-line treatment 1, 3

2. Consider antiandrogen therapy:

   • If hyperandrogenism is present
   • After correction of nutritional deficiencies 1

Alopecia Areata (Patchy Hair Loss)

1. Limited patches:

   • Intralesional corticosteroid injections (triamcinolone acetonide) - 62% success rate
   • Topical corticosteroids if injections not tolerated 1

2. Extensive patches:

   • Contact immunotherapy with diphenylcyclopropenone (DPCP) - 50-60% response rate
   • Topical minoxidil 5% (limited efficacy, 32-33% response) 1

Special Considerations

Chronic Telogen Effluvium

• Distinguished from acute telogen effluvium by duration (>6 months)
• May require scalp biopsy to differentiate from female pattern hair loss
• Management includes ongoing nutritional support and reassurance
• May take 3-10 years for spontaneous resolution 3

Psychological Support

• Assess for psychological impact as hair loss can cause significant emotional distress
• Consider referral to support groups
• Discuss cosmetic options (wigs, hairpieces, hair cosmetics) while awaiting regrowth 1

Documentation and Follow-up

• Take baseline photographs for comparison
• Schedule follow-up visits to assess response to treatment
• Consider quality of life measures to track improvement 1

Common Pitfalls to Avoid

1. Misdiagnosis: Failing to differentiate between telogen effluvium, female pattern hair loss, and chronic telogen effluvium
2. Incomplete workup: Not checking iron stores and thyroid function in all cases of diffuse hair loss
3. Unrealistic expectations: Not preparing patients for the time required for hair regrowth
4. Overlooking nutritional factors: Iron deficiency is a major cause of hair shedding in women before age 50 2
5. Neglecting psychological impact: Hair loss can be devastating and requires appropriate support 5

Remember that while many cases of hair shedding are self-limiting, identifying and addressing the underlying cause is crucial for effective management and preventing chronic hair loss.