What is the workup and treatment for nonscarring (non-scarring) hair loss, including recommended medications?

Workup and Treatment for Nonscarring Hair Loss

For nonscarring hair loss, the most effective approach includes a targeted diagnostic workup followed by condition-specific treatments, with topical minoxidil being the first-line medication for most types.

Diagnostic Workup

History Taking

• Assess duration and pattern of hair loss (diffuse, patterned, or focal) 1
• Inquire about family history of hair loss 2
• Review medication use that may cause hair loss 2
• Evaluate for systemic illnesses, endocrine dysfunction, and nutritional status 3
• Document hair care practices that may contribute to hair loss (tight hairstyles, chemical treatments) 2

Physical Examination

• Examine all hair-bearing sites, not just the scalp 3
• Perform pull test to assess hair fragility 2
• Use trichoscopy (specialized magnifying device) to examine scalp and hair follicles for signs of thinning, miniaturization, and vellus hairs 2
• Look for distinguishing features of nonscarring alopecia: absence of scalp inflammation, preservation of follicular ostia 2

Laboratory Testing

• Check serum levels of:
  • Thyroid-stimulating hormone (TSH) 4
  • Vitamin D 4
  • Zinc 4
  • Ferritin 4, 2
• Consider additional testing based on clinical suspicion:
  • Complete blood count if anemia suspected 5
  • Antinuclear antibodies if autoimmune disease suspected 5
  • Fungal culture if tinea capitis suspected 2

Advanced Diagnostics

• 4-mm punch biopsy of the scalp when diagnosis remains unclear or to differentiate from early scarring alopecia 3
• Hair counts and hair diameter measurements for objective monitoring of treatment response 2

Treatment by Type of Nonscarring Alopecia

Androgenetic Alopecia (Pattern Hair Loss)

• First-line treatment: Topical minoxidil 5% solution applied twice daily 6, 1
  • Results may be seen as early as 2 months but may take at least 4 months 6
  • Temporary increase in hair shedding during first 2 weeks is expected 6
• For men only: Oral finasteride 1 mg daily 1, 7
  • Consider dutasteride 0.5 mg daily as an alternative with potentially higher efficacy 7
• Emerging treatment: Low-dose oral minoxidil (0.25-5 mg daily) 7
• Combination therapy: Topical minoxidil 5% plus topical finasteride 0.25% shows greater efficacy than either treatment alone 8
• Adjunctive treatment: Platelet-rich plasma (PRP) injections to stimulate hair follicle growth 2

Alopecia Areata (Focal Hair Loss)

• First-line treatment for limited patches: Intralesional corticosteroid injections 2, 1
  • Triamcinolone acetonide (5-10 mg/mL) injected into the upper subcutis 2
  • 0.05-0.1 mL per injection site at monthly intervals 2
• For extensive alopecia areata: Contact immunotherapy (e.g., diphenylcyclopropenone) 2
• For alopecia totalis/universalis: Consider wigs as a practical solution 2
• Micronutrient supplementation if deficient:
  • Vitamin D 2
  • Zinc 2
  • Folate 2

Telogen Effluvium (Diffuse Hair Loss)

• Identify and address underlying cause (stress, medications, nutritional deficiencies) 1
• Typically self-limited once the trigger is removed 1
• Supportive treatment with topical minoxidil 5% may accelerate recovery 3

Traction Alopecia

• Primary treatment: Eliminate tension on hair by changing hairstyling practices 1
• Topical minoxidil 5% to promote regrowth in affected areas 3

Tinea Capitis

• Oral antifungal therapy (specific agent based on fungal culture) 1
• Antifungal shampoo as adjunctive treatment 3

Monitoring Treatment Response

• Photography: Before-and-after photos for visual comparison 2
• Trichoscopy: To evaluate changes in hair density and diameter 2
• Hair counts: To quantify improvement in specific areas 2
• Pull test: To assess improvement in hair strength 2
• Patient self-assessment questionnaires 2

Important Considerations and Pitfalls

• Hair regrowth takes time - normal hair grows only 1/2 to 1 inch per month 6
• Treatment must be continued to maintain results, especially for androgenetic alopecia 2
• Initial increased shedding with minoxidil is temporary and should not cause discontinuation 6
• Women should not use 5% minoxidil solution as studies show it works no better than 2% solution in women 6
• Patients with severe hair loss often experience psychological distress requiring additional support 1
• Scarring alopecia may initially present as nonscarring - early biopsy is crucial when in doubt 3