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

Hair Loss Workup and Treatment

The appropriate workup for hair loss should begin with a detailed clinical assessment to determine the specific type of alopecia, followed by targeted investigations and treatment based on the diagnosis. 1

Initial Clinical Assessment

• Document onset, duration, and progression of hair loss to distinguish between acute and chronic conditions 1
• Inquire about family history, which is present in approximately 20% of alopecia areata cases 1, 2
• Review medication use that could cause anagen effluvium (drug-induced hair loss) 1
• Ask about hair care practices that might cause traction alopecia 1
• Document any systemic symptoms that might suggest autoimmune disease 1

Physical Examination

• Examine the scalp for:
  • Redness or inflammation suggesting inflammatory conditions 1
  • Scaling, which may suggest tinea capitis 2
  • Short broken hairs (exclamation mark hairs) indicating alopecia areata 2
  • Pattern of hair loss (diffuse, patchy, or patterned) 3
• Assess for lymphadenopathy, particularly occipital and cervical nodes 1
• Examine nails, which are involved in about 10% of alopecia areata patients 1

Diagnostic Tools

• Dermoscopy can confirm diagnosis by showing characteristic patterns:
  • Yellow dots, exclamation mark hairs, and cadaverized hairs in alopecia areata 2
  • Regular round yellow dots commonly seen in areas of hair loss indicate active disease progression 2
• Pull test to assess active shedding 4

Laboratory Investigations

• No routine investigations are required for typical presentations of alopecia areata 2, 1
• When diagnosis is uncertain, consider:
  • Complete blood count, ferritin, thyroid stimulating hormone, and vitamin D levels 4
  • Fungal culture if tinea capitis is suspected 2
  • Skin biopsy in cases of suspected scarring alopecia or unclear diagnosis 2
  • Serology for lupus erythematosus or syphilis if clinically indicated 2

Differential Diagnosis

• Distinguish between:
  • Trichotillomania - broken hairs remain firmly anchored in scalp 2
  • Tinea capitis - scalp is inflamed but signs may be subtle 2
  • Telogen effluvium - diffuse shedding often following a trigger 2
  • Androgenetic alopecia - patterned hair loss 3
  • Scarring alopecias - permanent follicular destruction 2

Treatment Approaches

Alopecia Areata

• For limited patchy hair loss:

  • 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) 2
  • Intralesional corticosteroids for localized patches - triamcinolone acetonide (5-10 mg/mL) injected just beneath the dermis 2
  • Potent topical corticosteroids, though evidence for effectiveness is limited 2

• For extensive hair loss (alopecia totalis/universalis):

  • Contact immunotherapy (e.g., DPCP) is the best-documented treatment but has <50% response rate 2
  • Wigs or hairpieces for cosmetic coverage 2

Androgenetic Alopecia

• Topical minoxidil 5% solution applied twice daily (morning and night) 5
  • Results may be seen as early as 2 months, but some may need at least 4 months of treatment 5
  • Hair regrowth has not been shown to last longer than 48 weeks in large clinical trials with continuous treatment 5
  • Must be used continuously to maintain results 5

Other Forms of Hair Loss

• Telogen effluvium: Address underlying cause (stress, nutritional deficiency, medication) 3
• Traction alopecia: Decrease tension on hair 3
• Tinea capitis: Oral antifungal therapy 3

Common Pitfalls to Avoid

• Misdiagnosing diffuse alopecia areata as telogen effluvium 1
• Overlooking tinea capitis with subtle inflammation 1
• Failing to recognize trichotillomania 1
• Conducting unnecessary laboratory testing for typical presentations of alopecia areata 1
• Using hazardous treatments with unproven efficacy, particularly when the condition has no direct impact on general health 2

Psychological Support

• Acknowledge the significant psychological impact of hair loss on patients 2
• Consider referral for psychological support if the patient is profoundly upset by their alopecia 2
• Provide information about patient support organizations 2