What is the appropriate workup and management for a patient presenting with weight gain, hypertension, and alopecia?

Workup for Weight Gain, Hypertension, and Hair Loss

This triad of symptoms warrants immediate evaluation for secondary causes of hypertension, particularly Cushing syndrome and hyperaldosteronism, followed by cardiovascular risk stratification and targeted hair loss assessment.

Initial Diagnostic Priorities

Blood Pressure Confirmation and Classification

• Confirm hypertension diagnosis with out-of-office measurements (ABPM or HBPM) if screening BP is 140-159/90-99 mmHg 1
• If screening BP ≥160/100 mmHg, confirm within 1 month and exclude hypertensive emergency if ≥180/110 mmHg 1
• Measure BP in both arms; use the higher reading for diagnosis 1

Mandatory Baseline Laboratory Workup

The following tests are essential to identify secondary hypertension and assess end-organ damage:

• Serum creatinine, eGFR, and urine albumin-to-creatinine ratio (UACR) to evaluate renal function 1
• Fasting glucose or 2-hour glucose tolerance test to screen for diabetes/insulin resistance 2
• TSH to exclude thyroid disease as a cause of both hypertension and hair loss 2, 3
• Serum aldosterone and plasma renin activity (morning, upright position) given the association between elevated aldosterone, hypertension, and androgenetic alopecia 4
• Lipid profile (total cholesterol, HDL, LDL, VLDL, triglycerides) for cardiovascular risk assessment 5, 6
• Serum homocysteine and lipoprotein-a as emerging cardiovascular risk markers, particularly relevant in androgenetic alopecia 5

Additional Testing Based on Clinical Suspicion

• 24-hour urinary free cortisol or late-night salivary cortisol if Cushing syndrome is suspected (central obesity, striae, proximal muscle weakness, easy bruising) 1
• Prolactin if hyperprolactinemia suspected 2
• Vitamin D, zinc, and folate levels if diffuse hair loss pattern suggests telogen effluvium 3

Cardiovascular Assessment

• 12-lead ECG is mandatory for all hypertensive patients to detect left ventricular hypertrophy (LVH) and conduction abnormalities 1
• Echocardiography if ECG shows abnormalities or if LVH is suspected 1
• Calculate 10-year cardiovascular risk using SCORE2 (age 40-69) or SCORE2-OP (age ≥70) if not already at increased risk 1

Hair Loss Characterization

Clinical Examination of Scalp

• Determine if hair loss is scarring or non-scarring through direct scalp examination, as this fundamentally directs all subsequent decisions 2
• Look for exclamation mark hairs (short broken hairs with tapered bases) indicating active alopecia areata 2
• Assess for incomplete patches with firmly anchored broken hairs suggesting trichotillomania 2
• Check for scalp inflammation or scaling raising concern for tinea capitis or scarring alopecia 2

Pattern Recognition

For men with androgenetic alopecia (male pattern baldness):

• Grade severity using Hamilton-Norwood scale 5, 6
• Early-onset AGA (age <40 years, grade ≥III) significantly increases cardiovascular risk and warrants aggressive risk factor modification 5, 6
• Men with early-onset AGA show higher prevalence of metabolic syndrome components: abdominal obesity (measure waist circumference), hypertension, and low HDL 6

Targeted Hair Loss Investigations

• Fungal culture only if tinea capitis suspected (scalp inflammation/scaling) 1, 3
• Skin biopsy only if diagnosis uncertain after clinical examination 1, 3
• Do not order extensive autoimmune panels routinely for alopecia areata, as the increased frequency of autoimmune disease is insufficient to justify routine screening 1

Critical Clinical Correlations

The Aldosterone-Hypertension-Alopecia Connection

Patients with androgenetic alopecia demonstrate significantly elevated aldosterone levels (197.35 vs. 133.71 pg/mL in controls, P=0.007) and higher systolic blood pressure (136.23 vs. 124.10 mmHg, P=0.01) 4. This mechanistic link explains why:

• Blood pressure screening is particularly important in AGA patients 4
• Aldosterone antagonists or ACE inhibitors/ARBs may provide dual benefits 1, 7

Cardiovascular Risk Stratification in AGA

Men with early-onset androgenetic alopecia (grade II or higher, age 25-40) show significantly elevated cardiovascular risk factors compared to controls 5:

• Higher LDL, VLDL, triglycerides, homocysteine, and lipoprotein-a 5
• Lower HDL 5, 6
• Risk factors increase progressively with advancing AGA grade 5

Management Framework

Hypertension Treatment Priorities

In patients with both hypertension and hair loss, prioritize ACE inhibitors or ARBs as first-line therapy 1, 7:

• These agents provide RAAS blockade beneficial for LVH regression 1
• ACE inhibitors/ARBs reduce sudden cardiac death independent of BP reduction 1
• Lisinopril is FDA-approved for hypertension and reduces cardiovascular mortality 7

However, recognize that lisinopril's cardiometabolic benefits may be attenuated in men with early-onset androgenetic alopecia 8. In a pilot study, lisinopril (10-40 mg daily) showed weaker effects on UACR, hsCRP, fibrinogen, uric acid, and homocysteine in hypertensive men with early-onset AGA compared to those without 8.

Lifestyle Modifications (Essential for Both Conditions)

• Restrict sodium to approximately 2 g/day (5 g salt/day) 1
• Target stable BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1
• Moderate-intensity aerobic exercise ≥150 min/week plus resistance training 2-3 times/week 1
• Adopt Mediterranean or DASH diet 1
• Limit alcohol to <100 g/week of pure alcohol; preferably avoid completely 1
• Stop tobacco smoking with referral to cessation programs 1

Hair Loss Management Considerations

• Counseling is the essential first step before considering any treatment for alopecia areata, as no therapy alters long-term disease course 2
• For limited patchy alopecia areata: intralesional corticosteroids (triamcinolone acetonide 5-10 mg/mL) 1, 3
• For extensive alopecia areata: contact immunotherapy is best-documented but only 50-60% achieve worthwhile response 1
• "No treatment" is legitimate for many patients given 80% spontaneous remission within 1 year for limited patchy disease 2, 3

Common Pitfalls to Avoid

• Do not dismiss hair loss as purely cosmetic—it signals increased cardiovascular risk, particularly early-onset male pattern baldness in young men 5, 6
• Do not order extensive laboratory panels when clinical diagnosis is evident, as this wastes resources and delays appropriate management 2
• Do not overlook secondary hypertension screening when the triad of weight gain, hypertension, and hair loss is present—consider Cushing syndrome and hyperaldosteronism 1, 4
• Do not use beta-blockers as first-line in hypertensive patients with LVH, as they are inferior to other classes for LV mass reduction 1
• Do not promise cure for alopecia areata—no treatment alters long-term disease course, only induces temporary regrowth 2
• Do not confuse trichotillomania with alopecia areata: broken hairs in trichotillomania remain firmly anchored in anagen phase, unlike exclamation mark hairs 2