What are the treatment options for excessive hair loss?

Treatment of Excessive Hair Loss

The treatment approach depends critically on identifying the specific type of hair loss: for androgenetic alopecia (pattern baldness), topical minoxidil is first-line therapy; for limited patchy alopecia areata, intralesional corticosteroids are recommended; and for extensive alopecia areata, contact immunotherapy should be considered. 1, 2

Initial Diagnostic Classification

Before initiating treatment, determine which category of hair loss is present:

• Androgenetic alopecia (pattern baldness): Progressive thinning at the crown/vertex in men or diffuse mid-frontal thinning in women, typically with family history 3, 4
• Alopecia areata: Well-demarcated round patches of complete hair loss, often with "exclamation point" hairs at margins 5
• Telogen effluvium: Diffuse shedding of "handfuls" of hair 2-3 months after a triggering event (stress, illness, medication) 3, 6
• Tinea capitis: Patchy hair loss with erythema, scaling, or broken hairs requiring fungal culture 3, 6

Treatment Algorithm by Diagnosis

Androgenetic Alopecia (Most Common)

For men:

• Topical minoxidil 5% applied twice daily directly to the scalp is FDA-approved first-line treatment 2
• Results typically appear at 2-4 months; treatment must continue indefinitely to maintain regrowth 2
• Initial increased shedding for up to 2 weeks is expected and indicates the medication is working 2
• Oral finasteride is an additional option for men (not for women of childbearing potential) 3, 7

For women:

• Topical minoxidil (2% or 5% formulation for women) is the FDA-approved treatment 8, 4
• Women should NOT use the 5% men's formulation due to risk of facial hair growth 2
• Antiandrogens (spironolactone, cyproterone acetate) can be considered as adjunctive therapy 4

Critical caveat: Minoxidil only works while being used; hair loss resumes 3-4 months after discontinuation 2, 7

Alopecia Areata

For limited patchy disease (few small patches):

• Intralesional corticosteroid injections (triamcinolone acetonide) monthly achieve 62% full regrowth and represent first-line therapy 5, 1
• Each injection produces approximately 0.5 cm diameter of regrowth 5
• Skin atrophy at injection sites is a consistent side effect 5

For extensive patchy disease (>50% scalp involvement):

• Contact immunotherapy with diphenylcyclopropenone (DPCP) or squaric acid dibutylester (SADBE) is recommended, though it achieves cosmetically worthwhile regrowth in <50% of patients 5, 1
• Requires weekly hospital visits for months with careful concentration titration 5
• Response may take 6-32 months; treatment beyond 6 months is worthwhile as response rates improve with time 5

For alopecia totalis/universalis (complete scalp or body hair loss):

• Contact immunotherapy is the only potentially effective treatment, though response rates are very low (approximately 17%) 5
• Wigs or hairpieces are often the most practical solution for extensive disease 5

Important limitation: No treatment alters the long-term course of alopecia areata; relapse occurs in 62% even after successful treatment 5, 1

Telogen Effluvium

• Identify and remove the triggering cause (medication, nutritional deficiency, thyroid disorder, recent stress/illness) 3, 6
• Hair typically regrows spontaneously within 6 months once the trigger is resolved 6, 7
• Check ferritin, thyroid function (TSH, free T4), vitamin D, and zinc if cause is unclear 5
• No specific hair treatment is required; reassurance is key 8, 6

Tinea Capitis

• Requires systemic oral antifungal therapy (griseofulvin or terbinafine); topical treatments are insufficient 3, 6
• Obtain fungal culture before initiating treatment 6

Special Populations

Children:

• Intralesional corticosteroids are often poorly tolerated due to pain 5, 1
• Many clinicians avoid aggressive treatments like contact immunotherapy in pediatric patients 5, 1
• Tinea capitis is more common in children and must be ruled out 3

Women of childbearing potential:

• Avoid finasteride and high-dose minoxidil formulations 2, 8
• Screen for iron deficiency, thyroid disease, and hormonal abnormalities 5, 8

Treatments to Avoid

Insufficient evidence or unacceptable risk:

• Potent topical corticosteroids for alopecia areata (widely prescribed but no convincing efficacy evidence) 5
• Systemic corticosteroids (continuous or pulsed) for alopecia areata due to serious side effects without proven efficacy 5
• PUVA therapy for alopecia areata (potentially serious side effects, inadequate efficacy data) 5

Psychological Support

• Hair loss significantly impacts quality of life, causing anxiety, depression, and reduced work productivity in moderate to severe cases 3
• Provide realistic expectations: complete regrowth is unlikely with most treatments; the goal is stabilization and partial improvement 5, 2
• Consider referral for psychological support, particularly for adolescents and those with extensive disease 1, 3

Monitoring Response

• For androgenetic alopecia: Assess at 4 months; if no response, discontinue treatment 2
• For alopecia areata: Continue intralesional steroids for 3-6 months; contact immunotherapy may require 6-32 months for response 5, 1
• Use standardized photography and patient self-assessment to track progress 5