What are the treatment options for fatigue and hair loss?

Treatment of Fatigue and Hair Loss

For fatigue, exercise is the single most effective intervention with the strongest evidence base, and should be initiated immediately alongside systematic evaluation and treatment of underlying causes; for hair loss, topical minoxidil is first-line treatment while simultaneously screening for and correcting systemic causes like iron deficiency. 1, 2, 3, 4

Initial Assessment of Fatigue

Severity Screening

• Use a 0-10 numeric rating scale at every clinical encounter, where 1-3 indicates mild fatigue, 4-6 moderate, and 7-10 severe fatigue 2, 5
• Scores ≥4 require immediate comprehensive diagnostic evaluation 2, 6, 5
• Assess functional impact on daily activities and work capacity, as identical fatigue scores can produce vastly different disability levels 1, 2, 5
• Document onset timing, pattern throughout the day, duration, and factors that worsen or improve symptoms 2

Mandatory Laboratory Testing for Moderate-to-Severe Fatigue (Score ≥4)

• Complete blood count with differential to evaluate for anemia 2, 6, 5
• Comprehensive metabolic panel to assess electrolyte disturbances and renal/hepatic function 2, 6, 5
• Thyroid function tests (TSH, free T4) to exclude hypothyroidism 2, 6, 5
• Inflammatory markers (ESR, CRP) and creatine kinase to evaluate for inflammatory/autoimmune conditions 6, 5
• Consider vitamin D, iron studies, B12, and magnesium levels even if not in initial workup 6, 5

Assessment of Contributing Factors

• Screen for depression using validated tools (two-question test minimum) and evaluate for anxiety disorders 2, 6, 5
• Assess sleep quality, duration, patterns, sleep apnea risk factors, restless leg syndrome, and sleep hygiene practices 2, 6, 5
• Review all current medications and supplements for fatigue-inducing side effects, including combinations causing excessive sedation (narcotics, antidepressants, antiemetics, antihistamines, beta-blockers) 1, 2, 6, 5
• Evaluate for alcohol or substance abuse 1

Treatment Algorithm for Fatigue

Step 1: Address Identified Underlying Causes

• Treat anemia if hemoglobin is low using iron supplementation or erythropoietin as clinically indicated 2, 6
• Initiate antidepressants (SSRIs or SNRIs) if depression is present—this is a Category 1 recommendation 2, 6
• Implement cognitive behavioral therapy for insomnia (CBT-I) if sleep disturbance is identified, as this is more effective than pharmacologic sleep aids 2, 6
• Correct electrolyte disturbances and endocrine abnormalities 6
• Adjust or discontinue fatigue-inducing medications when possible 6, 5

Step 2: Exercise (Category 1 Recommendation—First-Line Treatment)

• Prescribe moderate aerobic exercise 3-5 times weekly, starting at low intensity and gradually increasing based on tolerance 1, 2
• Begin with 10-15 minutes of walking if significantly deconditioned, gradually working toward 150 minutes/week of aerobic exercise plus 2 days/week of strength training 1, 2, 5
• Tailor exercise programs to functional status and modify based on disease progression 6, 5
• Critical caveat: Do NOT recommend exercise for patients with postexertional malaise characteristic of ME/CFS, as this will worsen their condition 6, 5
• Counsel patients that exercise will improve fatigue symptoms despite initial skepticism, as this is often difficult for fatigued patients to accept 1

Step 3: Additional Nonpharmacologic Interventions

• Cognitive behavioral therapy (CBT) delivered by trained providers shows benefit during and after treatment; web-based versions are also effective 2
• Mindfulness-based stress reduction programs reduce fatigue through addressing cognitive and emotional factors 2
• Energy conservation techniques and counseling help patients develop self-monitoring strategies 1

Step 4: Pharmacologic Interventions (Reserved for Persistent Fatigue)

• Pharmacologic options have limited evidence and should be reserved for patients with persistent fatigue despite addressing underlying causes and implementing nonpharmacologic interventions 2
• Corticosteroids (methylprednisolone) may be considered for short-term use only in advanced cancer or severe inflammatory conditions, but toxicity limits long-term use 2, 6
• Psychostimulants (methylphenidate, modafinil) are NOT routinely recommended for fatigue, as evidence shows lack of efficacy 2

Step 5: Ongoing Monitoring

• Reassess fatigue levels at every visit using the same 0-10 numeric rating scale 2, 6, 5
• Modify management strategies based on response and changes in clinical status 2, 6, 5
• Refer patients with unresolved fatigue despite comprehensive management to specialists (endocrinology, psychiatry, physiatry) 2

Initial Assessment of Hair Loss

Clinical Evaluation

• Determine pattern: diffuse (telogen/anagen effluvium), patterned (androgenetic alopecia), or focal (alopecia areata, tinea capitis, traction alopecia) 7, 8
• Assess for scarring vs. nonscarring alopecia; scarring alopecia requires dermatology referral 8
• Document onset timing, progression, family history of hair loss, and associated symptoms 9, 7
• Examine for patches of erythema and scaling (tinea capitis), typical patches (alopecia areata), or patterned thinning (androgenetic alopecia) 7, 8

Screening for Systemic Causes

• Screen for iron deficiency in all patients with hair loss (both male and female, cicatricial and noncicatricial), as iron deficiency is associated with multiple forms of hair loss including telogen effluvium, androgenetic alopecia, and diffuse hair loss 10, 4
• Serum ferritin is the most efficient test for diagnosing iron deficiency 10
• Evaluate for nutritional deficiencies (vitamin A excess, severe nutritional problems), thyroid disorders (hypothyroidism), autoimmune diseases, and infectious agents 3, 9, 7
• Review medications and supplements that may cause hair loss 3, 9, 7
• Assess for physiologic or emotional stress causing telogen effluvium 7, 8

Treatment Algorithm for Hair Loss

Androgenetic Alopecia (Most Common Form)

• Topical minoxidil 5% is first-line treatment for men, applied twice daily directly to the scalp 3, 7, 8
• Results may occur at 2 months with twice daily usage; some men may need to use for at least 4 months before seeing results 3
• Initial temporary increase in hair loss for up to 2 weeks is expected as old hairs are shed to regrow new hairs 3
• Oral finasteride is another treatment option available for male patients 7
• Women should NOT use minoxidil 5% solution; studies show it works no better than minoxidil 2% in women, and some women may grow facial hair 3

Iron Deficiency-Related Hair Loss

• Treat iron deficiency anemia with adequate dietary intake and oral iron supplementation 10, 4
• Treatment of iron deficiency without anemia is controversial, but clinical judgment at specialized centers supports treating iron deficiency (with or without anemia) to enhance hair loss treatment 4
• Patients who do not respond to iron replacement therapy require additional testing to identify other underlying causes 4
• Avoid excessive iron supplementation, which can cause iron overload, especially in high-risk patients with hereditary hemochromatosis 4

Other Specific Causes

• Alopecia areata: typically self-limited; treat with intralesional corticosteroids or oral immunosuppressant therapy 7, 8
• Tinea capitis: requires systemic treatment with oral antifungals 7, 8
• Traction alopecia: decrease tension on hair from styling practices 7, 8
• Telogen effluvium: remove precipitating cause (stress, medications); hair typically regrows spontaneously 7, 8
• Trichotillomania: treat underlying psychiatric condition with impulse-control therapy 8

Critical Pitfalls to Avoid

For Fatigue

• Do not assume fatigue will resolve spontaneously; it requires active management even when disease is controlled 2, 6
• Do not skip nonpharmacologic interventions (exercise, CBT) in favor of medications, as they have the strongest evidence 2
• Do not assume normal initial labs exclude all treatable causes; systematically address sleep, medications, deconditioning, and nutrition 5
• Do not overlook medication interactions and polypharmacy as major contributors to fatigue 1, 5
• Do not recommend exercise for patients with postexertional malaise (ME/CFS) 6, 5

For Hair Loss

• Do not attribute all hair loss to androgenetic alopecia while overlooking systemic causes, some of which are life-threatening but treatable 9
• Do not use minoxidil 5% in women, during pregnancy, or in children under 18 years old 3
• Do not expect minoxidil to work for frontal baldness or receding hairline; it is intended for vertex (top of scalp) hair loss only 3
• Do not overlook gastrointestinal blood loss as a cause of iron deficiency in men and postmenopausal women 10, 4
• Do not give excessive iron supplementation, which can cause iron overload 4

Patient Education and Counseling

For Fatigue

• Inform patients that fatigue may be a consequence of treatment and is not necessarily an indication that treatment is not working or that disease is progressing 1
• Counsel that exercise will improve symptoms despite initial skepticism, and that even low-level activities provide benefit 1
• Explain that understanding typical patterns of fatigue can help set reasonable expectations and allay concerns about disease recurrence 1

For Hair Loss

• Educate that hair regrowth takes time, as normal hair grows only 1/2 to 1 inch per month 3
• Explain that temporary increase in hair loss during first 2 weeks of minoxidil treatment is expected and part of the regrowth process 3
• Counsel about expected hair changes, treatment options, and realistic outcomes to help patients feel heard and taken seriously 7
• Inform that hair loss is often distressing and can significantly affect quality of life, with accompanying anxiety, depression, and lower work productivity 7