What is the appropriate evaluation and treatment for a 32-year-old woman with scalp hair loss, but no hair loss from her eyebrows or axillary (armpit) region, and otherwise normal health?

Evaluation and Management of Scalp Hair Loss in a 32-Year-Old Woman

This patient most likely has alopecia areata, and the diagnosis can be made clinically without laboratory testing in most cases; intralesional triamcinolone acetonide injections (5-10 mg/mL) are the first-line treatment if intervention is desired, though reassurance and watchful waiting is equally appropriate for limited patchy hair loss of short duration. 1, 2

Clinical Diagnosis

The diagnosis of alopecia areata is usually straightforward and can be made clinically. 1 The fact that hair loss is limited to the scalp while eyebrows and axillary hair are preserved is consistent with limited patchy alopecia areata rather than more severe forms like alopecia totalis or universalis. 1

Key diagnostic features to look for on examination:

• Round or oval patches of complete hair loss on the scalp 1
• Short broken hairs with tapered ends (exclamation mark hairs) around the margins of expanding patches 1
• Slightly reddened but otherwise normal-appearing skin in affected areas 1
• Yellow dots visible on dermoscopy (if available) indicating active disease progression 1
• Nail involvement in approximately 10% of cases 1

Differential Diagnosis to Exclude

Important conditions that can mimic alopecia areata:

• Trichotillomania: Look for incomplete hair loss with broken hairs that are firmly anchored (remain in anagen phase, unlike exclamation mark hairs) 1
• Tinea capitis: The scalp will show inflammation, though signs may be subtle 1
• Telogen effluvium: Presents as diffuse rather than patchy hair loss 1
• Systemic lupus erythematosus and secondary syphilis: Consider if clinical presentation is atypical 1

Laboratory Testing

Investigations are unnecessary in most cases of alopecia areata. 1

When to consider testing:

• Only perform tests when the diagnosis is in doubt 1
• Appropriate tests may include fungal culture, skin biopsy, serology for lupus erythematosus, or serology for syphilis 1
• Do not routinely screen for iron deficiency—while one small case series suggested increased prevalence in women with alopecia areata, two subsequent studies failed to confirm this, and there are no published studies demonstrating treatment response to iron replacement 1
• The increased frequency of autoimmune disease in patients with alopecia areata is probably insufficient to justify routine screening 1

Treatment Approach

Initial Management: Watchful Waiting

Reassurance alone is a legitimate first approach for limited patchy hair loss of short duration (< 1 year), as spontaneous remission occurs in up to 80% of these patients. 2, 3 This "watchful waiting" approach avoids unnecessary treatment discomfort and cost while allowing natural resolution. 2

Critical counseling points:

• Advise the patient that regrowth cannot be expected within 3 months of patch development, even if spontaneous recovery occurs 2
• Explain that no treatment alters the long-term course of alopecia areata; treatments only induce hair growth while being used 2
• Warn about possible relapse following initially successful treatment, which occurs in up to 62% of cases 2

First-Line Active Treatment: Intralesional Corticosteroids

If treatment is desired, intralesional triamcinolone acetonide (5-10 mg/mL) achieves 62% full regrowth rates in patients with fewer than five patches less than 3 cm in diameter. 2, 3

Injection technique:

• Inject just beneath the dermis in the upper subcutis (not too superficially) to reach the hair follicle level 2
• Each 0.05-0.1 mL injection produces a tuft of hair growth approximately 0.5 cm in diameter 2, 3
• Repeat injections monthly until satisfactory regrowth is achieved 2
• Response typically becomes evident after 2-3 months, with effects lasting approximately 9 months 2

Side effects:

• Skin atrophy at injection sites is the most consistent side-effect 2
• Patient discomfort during injection is the main limitation 2

Alternative Treatment: Topical Corticosteroids

Apply clobetasol propionate 0.05% foam or ointment to the affected area twice daily if intralesional injections are not feasible. 2 However, evidence shows only 21% of patients (7 of 34) achieved at least 50% regrowth after 12 weeks with clobetasol foam, and topical corticosteroids have limited evidence for effectiveness compared to intralesional injections. 2, 3

Adjunctive Therapy: Minoxidil

Topical minoxidil 5% can be added as adjunctive therapy but should not be used as monotherapy for alopecia areata. 2 Early studies showed benefit with 1% minoxidil in patchy alopecia areata, but subsequent trials in extensive disease failed to confirm these results, with response rates of 32-33% and less than 10% experiencing sustained benefit. 2

Prognosis

Disease severity at presentation is the strongest predictor of long-term outcome:

• 68% of patients with less than 25% hair loss initially report being free of disease at follow-up 1
• 32% with 25-50% hair loss initially achieve remission 1
• Only 8% with more than 50% hair loss initially achieve remission 1

Hair follicles are preserved in alopecia areata and the potential for recovery of hair growth is maintained, even in longstanding disease. 1 Almost all patients will experience more than one episode of the disease. 1

Common Pitfalls to Avoid

• Do not inject corticosteroids too superficially—inject just beneath the dermis in the upper subcutis to reach the hair follicle level 2
• Do not expect immediate results—allow at least 3 months before assessing treatment response 2
• Do not routinely test for iron deficiency or autoimmune diseases without clinical indication 1

When to Refer

Refer to dermatology if:

• No response after 4-6 months of intralesional corticosteroid therapy for consideration of contact immunotherapy with DPCP 2
• The hair loss pattern is atypical (not round patches), suggesting alternative diagnoses like tinea capitis or trichotillomania 2
• Scarring alopecia is suspected 4

Psychosocial Support

Address the psychological impact of hair loss, as patients may feel self-conscious, conspicuous, angry, rejected, or embarrassed. 1 It is important to mention self-acceptance, particularly in those with long-standing, extensive, and persistent alopecia areata. 1 Patients with moderate to severe hair loss are more likely to have accompanying anxiety, depression, and lower work productivity and quality-of-life scores. 5