What is the next course of action for a 49-year-old female complaining of hair loss?

Initial Approach to a 49-Year-Old Female with Hair Loss

Begin with a focused clinical examination looking for specific patterns of hair loss, then perform targeted laboratory testing based on clinical findings, as most cases do not require extensive workup unless the diagnosis is uncertain. 1, 2

Clinical Examination Priorities

Pattern Recognition

• Examine the scalp for patchy versus diffuse hair loss to distinguish between alopecia areata (patchy) and other causes like telogen effluvium or androgenetic alopecia (diffuse). 1, 2
• Look for exclamation mark hairs (short broken hairs around expanding patches) which are pathognomonic for alopecia areata. 1
• Use dermoscopy to identify yellow dots, exclamation mark hairs, and cadaverized hairs that confirm alopecia areata, or to rule out other conditions like trichotillomania or tinea capitis. 1, 2

Key History Elements

• Duration of hair loss: Onset <1 year suggests better prognosis with potential spontaneous remission in 34-50% of cases. 1, 2
• Associated symptoms: Check for signs of hyperandrogenism (acne, hirsutism, irregular periods), thyroid dysfunction, or recent stressors (illness, surgery, emotional stress, rapid weight loss). 3, 4
• Medication history: Specifically ask about chemotherapy or other drugs that cause anagen effluvium. 1

Laboratory Testing Algorithm

When Testing is NOT Needed

Investigations are unnecessary in most cases of alopecia areata when the diagnosis is clinically evident. 1 The British Association of Dermatologists explicitly states that routine screening for autoimmune diseases or iron deficiency is not recommended in straightforward alopecia areata cases. 1

When Testing IS Indicated

Perform targeted laboratory tests only when:

For Uncertain Diagnosis

• Fungal culture if tinea capitis is suspected (look for scalp inflammation and scaling). 1, 2
• Skin biopsy for diffuse alopecia areata, early scarring alopecia, or when clinical diagnosis is unclear. 1, 2
• Serology for lupus erythematosus if systemic lupus is suspected. 1, 2
• Serology for syphilis if secondary syphilis is in the differential. 1, 2

For Nutritional Assessment (When Clinically Indicated)

• Serum ferritin: Check if iron deficiency is suspected, though routine testing is not recommended per British guidelines. 1 However, recent evidence shows 70% of female alopecia cases may be iron deficiency-related, with optimal ferritin ≥60 ng/mL needed for hair growth. 2, 5
• Vitamin D level: 70% of alopecia areata patients have levels <20 ng/mL versus 25% of controls, with inverse correlation to disease severity. 2
• Serum zinc: Tends to be lower in alopecia areata patients, particularly those with resistant disease >6 months. 2

For Hormonal Assessment

• TSH and free T4: Check for thyroid disease, which commonly causes hair loss. 2
• Total testosterone, free testosterone, and SHBG: Only if signs of androgen excess are present (acne, hirsutism, irregular periods). 2

Critical Pitfalls to Avoid

Common Diagnostic Errors

• Do not order excessive laboratory tests when alopecia areata is clinically evident—this wastes resources and delays appropriate counseling. 1, 2
• Do not miss the psychological impact: Assess for anxiety and depression, as alopecia can cause significant psychological distress requiring formal psychological support. 1, 2
• Do not overlook dermoscopy: This non-invasive tool provides valuable diagnostic information and should be used routinely. 1, 2

Management Considerations

• Recognize that 34-50% of patients recover within one year without treatment, making watchful waiting with reassurance a legitimate option for limited patchy hair loss of short duration. 1, 2
• Counsel patients that regrowth cannot be expected within 3 months of any individual patch development. 1
• Warn that no treatment alters the long-term course of alopecia areata, though some can induce temporary hair regrowth. 1

Differential Diagnosis to Actively Exclude

The following conditions require specific consideration:

• Trichotillomania: Incomplete hair loss with firmly anchored broken hairs in anagen phase (unlike exclamation mark hairs). 1, 2
• Tinea capitis: Scalp inflammation with scaling (signs may be subtle). 1, 2
• Telogen effluvium: Stress-induced diffuse shedding from physiologic or emotional stressors. 1, 2
• Androgenetic alopecia: Pattern hair loss related to DHT sensitivity, most common cause in women. 6, 4