Hair Loss in a 46-Year-Old Female
The first step is determining the pattern of hair loss through scalp examination: diffuse thinning suggests androgenetic alopecia or telogen effluvium, while patchy loss indicates alopecia areata, and if either is confirmed, treatment should begin with topical minoxidil 2% twice daily for androgenetic alopecia or watchful waiting for limited alopecia areata. 1, 2
Diagnostic Approach
Clinical Examination
Examine the scalp to distinguish between diffuse versus patchy hair loss patterns 1
Assess duration of hair loss, as onset <1 year has better prognosis with 34-50% spontaneous remission in alopecia areata 1
Take targeted medication history focusing on recent stressors, chemotherapy, or drugs causing hair loss 1
Laboratory Testing (Only When Indicated)
Most cases of clinically evident alopecia areata require no laboratory testing 1. However, order targeted tests when:
- TSH and free T4 if thyroid symptoms present (common cause of diffuse hair loss) 1, 4
- Serum ferritin if iron deficiency suspected; optimal level ≥60 ng/mL needed for hair growth 1
- Vitamin D and zinc levels if nutritional deficiency suspected 4
- Total testosterone, free testosterone, and SHBG only if signs of androgen excess present (acne, hirsutism, irregular periods) 1
- Fungal culture if tinea capitis suspected 4
Treatment by Diagnosis
Androgenetic Alopecia (Most Common in This Age Group)
Topical minoxidil is the first-line FDA-approved treatment for women 2, 5:
- Start minoxidil 2% solution twice daily applied to affected scalp areas 2
- Treatment must be long-term as it arrests progression rather than stimulates regrowth 3
- Hair regrowth cannot be expected within 3 months; sustained treatment required 3
Important caveat: Oral finasteride is NOT recommended for women of reproductive age and has limited evidence in postmenopausal women 2
Alopecia Areata (If Patchy Loss Present)
For limited patchy hair loss (<50% scalp involvement):
- Watchful waiting with reassurance is a legitimate first option, as 34-50% recover within one year without treatment 1, 6
- Intralesional corticosteroids (triamcinolone acetonide 5-10 mg/mL) if treatment desired (Strength of recommendation B III) 6, 4
For extensive patchy hair loss (>50% scalp involvement):
- Contact immunotherapy is the best-documented treatment but has <50% response rate and requires multiple hospital visits over months (Strength of recommendation B II-ii) 6
Critical counseling point: No treatment alters the long-term course of alopecia areata; treatments only induce temporary regrowth 1
Wigs are often the most effective solution for extensive alopecia areata in women, providing immediate cosmetic benefit 6
Telogen Effluvium (If Diffuse Shedding with Recent Trigger)
- Spontaneous remission occurs in up to 80% of cases with duration <1 year 4
- Remove precipitating cause (stress, medication, illness) 2
- Nutritional supplementation (vitamin D, zinc, folate) only if deficiencies identified 4
Treatments to AVOID
Do NOT use the following due to inadequate efficacy or serious side-effects:
- Potent topical corticosteroids for alopecia areata (no convincing evidence of effectiveness) 6
- Systemic corticosteroids or PUVA for alopecia areata (potentially serious side-effects with inadequate efficacy evidence) 6
- Oral zinc or isoprinosine (ineffective in controlled trials) 6
Psychological Support
Address the psychological impact as part of management, as hair loss severely affects quality of life and is associated with anxiety, depression, and lower work productivity 4, 2. Educating patients about expected outcomes and realistic treatment goals helps patients feel heard 2.
Emerging Options
Platelet-rich plasma (PRP) injections show promise for androgenetic alopecia with increased hair density in clinical trials, though this requires repeated treatments every 6 months 6. This represents an alternative when minoxidil fails or is not tolerated.