What is the recommended evaluation and treatment for a 55-year-old female with new onset hair loss for 2 months?

Evaluation and Management of New Onset Hair Loss in a 55-Year-Old Female

Begin with a focused clinical examination to determine the pattern of hair loss—diffuse thinning suggests androgenetic alopecia (most common in this age group), while patchy loss with exclamation mark hairs indicates alopecia areata—and obtain targeted laboratory tests only if clinical features suggest systemic disease. 1, 2

Initial Clinical Assessment

Physical Examination Findings to Document

• Pattern of hair loss: Diffuse thinning over the central scalp with preserved frontal hairline suggests androgenetic alopecia, while discrete patches indicate alopecia areata 1, 3
• Exclamation mark hairs: Short broken hairs at patch margins are pathognomonic for alopecia areata and can be identified with dermoscopy 1, 2
• Scalp inflammation or scaling: Presence suggests tinea capitis or early scarring alopecia rather than androgenetic alopecia or alopecia areata 1
• Signs of hyperandrogenism: Check for acne, hirsutism, or irregular menstrual history (though only one-third of women with androgenetic alopecia have abnormal androgen levels) 3

Essential History Elements

• Duration and onset: Hair loss <1 year has better prognosis with 34-50% spontaneous remission in alopecia areata 1, 2
• Medication review: Specifically ask about chemotherapy or drugs causing anagen effluvium 2
• Recent physiologic stress: Childbirth, surgery, severe illness, or emotional stress suggests telogen effluvium 4
• Family history: Present in 20% of alopecia areata cases 1

Laboratory Testing Strategy

Investigations are unnecessary in most cases when the diagnosis is clinically evident. 1, 2

Order Tests Only When Indicated:

• Serum ferritin: Check if iron deficiency suspected; optimal level ≥60-70 ng/mL needed for hair growth 2, 5
• TSH and free T4: Thyroid disease commonly causes hair loss 2
• Fungal culture: Only if tinea capitis suspected (scalp inflammation/scaling present) 1
• Androgens (total testosterone, free testosterone, SHBG): Only if signs of androgen excess present (acne, hirsutism, irregular periods) 2
• Skin biopsy: Reserved for uncertain diagnosis or suspected scarring alopecia 1

Do not routinely screen for autoimmune diseases in alopecia areata—the increased frequency is insufficient to justify routine testing. 1

Treatment Algorithm Based on Diagnosis

For Androgenetic Alopecia (Most Likely in This Age Group)

• Topical minoxidil 2% solution twice daily is first-line treatment; arrests progression rather than stimulates regrowth 2
• Consider oral antiandrogens (spironolactone) for more aggressive therapy, though long-term treatment is required 5, 6
• Platelet-rich plasma (PRP) injections show promise with increased hair density, requiring treatments every 6 months 1, 2

For Limited Patchy Alopecia Areata

• Watchful waiting with reassurance is legitimate first option since 34-50% recover within one year without treatment 1, 2
• Intralesional corticosteroids (triamcinolone acetonide 5-10 mg/mL) if treatment desired; 62% achieve full regrowth with monthly injections 7, 2
• Counsel that regrowth cannot be expected within 3 months of any individual patch development 2

For Extensive Alopecia Areata

• Contact immunotherapy is best-documented treatment but has <50% response rate and requires multiple hospital visits over months 7, 2
• Wigs provide immediate cosmetic benefit 2

Critical Management Principles

No treatment alters the long-term course of alopecia areata—warn patients about possible relapse during or following initially successful treatment. 7, 2

Treatments to Avoid:

• Potent topical corticosteroids for alopecia areata lack convincing efficacy evidence 2
• Systemic corticosteroids or PUVA have potentially serious side effects with inadequate efficacy 7, 2
• Oral zinc or isoprinosine are ineffective in controlled trials 7, 2

Psychosocial Support

Assess for psychological effects including anxiety and depression, particularly in adolescents and women with extensive hair loss, as alopecia can be devastating. 7, 8

Common Pitfalls

• Ordering extensive autoimmune panels in straightforward alopecia areata cases 1
• Expecting rapid results—androgenetic alopecia and chronic telogen effluvium require months of treatment before benefits are seen 5
• Missing telogen effluvium triggered by physiologic stress 2-3 months prior, which is self-limited once precipitating cause removed 2, 4
• Failing to consider trichotillomania, where broken hairs remain firmly anchored (anagen phase) unlike exclamation mark hairs 1