From the Guidelines
A comprehensive workup for female hair loss should include iron studies, such as serum ferritin, as part of the initial laboratory testing, despite the lack of strong evidence supporting a direct association between iron deficiency and hair loss, as suggested by studies including 1. When evaluating female hair loss, it is essential to consider the pattern and extent of hair loss, looking for diffuse thinning versus patchy loss.
- The workup should begin with a detailed medical history and physical examination.
- Laboratory testing should include:
- Complete blood count
- Thyroid function tests (TSH, free T4)
- Iron studies (ferritin, iron, TIBC)
- Vitamin D level
- Hormonal evaluation including total and free testosterone, DHEAS, and prolactin
- Consider testing for antinuclear antibodies if autoimmune conditions are suspected.
- A scalp biopsy may be necessary to differentiate between scarring and non-scarring alopecia. The evidence from 1 highlights the importance of iron in tissues with high cellular turnover, like the hair follicle matrix, but also notes that most studies were conducted only with female participants, leading to insufficient evidence to recommend screening for iron deficiency in hair loss patients. However, given the potential role of iron in hair growth, as suggested by 1, and the fact that iron deficiency is a common nutritional deficiency, including iron studies in the initial workup can help identify and address potential underlying causes of hair loss. For androgenetic alopecia, first-line treatment is topical minoxidil 5% applied twice daily to the scalp, as supported by recent guidelines, while for telogen effluvium, addressing the underlying cause and optimizing nutrition, including supplementing iron if ferritin is below 70 ng/mL, is essential, as indicated by 1.
From the Research
Female Hair Loss Workup
The workup for female hair loss typically involves a comprehensive clinical history and physical examination, as well as laboratory testing and potentially a scalp biopsy 2, 3, 4.
- A thorough medical history is essential to identify any underlying conditions that may be contributing to hair loss, such as hyperandrogenism or thyroid disorders.
- A physical examination of the scalp and hair can help to identify patterns of hair loss and rule out other conditions, such as alopecia areata or telogen effluvium.
- Laboratory tests, such as hormone level checks and thyroid function tests, may be ordered to rule out underlying conditions that could be contributing to hair loss.
- A scalp biopsy may be performed in some cases to confirm a diagnosis of female pattern hair loss (FPHL) or to rule out other conditions, such as scarring alopecia.
Diagnostic Considerations
When evaluating a patient with hair loss, it is essential to consider the potential psychological impact of the condition, as hair loss can cause significant emotional distress and anxiety 5, 4.
- A systematic approach to history taking, examination, and diagnosis can help to identify the underlying cause of hair loss and guide treatment.
- Specific types of hair loss, such as FPHL, alopecia areata, and telogen effluvium, have distinct clinical features and treatment options.
- Referral to a dermatologist may be necessary for diagnostically challenging or difficult-to-treat cases of hair loss 3, 6.
Treatment Options
Treatment for female hair loss depends on the underlying cause and may involve medical therapies, such as oral antiandrogen therapies and topical minoxidil, as well as hair systems and surgery for severe cases 2, 6.
- Mild-to-moderate FPHL can be treated with oral antiandrogen therapies, such as cyproterone acetate and spironolactone, and/or topical minoxidil.
- Hair systems and surgery may be considered for selected cases of severe FPHL.
- Physician support and counseling are essential for patients with hair loss, as the condition can have a significant impact on quality of life 6, 4.