What are the treatment options for an adult female with no significant medical history experiencing hair loss?

Treatment of Hair Loss in Women

For adult women with hair loss, topical minoxidil 2% solution applied twice daily is the first-line treatment for androgenetic alopecia (the most common cause), while limited patchy alopecia areata can be managed with watchful waiting or intralesional corticosteroids, and extensive disease requires contact immunotherapy. 1, 2, 3

Initial Diagnostic Approach

Before initiating treatment, determine the specific type of hair loss:

• Androgenetic alopecia presents with diffuse thinning over the central scalp (crown and parietal areas) with preserved frontal hairline, affecting fewer than 45% of women throughout life and increasing with age 1, 2, 4
• Alopecia areata shows discrete patchy hair loss with pathognomonic exclamation mark hairs (short broken hairs at patch margins) visible on dermoscopy, with 34-50% recovering spontaneously within one year 5, 1, 2
• Telogen effluvium causes diffuse shedding triggered by physiologic stressors (illness, surgery, childbirth, rapid weight loss) 1

Dermoscopy is the single most useful non-invasive diagnostic tool, looking for yellow dots and exclamation mark hairs in alopecia areata versus hair follicle miniaturization in androgenetic alopecia 1, 2

Laboratory Testing Strategy

Most cases of alopecia areata require no laboratory testing when clinically evident, but targeted testing is warranted for specific scenarios 5, 1, 2:

• Check serum ferritin if iron deficiency suspected—optimal levels ≥60 ng/mL are needed for hair growth, with iron deficiency being the most common nutritional deficiency worldwide 1, 2
• Check vitamin D levels as 70% of alopecia areata patients have deficiency (<20 ng/mL) versus 25% of controls, with lower levels correlating inversely with disease severity 1, 2
• Check TSH and free T4 to rule out thyroid disease, which commonly causes hair loss 1, 2
• Check total testosterone, free testosterone, and SHBG only if signs of androgen excess are present (acne, hirsutism, irregular periods) 2
• Fungal culture only if tinea capitis suspected based on scalp inflammation or scaling 5, 1, 2
• Skin biopsy reserved for uncertain diagnosis or suspected scarring alopecia 5, 1, 2

Treatment Algorithm by Diagnosis

Androgenetic Alopecia (Female Pattern Hair Loss)

First-line treatment:

• Topical minoxidil 2% solution twice daily is the only FDA-approved treatment and arrests progression rather than stimulates regrowth—treatment must be continued indefinitely to maintain effect 2, 3
• Initial therapeutic response takes 12-24 months, making clinical photography or standardized severity scales helpful for monitoring 4

Second-line systemic options when androgens are elevated:

• Oral antiandrogens (cyproterone acetate, spironolactone) combined with oral contraceptives containing ethinylestradiol are highly effective but require long-term therapy 6, 7
• Finasteride 2.5 mg daily improves postmenopausal alopecia even in normoandrogenic women, though the mechanism is unclear 6
• For polycystic ovary syndrome with insulin resistance, add metformin 6

Emerging option:

• Platelet-rich plasma (PRP) injections show promise with increased hair density in clinical trials, requiring repeated treatments every 6 months 2

Alopecia Areata

For limited patchy disease (<50% scalp involvement):

• Watchful waiting with reassurance is legitimate as first option since 34-50% recover within one year without treatment 5, 2
• Intralesional triamcinolone acetonide 5-10 mg/mL if treatment desired—strongest evidence for limited disease (Strength B, Quality III) 5, 2
• Counsel patients that regrowth cannot be expected within 3 months of any individual patch, and no treatment alters long-term course 2

For extensive patchy disease (>50% scalp involvement):

• Contact immunotherapy is the best-documented treatment but stimulates cosmetically worthwhile regrowth in <50% of patients, requires multiple hospital visits over months, and has even lower response rates in severe cases (Strength B, Quality II-ii) 5, 2
• Wigs provide immediate cosmetic benefit—acrylic wigs are cheaper and easier to maintain, while bespoke real hair wigs allow wider range of activities 5, 2

Treatments to avoid:

• Do not use potent topical corticosteroids—lack convincing evidence of effectiveness 2
• Do not use systemic corticosteroids or PUVA—potentially serious side-effects with inadequate efficacy evidence 5, 2
• Oral zinc and isoprinosine are ineffective in controlled trials 2

Nutritional Deficiency Management

Supplement when deficient:

• Vitamin D supplementation for levels <20 ng/mL according to general international recommendations, though no double-blind trials have examined this specifically for alopecia areata 1, 2
• Iron supplementation to achieve ferritin ≥60 ng/mL for optimal hair growth 1, 2
• Zinc supplementation when serum levels are low, particularly in resistant alopecia areata >6 months duration 1

Avoid excessive biotin supplementation due to potential diagnostic test interferences 8

Common Pitfalls to Avoid

• Do not order extensive autoimmune panels in straightforward alopecia areata cases when diagnosis is clinically evident 5, 1, 2
• Do not fail to assess psychological impact—alopecia can cause considerable psychological and social disability warranting evaluation for anxiety and depression 5, 2
• Do not overlook trichotillomania in the differential, where broken hairs remain firmly anchored unlike alopecia areata 1, 2
• Do not expect rapid results—all treatments require 12-24 months for initial response and must be continued indefinitely to maintain effect 4
• Do not miss childhood onset or ophiasis pattern (scalp margin involvement) in alopecia areata, which carry poorer prognoses with 14-25% progressing to total hair loss 1

Adjunctive Measures

• Counseling and psychological support are important given the devastating impact on quality of life 3
• Cosmetic camouflage with hairpieces, extensions, or partial prostheses provides immediate benefit 2, 6
• Weight loss improves hair loss in hyperandrogenic women 6