What are the treatment options for a female patient experiencing hair loss?

Treatment Options for Female Hair Loss

For female pattern hair loss (androgenetic alopecia), topical minoxidil 2-5% applied twice daily is the first-line treatment, while for patchy alopecia areata with limited involvement, intralesional corticosteroid injections are the most evidence-based approach. 1, 2, 3

Diagnostic Framework Before Treatment

Clinical Pattern Recognition

• Androgenetic alopecia presents with diffuse thinning at the crown while preserving the frontal hairline (Ludwig pattern), affecting over 50% of postmenopausal women 2, 4
• Alopecia areata shows well-demarcated patches with pathognomonic exclamation mark hairs (short broken hairs around expanding patches) 2, 5
• Telogen effluvium causes diffuse shedding triggered by physiologic stressors (illness, surgery, childbirth, rapid weight loss) occurring 2-3 months after the inciting event 2

Dermoscopy Findings

• Yellow dots, exclamation mark hairs, and cadaverized hairs indicate active alopecia areata 2
• Dermoscopy is the single most useful non-invasive tool to differentiate between alopecia areata, telogen effluvium, and androgenetic alopecia 2

Essential Laboratory Testing

• Serum ferritin: Iron deficiency is the most common nutritional deficiency causing chronic diffuse hair loss 2
• Vitamin D level: 70% of alopecia areata patients have deficiency (<20 ng/mL) versus 25% of controls, with inverse correlation to disease severity 2
• TSH and free T4: Rule out thyroid disease, which commonly causes hair loss 2
• Zinc level: Tends to be lower in alopecia areata patients, particularly those with resistant disease >6 months 2
• Testosterone, SHBG, prolactin: Only if signs of androgen excess (acne, hirsutism, irregular periods) are present 2

Treatment Algorithm by Diagnosis

Androgenetic Alopecia (Female Pattern Hair Loss)

Primary Treatment:

• Topical minoxidil 2-5% twice daily is the only FDA-approved treatment for women and should be continued indefinitely to maintain effect 6, 7, 3, 8
• Therapeutic response takes 12-24 months; early treatment is more effective at arresting progression than stimulating regrowth 7

Adjunctive Treatments for Hyperandrogenic Women:

• Oral antiandrogens (cyproterone acetate, spironolactone) combined with oral contraceptives containing ethinylestradiol for ovarian androgen suppression 6
• Finasteride 2.5 mg daily for postmenopausal women, even those without elevated androgens 6
• Metformin when polycystic ovary syndrome with insulin resistance is present 6

Alopecia Areata

Limited Patchy Disease (<50% scalp involvement):

• Intralesional corticosteroid injections are first-line with the strongest evidence (Strength of recommendation B, Quality of evidence III) 1, 2
• Natural history favors observation in many cases: 34-50% recover within one year without treatment 1, 2

Extensive Patchy Disease:

• Contact immunotherapy is the best-documented treatment, though response rates are <50% and even lower in severe cases 1, 2
• This requires multiple hospital visits over several months and is not widely available 1

Alopecia Totalis/Universalis:

• Contact immunotherapy is the only treatment likely to be effective, though response rates are very low 1
• Oral JAK inhibitors are FDA-approved for severe alopecia areata 4

Treatments to Avoid:

• Potent topical corticosteroids are widely prescribed but lack convincing efficacy evidence 1
• Systemic corticosteroids and PUVA cannot be recommended due to serious side-effects and inadequate efficacy evidence 1

Telogen Effluvium

• Identify and eliminate the trigger (medication, illness, nutritional deficiency, stress) 2, 3
• This condition is typically self-limited once the trigger is removed 1, 8
• Address any identified nutritional deficiencies (iron, vitamin D, zinc) 2

Nutritional Deficiency-Related Hair Loss

Vitamin D Deficiency (<20 ng/mL):

• Supplement according to general international recommendations for adults with maintenance therapy due to chronicity 2
• No double-blind trials yet exist for oral supplementation specifically for alopecia areata, but correction is recommended given the strong association 2

Iron Deficiency:

• Replete ferritin stores as iron deficiency is the most common nutritional deficiency worldwide causing chronic diffuse telogen hair loss 2

Zinc Deficiency:

• Zinc supplementation when deficient, particularly in alopecia areata and telogen effluvium patients 2
• Avoid excessive supplementation, especially with biotin, due to potential diagnostic test interferences 4

Non-Pharmacological Interventions

Cosmetic Management

• Wigs or hairpieces are often the most effective solution for extensive alopecia areata in women 1
• Acrylic wigs are cheaper and easier to maintain; real hair wigs allow wider range of activities 1
• Hair extensions or partial hairpieces for androgenetic alopecia 6

Psychological Support

• Assess for anxiety and depression, as alopecia causes considerable psychological and social disability 1, 2
• Connect patients with support groups 5
• Educate about expected outcomes and realistic treatment timelines 3

Emerging Natural Treatments

• Saw palmetto, pumpkin seed oil (5α-reductase inhibitors) show promise for promoting hair density 4
• Curcumin demonstrates anti-inflammatory effects contributing to scalp health 4
• Further studies needed to validate efficacy and safety of these interventions 4

Critical Pitfalls to Avoid

• Do not order excessive laboratory tests when diagnosis is clinically evident; alopecia areata is typically diagnosed clinically 2
• Do not delay treatment initiation for androgenetic alopecia, as early treatment is more effective at preventing progression than stimulating regrowth 7
• Do not promise rapid results: therapeutic response to minoxidil and antiandrogens takes 12-24 months 7
• Do not overlook dermoscopy: it provides valuable diagnostic information non-invasively 2
• Do not forget that many alopecia areata cases are self-limited: 34-50% recover within one year, making observation reasonable for limited disease 1, 2
• Do not use systemic corticosteroids or PUVA for alopecia areata due to serious side-effects without proven efficacy 1