What is the appropriate evaluation and treatment approach for a patient complaining of hair loss?

Evaluation and Treatment of Hair Loss

Begin by determining the pattern of hair loss through scalp examination: patchy loss with exclamation mark hairs indicates alopecia areata, diffuse thinning at the crown with preserved frontal hairline suggests androgenetic alopecia, and diffuse shedding points to telogen effluvium. 1

Initial Clinical Assessment

History Taking

• Document onset and duration: Hair loss <1 year has better prognosis with 34-50% spontaneous remission in alopecia areata 2, 1
• Family history: Present in 20% of alopecia areata cases 3, 4
• Medication review: Specifically ask about chemotherapy (anagen effluvium), anticoagulants, and beta-blockers 1, 3
• Systemic symptoms: Screen for autoimmune disease associations including thyroid disease, lupus, and vitiligo 3
• Hair care practices: Assess for traction from tight hairstyles (cornrows, ponytails) 4, 5

Physical Examination

• Scalp inspection: Look for inflammation/scaling (suggests tinea capitis or scarring alopecia), versus smooth scalp (alopecia areata or androgenetic alopecia) 1, 4
• Exclamation mark hairs: Short broken hairs at patch margins are pathognomonic for alopecia areata 1, 3
• Dermoscopy findings: Yellow dots, exclamation mark hairs, and cadaverized hairs confirm active alopecia areata 3, 4
• Nail examination: Pitting, ridging, or dystrophy occurs in 10% of alopecia areata patients 3, 4
• Lymph nodes: Check occipital and cervical nodes 4

Laboratory Testing Strategy

Most cases of alopecia areata require NO laboratory testing when the diagnosis is clinically evident. 2, 3

Test Only When Indicated:

• Fungal culture: Only if tinea capitis suspected (scalp inflammation/scaling present) 2, 3
• Skin biopsy: Reserved for uncertain diagnosis, suspected scarring alopecia, or diffuse alopecia areata 2, 3
• Serum ferritin: Check if iron deficiency suspected; optimal level ≥60 ng/mL needed for hair growth 1
• Vitamin D level: Test if deficiency suspected; 70% of alopecia areata patients have levels <20 ng/mL versus 25% of controls 3
• TSH and free T4: Check for thyroid disease, which commonly causes hair loss 1
• Serum zinc: Consider if zinc deficiency suspected, as levels tend to be lower in alopecia areata 3
• Lupus serology: Only if systemic lupus in differential 2, 3
• Syphilis serology: Only if secondary syphilis suspected 2, 3
• Testosterone/SHBG: Only check if signs of androgen excess present (acne, hirsutism, irregular periods) 1

Common pitfall: Avoid ordering extensive autoimmune panels in straightforward alopecia areata cases. 3

Treatment Algorithm by Diagnosis

Alopecia Areata

Limited Patchy Disease (<50% scalp involvement):

Watchful waiting with reassurance is a legitimate first-line option, as 34-50% recover within one year without treatment. 2, 1

• Counsel patients: Regrowth cannot be expected within 3 months of any individual patch development 2
• If treatment desired: Intralesional triamcinolone acetonide 5-10 mg/mL is first-line with strongest evidence (Level 2+) 2, 1
• Alternative: Clobetasol propionate 0.05% foam applied to affected areas, though evidence is limited 2

Important caveat: No treatment alters the long-term course of alopecia areata; treatments only induce temporary hair regrowth. 2

Extensive Patchy Disease (>50% scalp involvement):

• Contact immunotherapy (e.g., DPCP) is the best-documented treatment but has <50% response rate and requires multiple hospital visits over months 1
• Wigs provide immediate cosmetic benefit and may be preferable to treatments with low efficacy 2, 1

Treatments to AVOID:

• Potent topical corticosteroids: Lack convincing evidence of effectiveness 1
• Systemic corticosteroids or PUVA: Not recommended due to serious side-effects and inadequate efficacy 1
• Oral zinc or isoprinosine: Ineffective in controlled trials 1

Androgenetic Alopecia (Pattern Hair Loss)

For men: Topical minoxidil 5% solution twice daily is first-line treatment. 5, 6

• Application: Apply 1 mL directly to scalp in hair loss area twice daily 5
• Allow 4 hours before washing for optimal absorption 5
• Timeline: Results may occur at 2 months; some men need 4 months of use 5
• Maintenance: Treatment must be continuous; stopping results in resumed hair loss 1
• Add oral finasteride 1 mg daily for optimal results in men 1

For women: Topical minoxidil 2% solution twice daily arrests progression. 1

Adjunctive option: Platelet-rich plasma (PRP) injections show promise with 3-5 sessions at 1-month intervals, then maintenance every 6 months. 1

Telogen Effluvium

• Identify and remove trigger: Stress, illness, surgery, childbirth, rapid weight loss, nutritional deficiencies 3, 6
• Reassurance: Self-limited condition; hair typically regrows once precipitating cause removed 6, 7
• Supplement deficiencies: Vitamin D if <20 ng/mL, iron if ferritin <60 ng/mL 1, 3

Tinea Capitis

• Requires oral antifungal therapy: Topical treatment insufficient 3, 6
• Fungal culture mandatory before treatment; incorrect diagnosis is most common cause of treatment failure 3

Traction Alopecia

• Decrease tension on hair: Avoid tight hairstyles (cornrows, ponytails) 6, 7
• Hair care modification is primary treatment 7

Psychological Support

Acknowledge the significant psychological impact of hair loss on quality of life, anxiety, and depression. 2, 6

• Provide counseling: Explain nature, course, and available treatments 2
• Connect with support groups: Patient experts can help with self-acceptance of altered body image 2
• Consider referral: For profound distress, refer to clinical psychologist or social worker, especially in children 2
• Children: Watch for withdrawn behavior, low self-esteem, failing grades, or behavioral changes requiring psychological referral 2

Common Pitfalls to Avoid

• Failing to consider trichotillomania: Look for broken hairs that remain firmly anchored, distinguishing it from alopecia areata 3
• Missing tinea capitis: Signs may be subtle; maintain high index of suspicion with any scalp inflammation 3
• Over-testing: Avoid extensive laboratory workup when diagnosis is clinically evident 2, 3
• Unrealistic expectations: Warn patients about potential relapse during or after initially successful treatment 2
• Ignoring spontaneous remission: 80% of limited patchy alopecia areata <1 year duration remits spontaneously 2