How can hair loss, potentially due to underlying medical conditions, be effectively treated?

How to Help with Hair Loss

Start with topical minoxidil 5% twice daily for men or 2% twice daily for women as first-line treatment for androgenetic alopecia, which is the most common cause of hair loss. 1, 2

Determine the Type of Hair Loss

The pattern of hair loss guides diagnosis and treatment:

• Diffuse central scalp thinning with preserved frontal hairline indicates androgenetic alopecia (most common cause) 1
• Discrete circular patches with exclamation mark hairs (short broken hairs at margins) are pathognomonic for alopecia areata 1
• Sudden loss of "handfuls" of hair suggests telogen effluvium, often following stress or illness 3
• Scalp inflammation or scaling indicates tinea capitis or scarring alopecia requiring different management 1

Laboratory Testing Strategy

Do not order extensive testing when the diagnosis is clinically evident. 1 Most cases of androgenetic alopecia and alopecia areata do not require laboratory work.

Order targeted tests only when indicated:

• Check TSH and free T4 if thyroid disease is suspected (common cause of hair loss) 1
• Check serum ferritin if iron deficiency suspected; optimal level ≥60 ng/mL is needed for hair growth 1
• Check vitamin D and zinc levels if nutritional deficiency suspected 3
• Check total testosterone, free testosterone, and SHBG only if signs of androgen excess present (acne, hirsutism, irregular periods) 1
• Fungal culture only if tinea capitis suspected based on scalp inflammation 1
• Skin biopsy reserved for uncertain diagnosis or suspected scarring alopecia 1

Treatment by Diagnosis

Androgenetic Alopecia (Pattern Hair Loss)

For men: Initiate combination therapy with oral finasteride 1 mg daily plus topical minoxidil 5% solution twice daily for optimal results. 1 This combination halts progression and stimulates regrowth better than either agent alone.

For women: Topical minoxidil 2% solution twice daily is first-line treatment, which arrests progression rather than stimulates regrowth. 1 Women should not use minoxidil 5% as it works no better than 2% and may cause unwanted facial hair growth. 2

Critical application details from FDA labeling:

• Apply twice daily with 4 hours between application and hair washing 2
• Each 1 mL dose should be applied directly to the scalp in the hair loss area 2
• Treatment must be continuous; stopping results in resumption of hair loss 1
• Results may take 2-4 months to appear 2
• Initial increased shedding for up to 2 weeks is expected and indicates the medication is working 2

Adjunctive option: Platelet-rich plasma (PRP) injections with 3-5 sessions at 1-month intervals, then maintenance every 6 months, show increased hair density in clinical trials. 1

Alopecia Areata (Patchy Hair Loss)

For limited patchy disease (<50% scalp involvement): Watchful waiting with reassurance is legitimate first-line management, as 34-50% recover within one year without treatment. 1, 3

If treatment desired: Intralesional triamcinolone acetonide 5-10 mg/mL injected into affected patches. 1, 3

For extensive disease (>50% scalp involvement): Contact immunotherapy is the best-documented treatment, though response rate is less than 50% and requires multiple hospital visits over months. 1 Wigs provide immediate cosmetic benefit. 1

Counsel patients that:

• No treatment alters the long-term course of alopecia areata 1
• Regrowth cannot be expected within 3 months of any individual patch development 1
• Some treatments can induce temporary regrowth only 1

Telogen Effluvium (Diffuse Shedding)

Spontaneous remission occurs in up to 80% of cases with short duration (<1 year). 3 Treatment focuses on identifying and removing the trigger (stress, illness, medications, nutritional deficiency).

• Supplement vitamin D, zinc, and folate if deficiencies identified 3
• Reassure patients that recovery typically occurs once the underlying cause resolves 3

Tinea Capitis (Fungal Infection)

Requires systemic oral antifungal therapy as topical treatments are ineffective. 4 Confirm diagnosis with fungal culture before initiating treatment. 1

Treatments to Avoid

Do not use the following for alopecia areata due to lack of efficacy or serious side effects:

• Potent topical corticosteroids (lack convincing evidence) 1
• Systemic corticosteroids or PUVA (inadequate efficacy evidence with potentially serious side effects) 1
• Oral zinc or isoprinosine (ineffective in controlled trials) 1

Common Pitfalls

• Ordering extensive autoimmune panels in straightforward alopecia areata cases is unnecessary and wasteful 1
• Failing to consider trichotillomania where broken hairs remain firmly anchored, distinguishing it from alopecia areata 1
• Expecting rapid results from minoxidil; patients need 2-4 months minimum before assessing efficacy 2
• Discontinuing treatment prematurely when initial shedding occurs in the first 2 weeks of minoxidil use 2
• Not addressing psychological impact of hair loss, which commonly causes anxiety, depression, and reduced quality of life 4