What is the best course of action for a 45-year-old patient with newly noted elevated blood pressure (hypertension), significant hair loss, potential autoimmune etiology, family history of hypertension and colon cancer, current tobacco use, and uncertain tetanus immunization status, presenting with patches of hair loss, red rash on cheeks and nose, and a stye in one eye?

Management of a 45-Year-Old with Elevated Blood Pressure, Acute Hair Loss, and Malar Rash

Given the constellation of acute patchy alopecia, malar rash on cheeks and nose, and elevated blood pressure in a 45-year-old, the priority is to urgently evaluate the pending ANA and inflammatory markers (ESR, CRP) to rule out systemic lupus erythematosus (SLE), while simultaneously initiating blood pressure management and addressing modifiable cardiovascular risk factors, particularly the 30-pack-year smoking history.

Immediate Next Steps

Blood Pressure Management

Initiate antihypertensive pharmacotherapy immediately with combination therapy rather than waiting for additional confirmatory measurements, given the patient's multiple cardiovascular risk factors and confirmed readings across different settings. 1, 2

• Start a two-drug combination: an ACE inhibitor or ARB plus either a thiazide/thiazide-like diuretic or calcium channel blocker 3, 1, 4
• Target blood pressure is <130/80 mmHg, which should be achieved within 3 months 3, 1, 2
• The expected BP reduction with two-drug combination therapy is approximately 9/5 mmHg per drug, potentially lowering BP by up to 20/11 mmHg 1

Cardiovascular Risk Stratification

• Calculate 10-year ASCVD risk using the ACC/AHA Pooled Cohort Equations, which will be substantially elevated given age, smoking history (30 pack-years), and family history of hypertension 2
• The patient's 30-pack-year smoking history is the single most modifiable risk factor and requires immediate intervention 3
• Strongly counsel on smoking cessation with referral to a formal cessation program; most patients require multiple attempts before permanent success 3

Autoimmune Evaluation - Critical Priority

The combination of acute patchy alopecia (scalp and beard), malar rash (cheeks and nose), and systemic symptoms raises significant concern for SLE or another autoimmune connective tissue disease. 5

• Review the pending ANA results immediately - if positive, order anti-dsDNA, anti-Smith, complement levels (C3, C4), and complete autoimmune panel 5
• The acute onset over 3 weeks with photographic documentation of rapid progression is atypical for androgenetic alopecia and more consistent with autoimmune etiology 5
• Alopecia in autoimmune diseases can manifest as non-scarring patchy hair loss, which matches this presentation 5
• The malar rash distribution (cheeks and nose) is a classic feature of SLE and requires urgent rheumatology evaluation if ANA is positive

Dermatology Follow-Up Coordination

• Ensure dermatology appointment is expedited given the constellation of findings suggesting possible SLE
• Request scalp biopsy if dermatology evaluation is delayed beyond 2 weeks, as histopathology can distinguish between alopecia areata and lupus-associated alopecia 5
• Trichoscopy should be performed to evaluate for features of autoimmune alopecia 5

Lifestyle Modifications - Initiate Today

Smoking Cessation (Highest Priority)

• Provide prescriptions for nicotine replacement therapy or varenicline/bupropion 3
• Refer to formal smoking cessation program or behavioral therapy 3
• Document 30-pack-year history and counsel on cardiovascular and cancer risks 3

Dietary Modifications

• Prescribe DASH diet with specific written instructions: high in vegetables, fruits, whole grains, low-fat dairy, and soluble fiber 3, 1, 4
• Restrict sodium intake to <2,300 mg daily (ideally <1,500 mg) 3, 4
• Increase dietary potassium through food sources 4
• Limit free sugar consumption 1
• Reduce saturated fat, trans fat, and cholesterol 3

Physical Activity

• Prescribe 30-60 minutes of moderate-intensity aerobic exercise (brisk walking) on 4-7 days per week 3, 1
• For weight loss (if BMI >25), increase to 60-90 minutes daily combined with caloric restriction 3

Alcohol Limitation

• Although patient denies current alcohol use, document this and reinforce limitation to ≤1 drink daily if consumption resumes 3

Preventive Care - Address Today

Tetanus Vaccination

• Administer Tdap today given uncertain immunization status and no documented tetanus vaccination 3
• Document that patient declined influenza vaccine

Colorectal Cancer Screening

• Refer for colonoscopy immediately given age 45 and strong family history (colon cancer in two first-degree relatives) 3
• This meets criteria for high-risk screening and should not be delayed

Stye Management

• Continue warm compresses as already prescribed (appropriate management) 3
• Erythromycin ointment is not necessary for simple chalazion/stye unless signs of infection develop 3
• If persistent beyond 4-6 weeks despite conservative management, refer to ophthalmology for possible incision and drainage

Follow-Up Schedule

Short-Term (1-2 Weeks)

• Schedule urgent follow-up in 1-2 weeks to review pending laboratory results, particularly ANA, ESR, CRP, and autoimmune panel 1, 2
• If ANA is positive or inflammatory markers are significantly elevated, expedite rheumatology referral for same-week evaluation
• Assess blood pressure response to initial therapy and medication tolerance 1, 2

Medium-Term (1 Month)

• Reassess BP within 1 month of initiating therapy; adjust medications if target <130/80 mmHg not achieved 2, 4
• Review smoking cessation progress and reinforce behavioral interventions 3
• Confirm dermatology evaluation has occurred

Long-Term (3-6 Months)

• Follow up every 1-3 months until BP control is achieved, then at least yearly for BP and cardiovascular risk factors 1, 2
• Monitor for medication adverse effects including electrolyte abnormalities and renal function changes 2

Common Pitfalls to Avoid

• Do not delay antihypertensive therapy waiting for additional BP confirmations - the patient has documented elevated readings across multiple settings (urgent care, retina specialist, office) over one year 1, 2
• Do not start with monotherapy - combination therapy is more effective and recommended for most patients with confirmed hypertension ≥140/90 mmHg 3, 1
• Do not dismiss the dermatologic findings as isolated alopecia areata - the combination with malar rash requires systematic autoimmune evaluation 5
• Do not use aggressive BP lowering or parenteral medications - gradual reduction over days to weeks is appropriate for asymptomatic elevated BP 6
• Do not overlook the smoking cessation intervention - this is the single most impactful modifiable risk factor for this patient 3

Secondary Hypertension Screening

Given age 45 and severity of presentation, consider screening for secondary causes if BP remains resistant to therapy: 3, 1

• Renal function tests (already ordered - review eGFR and creatinine)
• Renin and aldosterone levels if hypokalemia present or BP resistant to 3-drug therapy 3
• Kidney ultrasound if renal function abnormal 1
• Sleep history already obtained - consider formal sleep study if symptoms of obstructive sleep apnea 3