What is the appropriate evaluation and management of an adult presenting with new or progressive hair loss?

QR678 and Hair Loss Evaluation

I cannot recommend QR678 for hair loss treatment, as it lacks FDA approval and is not mentioned in any established clinical guidelines from major dermatology societies. For adult patients presenting with new or progressive hair loss, the evaluation should focus on identifying the specific type of alopecia through clinical examination and targeted testing, followed by evidence-based treatments such as minoxidil, finasteride, or intralesional corticosteroids depending on the diagnosis. 1, 2

Initial Clinical Assessment

Pattern recognition is the cornerstone of diagnosis:

• Patchy hair loss with "exclamation mark" hairs (short broken hairs at patch margins visible on dermoscopy) confirms alopecia areata 2, 3
• Diffuse thinning over the central scalp with preserved frontal hairline indicates androgenetic alopecia 2, 3
• Diffuse shedding across the entire scalp suggests telogen effluvium, often triggered by stress, illness, or nutritional deficiency 2, 3
• Scalp inflammation or scaling points to tinea capitis or scarring alopecia and requires fungal culture or biopsy 2, 3

Key history elements to elicit:

• Duration of hair loss: onset <1 year predicts better prognosis, with 34-50% spontaneous remission in limited alopecia areata 1, 2
• Family history: present in 20% of alopecia areata cases 2
• Medication history: chemotherapy, anticoagulants, beta-blockers cause anagen or telogen effluvium 2
• Associated autoimmune diseases: thyroid disease, lupus, vitiligo commonly coexist with alopecia areata 2
• Nail changes: pitting, ridging, or dystrophy occur in 10% of alopecia areata patients and predict poorer prognosis 2

Dermoscopy: The Single Most Valuable Tool

Dermoscopy differentiates the three most common causes without biopsy: 2

• Alopecia areata: Yellow dots, exclamation mark hairs, cadaverized hairs, black dots 2
• Telogen effluvium: Absence of yellow dots and exclamation mark hairs 2
• Androgenetic alopecia: Hair diameter diversity, peripilar signs 2

Laboratory Testing Algorithm

Most cases of clinically obvious alopecia areata require NO laboratory testing. 1, 2, 3

Order targeted tests only when:

• Diagnosis is uncertain after clinical examination and dermoscopy 1, 2, 3
• Diffuse pattern raises suspicion for systemic causes 2, 3
• Scalp inflammation suggests infection or scarring process 2, 3

Specific test indications:

• Fungal culture: Only if scalp inflammation or scaling present (tinea capitis suspected) 1, 2, 3
• Scalp biopsy: Reserved for uncertain diagnosis, suspected scarring alopecia, or atypical diffuse alopecia areata 1, 2
• Serum ferritin: If chronic diffuse telogen hair loss suspected; optimal level ≥60 ng/mL needed for hair growth 2, 3
• Vitamin D level: Check if deficiency suspected; 70% of alopecia areata patients have levels <20 ng/mL versus 25% of controls, with inverse correlation to disease severity 2, 3
• Serum zinc: Tends to be lower in alopecia areata patients, particularly those with resistant disease >6 months 2, 3
• TSH and free T4: Only if clinical signs of thyroid disease present 2, 3
• Total testosterone, free testosterone, SHBG: Only if signs of androgen excess (acne, hirsutism, irregular periods) 2, 3
• Lupus serology: Only if systemic features like joint pain, photosensitivity, or facial rash present 2, 3
• Syphilis serology: Only if relevant risk factors present 2, 3

Treatment Algorithm by Diagnosis

Limited Patchy Alopecia Areata

Watchful waiting with reassurance is the preferred first option because 34-50% recover within one year without treatment. 1, 2, 3 Counsel patients that regrowth cannot be expected within 3 months of any individual patch. 1, 2, 3

If treatment desired:

• Intralesional triamcinolone acetonide 5-10 mg/mL has the strongest evidence (Strength of recommendation B, Quality of evidence III) 1, 3

Avoid these ineffective treatments:

• Potent topical corticosteroids lack convincing efficacy evidence 1, 3
• Dithranol and minoxidil lotion are widely prescribed but have no convincing evidence of effectiveness 1

Extensive Patchy Alopecia Areata

Contact immunotherapy is the best-documented treatment but stimulates cosmetically worthwhile regrowth in <50% of patients, requires multiple hospital visits over months, and is not widely available (Strength of recommendation C). 1

Alopecia Totalis/Universalis

Contact immunotherapy is the only treatment likely to be effective, though response rates are even lower than in extensive patchy disease. 1

Wigs provide immediate cosmetic benefit and are often the most practical solution for extensive, longstanding disease (Strength of recommendation D). 1, 3

Androgenetic Alopecia (Male Pattern)

Combination therapy yields optimal results: 3

• Oral finasteride 1 mg daily plus topical minoxidil 5% solution twice daily 3, 4
• Treatment must be continuous; stopping results in resumed hair loss 3, 4
• Results may appear at 2 months but may require 4 months of twice-daily use 4

Platelet-rich plasma (PRP) as adjunctive therapy:

• Protocol: 3-5 sessions at 1-month intervals, then maintenance every 6 months 3
• Increases hair density and count by inducing dermal papilla proliferation and accelerating telogen-to-anagen transition 3

Androgenetic Alopecia (Female Pattern)

Topical minoxidil 2% solution twice daily is first-line treatment; it arrests progression rather than stimulates regrowth. 3

Telogen Effluvium

Address the underlying trigger: stress, illness, nutritional deficiency, medications. 2, 5 The condition is typically self-limited once the cause is removed. 5

Tinea Capitis

Oral antifungal therapy is required; topical treatment alone is insufficient. 2, 3 Fungal culture is mandatory before treatment, as incorrect diagnosis is the most common cause of treatment failure. 2

Treatments to Avoid

Never recommend these for alopecia areata due to serious side-effects and inadequate efficacy:

• Continuous or pulsed systemic corticosteroids 1
• PUVA 1
• Oral zinc or isoprinosine (ineffective in controlled trials) 3

Common Pitfalls

• Ordering excessive laboratory tests when diagnosis is clinically evident with characteristic dermoscopic findings 1, 2, 3
• Mistaking trichotillomania for alopecia areata: In trichotillomania, broken hairs remain firmly anchored in anagen phase, whereas alopecia areata shows exclamation mark hairs 2, 3
• Overlooking the psychological impact: Hair loss causes considerable psychological and social disability; patients who become withdrawn, experience low self-esteem, or have work/social difficulties warrant referral to mental health services 1, 2, 3
• Failing to counsel about realistic timelines: No treatment alters the long-term course of alopecia areata, though some induce temporary regrowth 1, 2, 3

Micronutrient Supplementation

Supplement only documented deficiencies:

• Vitamin D: Supplement if <20 ng/mL according to general international recommendations for adults 2, 3
• Zinc: May contribute to hair health when deficient, particularly in alopecia areata and telogen effluvium 2
• Iron: Optimal ferritin ≥60 ng/mL needed for hair growth 2, 3