What are the next steps in evaluating and managing an 18‑year‑old female with a one‑week history of sudden diffuse hair shedding (clumps on pillow/comb), recent shampoo change, hair washed every other day, taking a multivitamin (Enervon), family history of alopecia, high stress weekends, normal vital signs and Ludwig grade 1 scalp thinning without inflammation?

Acute Telogen Effluvium: Next Steps in Evaluation and Management

This 18-year-old female most likely has acute telogen effluvium triggered by stress, and the appropriate next steps are targeted laboratory testing (serum ferritin, TSH/free T4, vitamin D, zinc), dermoscopy to confirm the diagnosis and exclude alopecia areata, and reassurance that spontaneous resolution occurs in 80% of cases within 3–6 months once the trigger is addressed. 1, 2

Clinical Pattern Recognition

The presentation strongly suggests telogen effluvium rather than alopecia areata based on several key features:

• Sudden onset of diffuse shedding (clumps on pillow, hair loss while combing) over one week is the hallmark of telogen effluvium, whereas alopecia areata typically presents with discrete patches 2, 3
• Ludwig grade 1 diffuse thinning without inflammation points away from alopecia areata, which would show patchy loss with exclamation-mark hairs 1, 4
• High stress from hectic weekends and schoolwork is a classic precipitant for telogen effluvium, which occurs 2–3 months after a physiologic or emotional stressor 2, 3
• Poor nutrition (microwaved meals) raises concern for nutritional deficiencies that commonly trigger telogen effluvium 1, 2

Essential Diagnostic Steps

1. Dermoscopy (First-Line Diagnostic Tool)

Perform dermoscopy immediately to differentiate telogen effluvium from diffuse alopecia areata: 1, 4

• Telogen effluvium shows: normal follicular openings, no yellow dots, no exclamation-mark hairs 1
• Alopecia areata shows: yellow dots, exclamation-mark hairs, cadaverized hairs, and black dots 1, 4
• Dermoscopy is the single most useful non-invasive tool and can obviate the need for scalp biopsy in most cases 1, 4

2. Targeted Laboratory Testing

Order the following labs because nutritional deficiencies and thyroid disorders are the two most common treatable causes of diffuse hair loss, often without obvious clinical features: 1, 2

• Serum ferritin: Iron deficiency is the most common nutritional deficiency worldwide and a frequent cause of chronic diffuse telogen hair loss; optimal ferritin ≥60 ng/mL is needed for hair growth 1, 4
• TSH and free T4: Thyroid disease commonly causes hair loss and must be excluded 1, 4
• Vitamin D level: 70% of alopecia areata patients have deficiency (<20 ng/mL), and vitamin D plays a critical role in hair follicle cycling 1, 4
• Serum zinc: Zinc deficiency impairs hair follicle function and levels tend to be lower in patients with hair loss 1, 4

Do NOT order extensive autoimmune panels unless dermoscopy reveals findings consistent with alopecia areata, as routine screening is not justified by the modest increase in autoimmune disease prevalence 5, 1

3. Additional Testing Only If Indicated

• Fungal culture: Only if scalp shows inflammation or scaling suggestive of tinea capitis 5, 1, 4
• Scalp biopsy: Reserved for cases where diagnosis remains uncertain after clinical examination and dermoscopy 5, 1, 4
• Lupus serology: Only if systemic features (joint pain, photosensitivity, facial rash) are present 5, 1

Management Algorithm

Immediate Management (Week 1)

Provide strong reassurance that this represents excessive shedding rather than actual permanent hair loss and does not lead to baldness: 2, 6

• Explain that telogen effluvium is self-limited and resolves in 3–6 months once the trigger is removed or treated 2, 3
• Counsel that visible regrowth cannot be expected within the first 3 months 5, 4
• Up to 80% of patients with limited-duration telogen effluvium experience spontaneous remission 1, 4

Address Modifiable Triggers

• Stress management: The hectic schedule and schoolwork are likely precipitants; recommend stress-reduction strategies 2, 3
• Nutritional optimization: Microwaved meals suggest poor nutrition; counsel on balanced diet rich in protein, iron, and vitamins 1, 2
• Reassure about shampoo changes: Switching from Palmolive to Dove is unlikely to be causative or therapeutic; normal hair washing frequency (every other day) is appropriate 2

Treatment Based on Laboratory Results

If ferritin <60 ng/mL: Supplement iron to achieve optimal levels for hair growth 1, 4

If vitamin D <20 ng/mL: Supplement according to general international recommendations for adults 1, 4

If zinc deficiency confirmed: Zinc supplementation may contribute to hair health 1, 4

If TSH elevated with low free T4: Treat hypothyroidism appropriately 1, 4

Follow-Up Strategy

• Recheck in 3 months to assess for spontaneous resolution 2, 3
• If hair loss persists beyond 6 months or worsens, consider alternative diagnoses (chronic telogen effluvium, female pattern hair loss) and refer to dermatology 2, 6

Critical Differential Diagnosis Considerations

Alopecia Areata (Less Likely Here)

• Would show discrete patches rather than diffuse thinning 1, 4
• Exclamation-mark hairs on dermoscopy are pathognomonic 1, 4
• Family history in brother increases suspicion, but clinical pattern does not fit 1, 7
• If dermoscopy reveals yellow dots and exclamation-mark hairs, diagnosis shifts to alopecia areata and management changes to watchful waiting (34–50% spontaneous remission within one year) or intralesional corticosteroids for limited patches 5, 1, 4

Chronic Telogen Effluvium (If Persists >6 Months)

• Excessive diffuse shedding from a normal-looking scalp without obvious cause 2, 6
• May fluctuate for 3–10 years but is self-limiting in the long run 2, 6
• Biopsy shows normal histology, distinguishing it from female pattern hair loss 2

Female Pattern Hair Loss (Less Likely at Age 18)

• Gradual onset with central scalp thinning and widening of central part 2, 8
• Would not present with sudden clumps of hair loss 2

Common Pitfalls to Avoid

• Do not order extensive autoimmune panels for straightforward telogen effluvium; this adds no value and increases cost 5, 1, 4
• Do not overlook the psychological impact: Hair loss can profoundly affect quality of life in young women; assess for anxiety or depression and provide mental health referral if needed 5, 1, 7
• Do not confuse with trichotillomania: In trichotillomania, broken hairs remain firmly anchored in anagen phase, whereas telogen effluvium shows diffuse shedding of club hairs 5, 1, 4
• Do not prescribe topical minoxidil for acute telogen effluvium; it is indicated for androgenetic alopecia, not stress-induced shedding 4, 2, 3
• Do not biopsy routinely: Scalp biopsy is reserved for uncertain diagnoses after dermoscopy, not for classic telogen effluvium 5, 1, 4