What is the appropriate evaluation and management for hair loss?

Management of Hair Fall

Start with topical minoxidil as first-line treatment for androgenetic alopecia (the most common cause of hair loss), adding oral finasteride for men if needed, while simultaneously ruling out reversible causes through targeted laboratory testing. 1

Initial Diagnostic Approach

Classify the Pattern of Hair Loss

• Determine if the alopecia is diffuse, patterned, or focal to guide your differential diagnosis and treatment strategy 1
• For women with progressive scalp thinning, chronic telogen effluvium is the most important differential diagnosis to consider alongside female pattern hair loss 2
• Other mimickers include acute telogen effluvium, diffuse alopecia areata, trichotillomania, early scarring alopecia, and systemic lupus erythematosus 2

Essential Laboratory Testing

Order these four tests in all patients with hair loss: 3

• Complete blood count
• Ferritin level
• Thyroid stimulating hormone (TSH)
• Vitamin D 25OH

These tests identify malnutrition, autoimmune diseases, and endocrine disorders that commonly cause hair loss 1

Physical Examination Findings

• Perform a hair pull test and hair tug test to assess active shedding 3
• Use trichoscopy (dermoscopy of the scalp) to identify diagnostic features like yellow dots, black dots, and dystrophic hairs 4
• Scalp biopsy is essential in all cases of scarring (cicatricial) alopecia to confirm diagnosis 3

Treatment Algorithm by Type

Androgenetic Alopecia (Pattern Hair Loss)

This is the most common form of alopecia and is typically genetic 1

First-line treatment:

• Topical minoxidil for both men and women 1
• Oral finasteride for men as an additional or alternative option 1
• Low-dose oral minoxidil (LDOM) is an emerging alternative with promising results 5

Adjunctive therapies with synergistic benefits:

• Low-level laser therapy (LLLT) 5
• Platelet-rich plasma (PRP) injections 5

Novel device-based therapy:

• Electrotrichogenic devices delivering low-level electrical stimulation showed 19.3% increase in hair density at 6 months with no adverse effects 6

Telogen Effluvium (Diffuse Hair Loss)

• These conditions are usually self-limited and depend on stopping the underlying cause such as stress, medications, or nutritional deficiencies 1
• Address the triggering factor (medication discontinuation, stress management, nutritional supplementation) 1
• Reassure patients that recovery typically occurs within 6-12 months after removing the trigger 7

Alopecia Areata (Focal Hair Loss)

Treatment intensity depends on severity:

For mild to moderate disease:

• Intralesional corticosteroid injections are first-line 1
• The condition is typically self-limited 1

For severe disease (SALT score ≥50):

• Baricitinib 4 mg daily (JAK inhibitor) is highly effective, with 63.2% of patients achieving SALT ≤20 at 48 weeks in real-world data 4
• Baricitinib also significantly improves quality of life and reduces anxiety/depression associated with severe alopecia areata 4
• Oral immunosuppressant therapy is an alternative option 1
• Adverse events with baricitinib occurred in only 9.4% of patients 4

Tinea Capitis (Fungal Infection)

• Treat with oral antifungals as topical therapy is insufficient 1

Traction Alopecia

• Decrease tension on the hair by modifying hairstyling practices 1
• Early intervention prevents progression to permanent scarring alopecia 7

Critical Pitfalls to Avoid

• Do not overlook the psychological impact: Patients with moderate to severe hair loss commonly experience anxiety, depression, lower work productivity, and reduced quality-of-life scores 1
• Do not delay treatment in scarring alopecias: These require urgent diagnosis and treatment to prevent permanent hair loss 7
• Do not assume all diffuse hair loss is androgenetic alopecia: Chronic telogen effluvium is frequently misdiagnosed as female pattern hair loss 2
• Do not skip laboratory testing: Systemic diseases including thyroid disorders, iron deficiency, and autoimmune conditions are common reversible causes 3

When to Refer

Refer to dermatology for: 7

• Diagnostically challenging cases
• Scarring (cicatricial) alopecias requiring biopsy
• Cases not responding to first-line treatment
• Patients requiring advanced therapies like JAK inhibitors

Patient Education

Educate patients about: 1

• Expected timeline for hair regrowth (typically 3-6 months minimum)
• Realistic treatment outcomes
• The chronic nature of androgenetic alopecia requiring ongoing treatment
• This helps patients feel heard and reassures them their condition is being taken seriously 1