Diagnosing and Treating Hair Loss Among Women

Include the differential on the requisition slip that you want to distinguish (e.g., “androgenic alopecia rule out telogen effluvium or alopecia areata”). A sample of at least 6 mm is required to ensure that hair follicles at several stages of the growth cycle are present. 

Ideally, a dermatopathologist as well as a clinician who is experienced in analyzing hair biopsies should read the hair pathology. For this reason, it may preferable to have the biopsy performed by a local dermatologist who has a working relationship with different pathologists.

The pathology is particularly important because androgenic alopecia has a classic presentation of miniaturization of terminal pigmented anagen hairs to fine hypopigmented vellus hairs.


Treatment options include topical OTC minoxidil 2% (Rogaine, Theroxidil) applied twice a day¹ or hair transplanation. Minoxidil increases the length of time follicles spend in anagen, wakes up follicles in catagen, and enlarges the actual follicles. 

The most common side effect associated with minoxidil is irritant dermatitis, which is most likely attributable to the vehicle and stabilizers rather than the active ingredient. Unwanted hair growth may be seen in other places on the body. Women who are pregnant or breastfeeding should not use minoxidil, as it can cause hypertrichosis in infants.

Patients must use minoxidil for at least four to six months to evaluate efficacy. Many patients report that minoxidil does not lead to new hair growth but simply slows the rate of hair loss. Use of the product must be continued for as long as the patient wishes to sustain the results.


Hair transplantation is a cosmetic procedure performed in the office under local anesthesia. Hair from the uninvolved area is transplanted to the area with loss. Disadvantages of this treatment option include cost and the appearance of the final result.



Telogen Effluvium


Hairs are normally shed in the telogen phase. Telogen effluvium is a scalp disorder characterized by increased shedding of undamaged hairs in the telogen phase in response to a change in health status. The process that tells the hair when to enter the anagen, telogen, and catagen phase is complex.

In individuals with telogen effluvium, some external factor instructs an abnormally large number of hairs to enter the telogen phase and subsequently be shed. These external factors include, but are not limited to, medications, pregnancy, malnutrition and stress (Table 2).² 

Table 2. Common causes of telogen effluvium

Childbirth, pregnancy, or miscarriage

Chronic illness (e.g., HIV, lupus)

Endocrine abnormality (e.g., hypothyroidism, hyperthyroidism, hyperparathyroidism)

Malnutrition

Medications (e.g., retinoids, high-dose vitamin A, anticoagulants [especially heparin], antithyroids, anticonvulsants, interferon, heavy metals, and beta-blockers)

Post-febrile/post-infection

Post-surgery

Psychological stress

Rapid weight loss following a crash diet or bariatric surgery

Discontinuing oral contraception

Since it can take up to three months for the hair loss to start or become noticeable, a thorough medical, psychological and surgical history must cover at least the past six months.


The diagnosis of telogen effluvium is one of exclusion combined with analysis of the hair-loss pattern, lab results, and patient history. Laboratory work should include thyroid and chemistry panels, erythrocyte sedimentation rate, antinuclear antibody, and a complete blood count with differential, hematocrit, and ferritin tests. If possible, stop the offending agent/medication or correct the underlying abnormality.

Consider recommending counseling and or medication if psychological stress is the underlying cause. The “tincture of time” (that is, waiting for the body to normalize) may be the best bet for a patient recovering from a change in his or her health status. Make sure the patient is otherwise healthy, eating a balanced diet, taking a multivitamin containing very little or no vitamin A (too much vitamin A can cause hair loss), and 5 mg/day of OTC biotin, which has been shown to accelerate hair growth and thicken existing hair. 

 

Trichotillomania


Individuals with trichotillomania pull out their own hair, including eyebrows and eyelashes. This condition is more commonly seen in women and may be accompanied by such concomitant psychological disorders as depression, psychosis, impulse-control disorders, personality disorders, anxiety, and body dysmorphic disorder.

The patches of alopecia caused by the hair pulling often have bizarre sharp, irregular borders, and result in hairs of varying lengths. Some describe confirming the diagnosis by shaving the same patch of scalp weekly to show the normal dense regrowth, but I have rarely seen this in practice.

This article originally appeared on Clinical Advisor