Levels of evidence (grades A-C) and recommendation grades (levels I-III) are defined at the end of the "Major Recommendations" field.
Major Recommendations (All are level II)
Diagnostic Evaluation
History and Physical Examination
- Patient history of alopecia: onset of hair loss, hair loss pattern (diffuse or focal), rate and timing of hair loss, other scalp symptoms (itching, burning, tingling)
- Personal history: dietary changes, diet, hair-care routine, hygiene products, medications (prescription medications, vitamins, over-the-counter [OTC] medications, and herbal remedies), stress, major illness
- Female patient: menstrual and reproductive histories
- Any family history of alopecia, patient's concurrent systemic/chronic illness, physical stress, medication, environmental exposure, psychiatric disorders, hairstyle, signs and symptoms of hormonal abnormalities
- Physical examination:
- Scalp exam for any scars, erythema, scaling, or inflammation
- Density and distribution of hair
- Hair shaft exam for caliber, length, shape, and fragility
- Thyroid palpation to determine thyroid size, nodularity, or vascularity
- Use "pull test" technique for hair loss. Grasp about 60 hairs between the thumb, the index, and the middle fingers. The hairs are then gently but firmly pulled. A positive test (2–10 hairs obtained) indicates an active hair shedding.
If a patient demonstrates positive hair-pull tests all over the scalp, he/she may be warned he/she will most likely lose all of their hair. Next, provide anticipatory guidance during the period of extensive hair loss as the cycle reestablishes and regrowth begins.
Finally, determine if eyebrow, eyelash, axillary, or body hair is affected. Examine hair density in other areas such as the face and extremities. A female patient who presents with thinning scalp hair and demonstrates increased facial, thigh, chin, or chest hair may have an androgen excess.
Laboratory Studies
Once other causes such as malnutrition, androgenetic, hereditary conditions (by history, progression, and presentation), trauma (trichotillomania, traction alopecia), and drugs (telogen effluvium) have been ruled out, consider labs for secondary conditions:
- For female alopecia with symptoms of hyperandrogenism (such as menstrual irregularities, infertility, cystic acne, virilization, or galactorrhea), check total testosterone, free testosterone, dehydroepiandrosterone sulfate (DHEA-S), or prolactin levels.
- For male and female alopecia without symptoms of hyperandrogenism, consider measurement of serum thyroid stimulating hormone concentration to rule out thyroid disease; venereal disease research laboratory (VDRL) technique to rule out syphilis; serum ferritin to rule out anemia; antinuclear antibody test (ANA), RF (rheumatoid factor) to rule out autoimmune disease; potassium hydroxide (KOH) examination to rule out tinea capitis; swab a wound culture to rule out infections; and scalp biopsy as needed to rule out neoplasm.
Disorders Causing Hair Loss in Adults
- Androgenetic alopecia
- Male: Hereditary. Dihydrotestosterone compels follicles into perpetual telogen phase. The earlier oral or topical treatment is started, the better results one may expect.
- Female: Female androgenetic pattern incidence increases with age. Incidence is approximately 6% in women under 50, but increases to 38% in women over 70. Female pattern hair loss typically demonstrates a lower density of hair but maintains a relatively even distribution, known as "Ludwig" distribution. Even thinning across the crown is typical, while the frontal line maintains position.
- Telogen effluvium
- Telogen effluvium is the most common form of diffuse alopecia. It is often diagnosed from a history of an initiating event 3 months before the onset of shedding. Causes include childbirth, sustained high fever, surgery, systemic disease exacerbation, crash low protein diets, severe emotional stress, and drug reactions. Pull tests are positive all over the scalp. Bitemporal recession is a useful diagnostic sign in women. The acute form normally subsides in 3 to 6 months. In true telogen effluvium, the hair invariably regrows within a short time.
- Postpartum telogen effluvium
- This condition is associated with postpartum hormone-related changes that temporarily prolong hair resting phase. It is most commonly seen 2 to 4 months postpartum.
- Anagen effluvium
- Anagen effluvium is drug or toxin-induced and may mimic diffuse alopecia areata. Chemotherapy is the most common cause.
- Trichotillomania
- Trichotillomania is the manifestation of a psychogenic behavioral pattern of frequent hair-pulling by the patient. It is frequently related to obsessive-compulsive disorder and can be seen in males and females of all ages, but most commonly in preadolescent and early adolescent girls. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The bald area manifests as a distinct, unnatural geometric shape. Hair may be pulled from a secondary site, such as the eyelashes, eyebrows, underarms, body, or pubis. Assess for other psychosocial factors and disorders and refer for counseling as indicated.
- Diagnostic and Statistical Manual-IV (DSM-IV) Criteria for Trichotillomania:
- Recurrent pulling out of one's hair, resulting in untreatable hair loss
- Increasing sense of tension immediately before pulling out the hair or when attempting to resist behavior
- Pleasure, gratification, or relief when pulling out the hair
- The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatologic condition).
- Alopecia areata
- Alopecia areata is an inherited autoimmune condition of varying severity. In some patients, hair loss is confined to one or more small oval patches; in others, the scalp is essentially denuded except for a few tufts of hair. It may involve the entire scalp (alopecia totalis) or the surface of the whole body (alopecia universalis). The condition is marked by exacerbation and recovery with high variability among individuals.
- Tinea capitis
- Tinea capitis is a contagious fungal infection of the scalp mostly seen in ages 4 to 14 years. There are fine, scaly, circumscribed areas that are frequently itchy and inflamed. Hair is dull and brittle, breaking off at scalp. In more extensive cases, there may be fever and cervical lymphadenopathy. In the United States, over 90% of cases are from the nonfluorescent Trichophyton fungus. Potassium hydroxide (KOH) examination shows hyphae. Antifungals such as terbinafine, fluconazole, itraconazole, or griseofulvin are used for treatment.
- Systemic lupus erythematosus (SLE)
- SLE is a chronic autoimmune inflammatory disease affecting collagen. It involves multiple systems of the body including hair loss.
- Secondary syphilis
- Secondary syphilis usually begins 2 to 8 weeks after chancre type lesions appear. It can present with patchy hair loss, mostly on the scalp and often elsewhere on the body. This hair loss is often described as having a moth-eaten appearance. High-risk clients should also be questioned regarding past rashes, especially on the palms, soles, and any chancroid lesions or condyloma. Diagnosis is serologic (VDRL or rapid plasma regain [RPR]), and hair regrowth occurs after penicillin therapy. Penicillin remains the first choice, but if an allergy exists, intramuscular Rocephin (x 10 days), tetracycline, or doxycycline may be tried for 2 weeks.
- Side effects of medications
- Medications such as cytotoxic agents, colchicine, heparin, oral anticoagulants, hydroxyurea therapy, vitamin A, captopril, protease inhibitors such as indinavir and nelfinavir, amphetamines, anticancer agents, gout medication, isotretinoin (Accutane), lithium, male hormones, propranolol hydrochloride (Inderal), and valproic acid (Depacon, Depakene, Depakote), can all induce nonscarring hair loss.
- Birth control pills
- Women who lose hair while taking birth control pills may have an inherited tendency for hair thinning. If hair thinning occurs, a woman can consult her gynecologist about switching to another birth control pill. When a woman stops using oral contraceptives, she may notice that her hair begins shedding two or three months later. This may continue for six months when it usually stops. This is similar to hair loss after the birth of a child.
- Caustic chemicals
- Anyone who curls, straightens, colors, or dyes their hair may cause hair loss. Repeated exposure to these substances can injury hair follicles, weaken hair, or even damage the scalp. It is most often seen in African women, and inflammation is not always obvious.
- High fever or severe infection
- Acute and some chronic illnesses may cause hairs to enter a prolonged resting telogen phase (also known as telogen effluvium). It is not uncommon to experience a higher incidence of hair loss up to three months after high fever, severe illness, or infection. This resting phase typically resolves after several months and normal hair growth rebounds when the growth cycle returns.
- Other causes of hair loss
- Other causes of hair loss include anemia, hypoalbuminemia, malnutrition, Lichen planus, Staphylococcal folliculitis, scleroderma, psoriasis, seborrhoeic dermatitis, menopause, hypothyroidism, herpes zoster, and others.
Treatment Recommendations
The choice of therapeutic intervention for alopecia depends on several factors:
- The underlying cause
- The goals of therapy
- The long-term risks, benefits, costs
The evaluation and treatment of alopecia should begin as early as possible after the onset of symptoms. Many conditions causing alopecia or reduced hair density may be reversed or minimized with prompt intervention.
Pharmacologic – Treatment of the Underlying Illness
- Hypothyroidism
- Thyroid replacement or adjustment as indicated
- Fungal infection
- Ketoconazole, oral antifungal agents such as griseofulvin (Grifulvin), itraconazole (Sporanox), terbinafine (Lamisil), and fluconazole (Diflucan) may be used. Oral steroids may be necessary to decrease inflammation and scarring.
- Hormone imbalance
- If female androgen excess is suspected (hirsutism, acne) or menses is irregular, check DHEA-S and free testosterone levels first to rule out adrenal or ovarian cancer.
- Once ruled out, consider spironolactone, flutamide, or finasteride.
- Spironolactone competes with testosterone and dihydrotestosterone at the androgen receptor level. Spironolactone 100 mg per day can be given in divided doses; this dose may be increased to 200 mg.
- Flutamide (Eulexin), an antiandrogen that blocks androgen uptake and nuclear binding, is a very effective drug in treating hyperandrogenism. Give 250 mg daily and monitor hepatotoxicity.
- Finasteride (Propecia) blocks the conversion of testosterone to dihydrotestosterone. The plasma levels of testosterone may increase during treatment, whereas the dihydrotestosterone level decreases. Of utmost importance, the patient should be aware that she must avoid pregnancy during treatment with finasteride because of the potential for causing ambiguous genitalia in a male fetus.
- Drug-induced hair loss (effluvium)
- Drugs that induce hair loss include antihypertensive agents, anti-gout medications, etc. Consider tapering or discontinuing the medication if untoward risks are low.
- Chemotherapy
- Recommend nonpharmacologic therapy (wig, hairpiece).
- Psychological causes of hair loss (Trichotillomania)
- Consider behavioral therapy, antianxiety or antidepressant medication, or any combination of the two.
- Physical stress from surgery/acute illness
- Reassure patient hair regrowth once stress removed.
- Lupus and diabetes
- Treat underlying diseases.
- Traction alopecia
- Hair loss that is secondary to grooming such as tight braids, "cornrows," pony tail: Change hair styling technique.
- Drug therapy for alopecia (alopecia with no underlying disease)
- Minoxidil (Rogaine 2% for women, Rogaine 5% for men): Apply 1 mL twice a day (BID) regardless of the extent of the affected area; one year of use may be needed before obvious efficacy. Minoxidil is mainly for hair loss at vertex, not for frontal baldness.
- Propecia (finasteride 1 mg): Food and Drug Administration (FDA) approved; for MEN ONLY
- Monotherapy or synergistic use:
- For women - May add estrogen to any therapy
- For men/women - May add tretinoin (Retin-A) topical as an adjunct/synergistically with minoxidil
Nonpharmacologic Treatment
- Cosmetic measures (hairstyle adjustments, wigs, extensions, hair pieces, hats, scarves)
- Cessation of wearing tight braids, buns, pins
- In chemical/allergic causes, avoidance of the identified sources
Monitoring Treatment/Discontinuation of Treatment
Patients with Hypothyroidism
Initiate thyroid hormone replacement therapy to obtain thyroid-stimulating hormone (TSH), triiodothyronine (T3), and thyroxine (T4) in the normal range. Treatment will be long term, even as hair regrowth occurs. Monitor hair regrowth in each follow up with hypothyroidism.
Patients Considered for Treatment Related to Fungal Infection
If long-term antifungal treatment is required, monitor liver function and gastrointestinal (GI) symptoms. Obtain baseline alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin before treatment. Reevaluate in 4 to 8 weeks. Discontinue if there are any GI symptoms or signs of liver dysfunction such as fatigue, nausea, anorexia, vomiting, dark urine, or pale stools. Monitor drug interactions when patients have comorbidities and are using other medications. Check safety of different antifungals on women in childbearing ages.
Patients with Androgenetic Imbalance
Monitor hepatotoxicity if the patient is treated with flutamide. Monitor irregular menses, reduced libido, mood swings, and electrolytes if treated with spironolactone.
Patients on Medications for Hair Loss
Minoxidil (Rogaine) - Topical use
Since its mechanism of action is to stimulate hair growth by vasodilation, it may exacerbate angina pectoris. Use with caution in patients with pulmonary hypertension, congestive heart failure, coronary artery disease, and significant renal failure. Topical use may also cause pruritus, and Stevens-Johnson syndrome.
Finasteride (Propecia)
Give 1 mg daily (QD) with or without food to MALE patients only. Pregnant women or women who may potentially become pregnant should not touch crushed tablets because of teratogenic effects on male fetus. Monitor hepatic function. Potential side effects include decreased libido and erectile dysfunction.
Steroids (e.g. prednisone)
Side effects of steroids include diabetes, weight gain, hypertension, electrolyte and fluid imbalance, osteoporosis, striae, acne, renal function impairment, avascular necrosis, and immunosuppression. Abrupt discontinuation may cause adrenal crisis.
Individualization of Therapy
- The Women's Androgenetic Alopecia Quality of Life Questionnaire (WAA-QOL) is useful in evaluating health-related quality of life (HRQOL) specific to women. It is self-completed in about 10 minutes and may serve both to indicate the impact on the patient (and potential indication for intervention) and evaluate therapeutic responses to therapy.
- Decide whether the patients want to use topical treatment or oral treatment. Patients at different ages may have preferences.
- The hair growth cycle is slow. Affected changes take time to notice. Once therapy is selected, stick with it for 3 to 6 months and then reevaluate.
- Treatment follow-up (3- to 6-month intervals).
- Adjust therapy and identify causes if inadequate response.
Important Considerations
Cosmetic management and psychosocial adaption
- Regrowth of new or thicker hair for larger scalp coverage
- Decreased rate of hair loss (i.e., slow down balding progression)
- Surgical reconstruction
- Cost and side effects of drug therapy
- Tolerability of therapy (patient satisfaction with care, quality of life, and adherence to treatment regimen)
- Final assessment and evaluation including hair density readings
- Assessment of patient satisfaction as measured by quality of life index
Screening and diagnosis
Routine laboratory tests help to determine the presence of underlying causes and risk factors that would affect treatment. Optional tests may be used, depending on findings obtained in the history and physical examination and previously known conditions. A greater, more inclusive assessment can be determined by referral to dermatology.
Informed guidance to treatment options
Clinicians should begin by providing the patient with a summary of information on:
- Causes of hair loss and their respective potential to respond to medical therapies
- Details of what therapeutic options involve, including directions for use, potential side effects, interactions, timeline for responses, follow-up visits, financial expense, and long-term outcomes
Evaluate treatment goals
The primary objective of treatment is to reach therapeutic responses as closely to patient goals within budget and expectation that is both understood and acceptable by the informed patient. To modify drug therapy and maximize response toward patient goals, clinicians should consider cost where therapeutic effect is equal. To facilitate compliance, clinicians should choose medications with simple regimens.
Therapeutic adjustment and further individualization
- Titrate drug or add another agent if there is good tolerance but poor response. Allow for several weeks to two months before drug or dosage changes are made. If the response remains less than anticipated, substitute with a drug of a different class or action.
- Always consider alternative explanations for poor response to drug therapy to explore secondary causes.
- In each patient encounter, reassess adherence, quality of life, and patient goals. Assess the long-term response to therapy. Reassess side effects that might complicate therapy or limit efficacy. Monitor the development of target organ damage. Reinforce lifestyle modification.
Evaluate the efficacy of therapy
- To assess adequacy of hair growth, use an objective measurement tool such as a scalp chart, comparison with before-treatment photos, and a subjective self-assessment of quality of life before and after treatment.
- Patients should be seen within 1 or 2 months after the initiation of therapy to determine therapeutic response, degree of patient adherence, and presence of adverse effects. Earlier follow-up may be necessary for patients with underlying comorbid conditions.
- Once the patient's response is observed, follow-up at 3- or 6-month intervals (depending on the patient status) is generally appropriate.
- Consider referral or consultation in unresponsive or complex comorbid cases.
Definitions
Levels of Evidence
Grade A: Randomized clinical trials
Grade B: Well-designed clinical studies
Grade C: Panel consensus
Strength of Recommendation
Level I: Usually indicated, always acceptable, and considered useful and effective.
Level II: Acceptable, of uncertain efficacy, and may be controversial. Weight of evidence in favor of usefulness/efficacy.
Level III: Acceptable, of uncertain efficacy, and may be controversial. May be helpful, not likely to be harmful.
