MKSAP Quiz: Evaluation for generalized hair loss
A 27-year-old woman is evaluated in the office for generalized hair loss. She has not had any similar episodes previously. The patient is 3 months postpartum and does not take any medications. Following a physical exam, what is the most appropriate management?
A 27-year-old woman is evaluated in the office for generalized hair loss. She has not had any similar episodes previously. The patient is 3 months postpartum and does not take any medications.
On physical examination, vital signs are normal. The scalp skin itself appears normal with no erythema, scale, or scarring. The hair shafts are normal as well. As the hair was combed through, several hairs fell out at the root. The remainder of the examination is unremarkable.
Which of the following is the most appropriate management?
A. Intralesional glucocorticoids
B. Oral finasteride
C. Topical minoxidil
D. Reassurance
MKSAP Answer and Critique
The correct answer is D. Reassurance. This content is available to MKSAP 18 subscribers as Question 29 in the Dermatology section. More information about MKSAP is available online.
This patient has telogen effluvium, and the most appropriate management is reassurance. Telogen effluvium is the most common cause of diffuse alopecia in adult women. Telogen effluvium is a generalized nonscarring alopecia that presents with excessive shedding of normal telogen club hairs. It is due to premature conversion of anagen hair follicles into the telogen, or final, phase of hair development after a physically or psychologically traumatic event such as surgery, parturition, or fever, commonly occurring 3 to 5 months after the event. It is particularly common after pregnancy. No specific therapy is required, and most cases will resolve spontaneously in about 6 to 12 months. Prognosis is especially good if the event causing the alopecia is identifiable.
Intralesional glucocorticoids are the treatment of choice for localized alopecia areata. This tends to present as rapid and complete loss of hair in well-demarcated round or oval patches. There may be some exclamation point hairs at the periphery.
In properly selected patients, finasteride is used to treat androgenic alopecia. Dihydrotestosterone (DHT) binds to androgen receptors in hair follicles, transforming terminal hair follicles to miniaturized hair follicles. Finasteride inhibits the conversion of testosterone to DHT and slows the process of androgenic alopecia. In androgenic alopecia the pattern of hair loss reflects the sensitivity of the hair follicle to DHT. Typically male-pattern hair loss starts with anterior hair line recession with eventual biparietal and vertex hair loss. In contrast, in women the top of the head is affected, and balding is not complete. A classic examination finding is a widening of the central part compared with the occipital part. Finasteride is contraindicated (FDA category X) in pregnant women because it is known to cause birth defects in the male fetus. Women who are or may potentially be pregnant should not take finasteride and should avoid contact with crushed or broken tablets because it can be absorbed through the skin.
Topical minoxidil can be used for male or female patterned hair loss. Minoxidil prolongs the duration of anagen, shortens telogen, and enlarges miniaturized follicles. Like finasteride, minoxidil is ineffective (and unnecessary) in hair loss caused by telogen effluvium.
Key Point
- Telogen effluvium is a generalized nonscarring alopecia triggered by a physically traumatic event such as surgery, parturition, or fever; it usually spontaneously resolves in about 6 to 12 months if the trigger is removed or treated.