Special Considerations in the Evaluation of Females with Hair Loss

19 Special Considerations in the Evaluation of Females with Hair Loss

Nicole E. Rogers

Summary

To be an excellent hair surgeon requires knowing when and when not to transplant. In females, it is especially important to recognize underlying causes of hair loss before they may potentially undermine a successful surgical outcome. For instance, patients with endocrine or hormonal causes for hair loss may see their hair loss easily reversed without need for surgery. Other patients with an early, undiagnosed cicatricial alopecia may lose transplanted hairs if the underlying inflammation is not identified and controlled. In this chapter, we discuss the many factors that must be considered specifically for women with hair loss, although some of these conditions may overlap with those seen in male patients.

Keywords: telogen effluvium hormones thyroid lab workup scalp biopsy

Key Points

•Hair loss can result from thyroid disorder, polycystic ovarian disease, childbirth, starting or stopping birth control pills, and taking androgenic hormones or supplements.

•Hair breakage can masquerade as hair loss.

•While hair loss has been linked with low iron or vitamin levels, correcting these alone may or may not address the underlying problem of female pattern hair loss.

•The presence of miniaturization on dermoscopy and a strong family history of hair loss can simplify the diagnosis of female pattern hair loss.

•A scalp biopsy can be helpful in identifying the nature of hair loss.

19.1 Introduction

Hair loss in women is particularly devastating. Women also must often undergo a more circuitous evaluation before arriving at a diagnosis of female pattern hair loss (FPHL). In many patients, the diagnosis is relatively straightforward, especially if they have a close family relative who developed hair loss at an early age. However, in other cases, there is no family history of hair loss, or it is unknown. These patients are often referred from one physician to another (internist, obstetrician, endocrinologist, etc.) before finally arriving in your office for the correct diagnosis.

19.2 Underlying Etiology

A key component to the workup of hair loss in women is to understand the timing of their hair loss. A history of gradual thinning will point to FPHL, while an abrupt onset of shedding will point to a telogen effluvium (temporary hair shedding due to an underlying physiologic change or stressor). Many patients may have a combination of the two, wherein one condition (telogen effluvium) unmasks another (inherited FPHL, or androgenetic alopecia [AGA]). Shedding for more than 6 months is considered chronic telogen effluvium and can be more difficult to identify and treat.

There may also be a component of hair breakage that masquerades as hair loss. In Caucasian women, one should ask about grooming techniques such as the use of flat irons or “keratin” treatments, which can result in trichorrhexis nodosa. Both techniques use very high heat that can cause fractures in the hair shaft and lead to breakage. Frequent highlighting of hair in combination with use of curling iron can also make the hair more porous and subject to breakage. This is especially true if they have an underlying FPHL wherein the miniaturized hairs are already more prone to damage. This breakage may be perceived as a loss of hair because of the loss of overall volume.

Patients of African ancestry who wear their hair in tight braids, wigs, or use glued-in hair pieces can suffer from varying degrees of temporary or more permanent hair loss. The use of sewed-in “weaves” or “quick weaves” (where a stocking cap is placed on the head, coated in superglue, and tracts are applied) has resulted in permanent hair loss for thousands of unsuspecting women of African ancestry who are only following their hairdressers’ recommendations. They may also suffer from breakage due to flat irons or relaxers.

19.3 Past Medical History

It is essential to obtain a complete medical history. Women who recently delivered a baby can present with abrupt shedding 3 to 6 months after childbirth (telogen effluvium). Patients with recent history of cancer treated with chemotherapy may have anagen effluvium. In these cases, the hair may or may not regrow, or it may only partially return. The hair that grows back may also present with a completely different color or texture. Patients with a recent history of massive weight loss or who have undergone crash dieting can also present with unusual shedding.

Patients starting on new medications may have hair loss related to a new drug. The most common offenders are isotretinoin (Accutane) or high-dose vitamin A supplements. A number of cardiovascular drugs have been blamed for FPHL such as warfarin and beta-blockers. It is important to understand that there is an underlying genetic link between hair loss and cardiovascular diseases such as diabetes, hypertension, and hypercholesterolemia 1^,². Thus, it is not always easy to pin hair loss on this class of medications when there may be confounding data.

Starting or stopping birth control pills can create hair loss. Postmenopausal women who are starting on hormone supplements containing testosterone or other more androgenic progesterone formulations such as norethindrone can also develop hair loss. There is also possibility (still unproven) that the simple process of going through menopause may result in hair shedding. As estrogen production wanes, it is less able to mask the concomitant androgen production.

Be sure to identify all prior treatments. This will also be helpful in learning what over-the counter products the patient has tried, as well as supplements or hair loss medications. It is also helpful to know how long they tried each regimen: patients can hardly say that they “failed” minoxidil if they tried it only for 3 weeks. Likewise, find out what formulations of hair loss treatments were taken. If patients stopped minoxidil solution early due to scalp itching, consider how they may have had a contact dermatitis to the preservative propylene glycol and consider trying again with the foam formulation instead.

Perhaps the most important aspect of the history is collecting the family history of hair loss. As a physician you may spend 30 to 45 minutes going through medications only to find out at the end that her twin sister wears a wig, or that their father went bald while he was still in college. Knowing these clues early on can help you arrive at a diagnosis of FPHL much earlier than you might otherwise.

19.4 Review of Systems

It is helpful to ask about the presence of acne, unwanted facial hair, irregular periods, dandruff, and difficulty getting pregnant. These may occur in the setting of polycystic ovarian disease (PCOS), which can lead to hair thinning. Patients are usually diagnosed with PCOS by their gynecologist based on ultrasound results showing ovarian cysts. However, more subtle cases may be diagnosed based on an elevated luteinizing hormone/follicle-stimulating hormone ratio and/or elevated testosterone levels. These patients may benefit from antiandrogen therapies such as spironolactone, metformin, or combination birth control (estradiol + drospirenone). Likewise, an androgen-secreting tumor may present with deepening of the voice or virilization of external sex organs.

Patients with menstrual irregularity or no periods (oligomenorrhea) in addition to a milky discharge from the breasts (galactorrhea) while not pregnant or breast-feeding should also be worked up for prolactinemia. Transgender patients may require extra time and consideration during the workup. They frequently are already taking finasteride in addition to estrogenic hormone supplementation. In such instances, it may even be helpful to work with their primary physician or endocrinologist.

The presence of fatigue may also be helpful. For instance, it may suggest an underlying thyroid abnormality, as well as low ferritin (iron stores) or anemia. Women with very heavy periods either due to fibroids or family history may be especially vulnerable to low iron stores and need supplementation. Fatigue may also point to a vitamin or mineral deficiency. Many physicians empirically give their hair loss patients B12 injections “for energy,” but there are little data to support this. Cases of extreme sleep apnea may also present with hair loss and fatigue. For each patient, the personal history and medical conditions must be considered on a case-by-case basis.

All females with hair loss should be questioned about the presence of scalp itching, burning, or tenderness. This may be an indicator of an underlying inflammatory cause of hair loss. Severe seborrheic dermatitis, scalp psoriasis, or contact dermatitis to a cosmetic ingredient in shampoo, conditioner, or other hair product could lead to abrupt onset of shedding. Likewise, scarring alopecias such as lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), or central centrifugal cicatricial alopecia (CCCA) can present with scalp itching or burning. Less common inflammatory causes of hair loss are folliculitis decalvans, dermatomyositis, lupus, or scleroderma.

19.5 Laboratory Workup

It can be helpful to do blood work in women with hair thinning, but it does not always solve the issue at hand. For instance, it is known that women with hyper- or hypothyroidism can and will often present with hair loss. However, the treatment of this, in the context of inherited female pattern thinning, may not fully resolve the hair thinning or shedding until relevant medical therapy is started. While many physicians order a full panel of thyroid tests, a simple thyroid-stimulating hormone (TSH) is very sensitive. Patients whose TSHs are in the normal range do not generally require additional evaluation, unless suspicion is very high due to symptomology.

It is important to ask patients to stop biotin supplementation prior to thyroid testing. There is a report in the medical literature of a gentleman who was erroneously diagnosed with Graves disease while on high-dose biotin for his multiple sclerosis.3 Many hair loss patients will have already initiated high-dose biotin before coming in for their visit. Fortunately, the washout period is very short and so patients only need be off of it for about a week before thyroid testing is done.

For iron stores, the connection with hair loss is still controversial. Some studies have confirmed a correlation, while others have shown that treating the low iron stores does not reverse the hair loss (especially in cases of inherited FPHL). While a screening complete blood cell count can be helpful in such situations, it is usually more accurate to order ferritin levels (a measure of iron stores) as well as iron/total iron-binding capacity levels directly.

Recent data found that in patients with telogen effluvium, the most relevant labs to test were ferritin, vitamin D, and zinc.⁴ Another study recently confirmed a link between low vitamin D levels and FPHL.⁵ There have been reports of alopecia in infants with faulty vitamin D receptors, but the data are still fairly limited linking FPHL with low vitamin D. For each patient, one should also consider a patient’s willingness to undergo potentially expensive lab testing. For instance, various government-subsidized programs may or may not cover a vitamin D test for a woman with alopecia. It is wise to discuss this with patients beforehand so they are not surprised after the fact.

It is important to rule out easily identifiable underlying causes of hair loss before committing a patient to lifelong medical therapy or hair transplantation. Different physicians will order more or less extensive lab workup based on their experience and the review of symptoms. Table 19.1 summarizes some of the lab values that may be helpful in evaluating your patient.

Table 19.1 Laboratory work-up and corresponding referral plan

Additional symptoms	Pertinent lab test	Referral or treatment
Fatigue	Ferritin^a, iron/TIBC	Internist or hematologist
Fatigue, restlessness, temperature irregularities, heart palpitations	TSH	Endocrinologist
Fatigue especially in darker skin types	Vitamin D	Vitamin D3 50,000 units weekly × 8 wk
Unwanted facial hair, deepening of voice, irregular periods, infertility	Testosterone, DHEAS, LH/FSH	Gynecologist or endocrinologist
Dermatitis, diarrhea, dementia	Zinc	Internist
Oligomenorrhea, galactorrhea	Prolactin	Gynecologist or endocrinologist
Abbreviations: DHEAS, dehydroepiandrosterone sulfate; FSH, follicle-stimulating hormone; LH, luteinizing hormone; TSH, thyroid-stimulating hormone; TIBC, total iron-binding capacity. ^a If elevated consider hemochromatosis.

19.6 Physical Examination

Patients should be seated at or below eye level for scalp examination. Ideally, the patient should be seated on a stool or chair with 360-degree access. A careful clinical examination should include the frontal and occipital hairline, the sideburns, the eyebrows, and the face. By parting the hair down the center, one can compare the width of the part over the top of the scalp with the width in the occipital scalp. Where there is a noticeably wider part over the top of the scalp than the occiput, FPHL should be strongly considered (Fig. 19.1).