A 27-year-old woman comes to the office due to hair loss. For the last week, small clumps of hair have come out when she showers or brushes her hair. There is no associated pain or itching in the scalp. The patient had an uncomplicated vaginal delivery of her second child 3 months ago, and her medical history is otherwise unremarkable. She is breastfeeding and continues to take a prenatal vitamin. She does not use tobacco, alcohol, or illicit drugs.
Vital signs are normal. Skin examination shows diffuse hair loss across the scalp with no other abnormalities. Complete blood count and serum chemistries are normal. Serum TSH is 4.0 µU/mL and free T4 is 1.2 ng/dL (normal: 0.9-2.4).
Which of the following is the most appropriate next step in management of this patient's hair loss?

Question

A 27-year-old woman comes to the office due to hair loss.  For the last week, small clumps of hair have come out when she showers or brushes her hair.  There is no associated pain or itching in the scalp.  The patient had an uncomplicated vaginal delivery of her second child 3 months ago, and her medical history is otherwise unremarkable.  She is breastfeeding and continues to take a prenatal vitamin.  She does not use tobacco, alcohol, or illicit drugs.
Vital signs are normal.  Skin examination shows diffuse hair loss across the scalp with no other abnormalities.  Complete blood count and serum chemistries are normal.  Serum TSH is 4.0 µU/mL and free T4 is 1.2 ng/dL (normal: 0.9-2.4).
Which of the following is the most appropriate next step in management of this patient's hair loss?

Quizplus · Accepted Answer

11ec193a_9796_c21e_853d_736218348181_MD0002_00 This patient has acute, diffuse, noninflammatory hair loss consistent with telogen effluvium (TE), one of the most common causes of hair loss in adults. Hair follicles pass through 3 phases: growth phase (anagen; 90% of follicles), transformative phase (catagen; <1%), and rest/shedding phase (telogen; 10%). In TE, follicles undergo a widespread shift into the rest/shedding phase, with cessation of growth and subsequent shedding. It is often triggered by a stressful event, such as severe weight loss, pregnancy, major illness or surgery, or psychiatric trauma. The diagnosis of TE is based on clinical findings. Patients have widespread thinning of hair, but the scalp and hair shafts appear normal. In the hair pull test, small tracts of hair (50-60 fibers) are pulled firmly; extraction of >10%-15% of fibers is abnormal and suggests TE. If the cause is not apparent, a limited laboratory evaluation, including complete blood count (and ferritin), TSH, and a serum chemistry panel, may be worthwhile. There is no specific treatment for TE. It is a self-limited disorder but may take up to a year to resolve completely. (Choices A and C) Finasteride and minoxidil are used in the treatment of androgenetic alopecia, which causes chronic, gradual thinning of the hair; in women, this thinning occurs predominantly at the vertex. Minoxidil is occasionally used off-label for TE but is poorly studied. Finasteride is contraindicated in women of childbearing age. (Choice B) Topical corticosteroids are occasionally used for alopecia areata (circumscribed patches of hair loss) and seborrheic dermatitis (erythema and greasy scaling). They are not useful for TE. (Choice E) Cognitive-behavioral therapy is typically used for trichotillomania. Patients with this disorder have irregular areas of broken hairs, often predominantly affecting the front and sides of the scalp, eyebrows, and eyelashes. Diffuse hair loss is more consistent with TE. Educational objective: Telogen effluvium causes diffuse, noninflammatory hair loss. It is often triggered by a stressful event, such as severe weight loss, pregnancy, major illness or surgery, or psychiatric trauma. Patients have thinning of the hair across the scalp and a positive hair pull test. Telogen effluvium is self-limited but may take up to a year to resolve completely. __________ References: Hair loss: common causes and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28925637)

A 27-Year-Old Woman Comes to the Office Due to Hair