An 18-year-old woman comes to the office due to hair loss. The patient says, "I can't even brush or wash my hair because it just falls out. I've already been so stressed since college started, and losing my hair is making everything worse." She has felt "overwhelmed" with adjusting to college and is also working part-time at a coffee shop. The patient says, "I've felt pretty low-my life isn't going as planned, and I don't know how to get back on track." She says the only thing that makes her feel good is cycling, which she does for 1-2 hours every day. The patient also adheres to a strict diet to "maintain a good body image." She has no other medical conditions and does not use tobacco, alcohol, or illicit drugs. Temperature is 36.1 C (97 F), blood pressure is 100/65 mm Hg, pulse is 60/min, and respirations are 14/min. BMI is 17.5 kg/m². Physical examination shows generalized thinning of the hair with no scarring of the scalp. The skin is dry with no rashes. The remainder of the examination is unremarkable, and the patient has no suicidal ideation. Laboratory results are as follows: Which of the following is the most appropriate management for this patient's condition?

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11ec25c8_d792_02a3_bc81_7fcd321d0ff2_MD0003_00 This patient's low body weight (BMI <18.5 kg/m²), fear of weight gain, preoccupation with body image (eg, strict dieting despite being underweight, intense exercise), hair loss, and dry skin are suggestive of anorexia nervosa (AN). Dermatological complications of AN are common and may include dry, scaly skin; hair loss; and lanugo (fine, downy hair). Because patients with AN frequently have limited insight or attempt to hide their disorder, clinicians must be alert for physical signs of AN in underweight patients. Behavioral manifestations commonly associated with AN include dysphoria, anxiety, and perfectionism. ² First-line treatment for AN consists of nutritional rehabilitation (eg, refeeding, establishing and reinforcing normal eating patterns) and psychotherapy. Weight restoration through nutritional rehabilitation is a key component of treatment because it can reverse many of the medical and psychiatric complications due to malnutrition. (Choice A) Biofeedback (ie, using physiological monitoring as feedback) and relaxation techniques are primarily used to treat conditions involving muscle tension, anxiety, and pain. They do not address disordered eating behavior and are not treatments for AN. (Choices B and F) Intradermal corticosteroid injections are indicated for alopecia areata, which causes discrete patches of hair loss rather than generalized hair thinning. Topical minoxidil therapy has been used to treat male pattern hair loss as well as female pattern hair loss, which classically causes frontal scalp or scalp vertex hair loss. Neither would explain this patient's low BMI and fear of weight gain. Her hair loss should improve with AN management and weight restoration. (Choice D) The selective serotonin reuptake inhibitor fluoxetine is a first-line treatment in bulimia nervosa (which would not be associated with a BMI <18.5 kg/m²); antidepressant medications are not effective in the treatment of AN. Comorbid mild to moderate depression typically improves with nutritional rehabilitation and psychotherapy. ² (Choice E) Low-normal TSH levels are characteristic of AN and do not require treatment. Patients with AN may have low levels of T3 and/or T4 (euthyroid sick syndrome) due to the body's adaptation to nutritional depletion. Thyroid hormone replacement is not indicated because thyroid hormone levels will normalize with adequate weight gain. Educational objective: Dermatological complications of anorexia nervosa (AN) include dry, scaly skin; hair loss; and lanugo. First-line treatment for AN consists of nutritional rehabilitation and psychotherapy. Most medical complications of AN (eg, hair loss) improve with weight restoration. References: Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. (http://www.ncbi.nlm.nih.gov/pubmed/25591200) Nutritional rehabilitation in anorexia nervosa: review of the literature and implications for treatment. (http://www.ncbi.nlm.nih.gov/pubmed/24200367) Medical complications in anorexia and bulimia nervosa. (http://www.ncbi.nlm.nih.gov/pubmed/29848283)

An 18-Year-Old Woman Comes to the Office Due to Hair