A 16-year-old girl is brought to the office due to hair loss. Over the last few months, she has developed a few patches of hair loss on the scalp. The lesions are associated with mild itching just before the loss of hair but are otherwise asymptomatic. Medical history is unremarkable; the patient's only current medication is an oral contraceptive. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. Scalp examination findings are shown in the exhibit. Which of the following is the most appropriate next step for this patient's hair loss?

Question

A 16-year-old girl is brought to the office due to hair loss.  Over the last few months, she has developed a few patches of hair loss on the scalp.  The lesions are associated with mild itching just before the loss of hair but are otherwise asymptomatic.  Medical history is unremarkable; the patient's only current medication is an oral contraceptive.  She does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  Scalp examination findings are shown in the exhibit.  Which of the following is the most appropriate next step for this patient's hair loss?

Quizplus · Accepted Answer

11ec25c8_d37a_7e82_bc81_95bc0c13a99b_MD0003_00 This patient has patchy, nonscarring hair loss with no scaling. This presentation is most consistent with alopecia areata (AA), an autoimmune disorder involving the hair bulb cells that is often associated with other autoimmune conditions (eg, vitiligo, hypothyroidism). The diagnosis of AA is usually based on visual inspection (often with the assistance of dermatoscopy); close inspection may show narrowing of the hair shafts close to the skin surface (exclamation point hairs). exclamation point hairs Management of AA depends on the size and extent of the lesions. Intralesional corticosteroids (eg, triamcinolone) are typically used for patients with limited areas of involvement, such as this patient; topical corticosteroids can also be used for patients who wish to avoid injections (eg, children). Topical immunotherapy (eg, diphenylcyclopropenone) can be considered for patients with severe, widespread hair loss (eg, alopecia totalis). AA does not cause permanent damage to the hair follicle, and most patients have at least partial regrowth, although recurrences are common. (Choice A) Cognitive behavioral therapy is used in the management of trichotillomania, which causes patchy hair loss but usually shows signs of irregular regrowth with hair of variable lengths. (Choices B and E) Telogen effluvium is characterized by slowed hair growth and shedding of hair shafts. It can be triggered by physiologic stressors (eg, severe illness, iron deficiency), hormonal changes (eg, initiation or discontinuation of oral contraceptives), or emotional distress. It generally resolves spontaneously and is primarily managed with reassurance and observation. However, telogen effluvium causes diffuse, not patchy, hair loss. (Choice D) Griseofulvin is effective in the treatment of tinea capitis, a superficial dermatophyte infection that presents with scaly, erythematous patches of hair loss, often with prominent itching and tender lymphadenopathy. (Choice F) Minoxidil is a possible second-line treatment for AA but is more commonly used for female and male (androgenetic) pattern hair loss. Female pattern hair loss presents with chronic, diffuse thinning of the hair at the midline and vertex with sparing of the frontal hairline. Educational objective: Alopecia areata is characterized by patchy, nonscarring hair loss. It is an autoimmune disorder and is often associated with other autoimmune conditions. Treatment includes topical or intralesional corticosteroids. A recurring course is common, but most patients have regrowth over time. References: Alopecia areata. (http://www.ncbi.nlm.nih.gov/pubmed/28300084)

A 16-Year-Old Girl Is Brought to the Office Due to Hair