A 53-year-old woman comes to the office due to hair loss. She has had gradual thinning of her hair since undergoing menopause 3 years ago. There is no associated pain or itching, but the patient is concerned due to the progressive course of hair loss. Medical history is notable for hypertension, which has been managed with dietary modification and exercise. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 31 kg/m². Examination shows thinning of the hair at the vertex and midline of the scalp, as shown in the exhibit. There is no excess hair growth on the face or trunk, and there is a normal female pattern of pubic hair growth. Which of the following is the most appropriate next step in management of this patient's hair loss?

Question

Quizplus · Accepted Answer

11ec25c8_d37b_de14_bc81_cd49f820d996_MD0003_00 This postmenopausal patient has female pattern hair loss (FPHL). FPHL is characterized by the replacement of terminal hairs by smaller vellus hairs (follicular miniaturization). Although most hair loss in men is driven by androgens (primarily dihydrotestosterone, ie, androgenetic alopecia), and hair loss often occurs in women with hyperandrogenic states (eg, polycystic ovary syndrome), androgen levels in most women with FPHL are normal. The diagnosis of FPHL is usually obvious based on the characteristic pattern of hair loss demonstrating gradual thinning of the hair at the vertex and midline. Whereas men with androgenetic alopecia usually have a receding hairline, the hairline in women is often preserved. The first-line treatment for FPHL is topical minoxidil, a direct vasodilator that increases blood flow to the scalp. Primary side effects include local irritation and itching; systemic absorption can lead to lightheadedness and reflex tachycardia, but this is uncommon. (Choice A) Antiandrogenic agents (eg, spironolactone, finasteride) are used primarily for women with hair loss who have signs of androgen excess (eg, hirsutism). Although these drugs are occasionally considered for those who fail treatment with minoxidil, finasteride is not well studied in women. (Choice B) Terbinafine is used for the treatment of tinea capitis, which presents with patchy hair loss associated with itching, pain, and scaling. (Choice C) Reassurance is appropriate for patients with telogen effluvium, which causes diffuse hair loss and often occurs in response to physiologic stress (eg, pregnancy). FPHL is likely to worsen without treatment, and simple observation is not advised. (Choice D) Alopecia areata is characterized by rounded patches of nonscarring, complete hair loss. First-line treatment includes intralesional corticosteroids, although topical agents can also be used. This patient's regional hair thinning is more consistent with FPHL. (Choice F) An aggressive weight loss program can lead to improvement in women with polycystic ovary syndrome. These patients can have hair loss but usually also have signs of androgen excess (eg, hirsutism). Educational objective: Female pattern hair loss (FPHL) usually presents with gradual thinning of the hair at the vertex and midline and is characterized by replacement of terminal hairs by smaller vellus hairs (follicular miniaturization). Hair loss can be seen in women with hyperandrogenic states, but androgen levels in most women with FPHL are normal. The first-line treatment is topical minoxidil. References: The effectiveness of treatments for androgenetic alopecia: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/28396101)

A 53-Year-Old Woman Comes to the Office Due to Hair