Friday, December 5, 2014

A 32-year-old woman presents to her physician complaining of hair loss.

A 32-year-old woman presents to her physician complaining of hair loss. She is currently 10 weeks postpartum after delivery of a normal healthy baby girl.

She admits to having increased stress and sleep loss because her child has colic.

She also has not been able to nurse because of poor milk production.

On examination, the patient’s hair does not appear to have decreased density. With a gentle tug, more than 10 hairs come out but are not broken and all appear normal. There are no scalp lesions. What do you recommend for this patient?

A. Careful evaluation of the patient’s hair care products for a potential cause
B. Reassurance only
C. Referral for counseling for trichotillomania
D. Treatment with minoxidil
E. Treatment with topical steroids

The answer is B. This patient presents with complaints of diffuse hair loss that has been associated with increased stress as well as hormonal changes after pregnancy and delivery. On physical examination, there is diffuse shedding of normal hairs without scalp lesions or scarring consistent with a diagnosis of telogen effluvium. Telogen effluvium occurs when a stressor causes the typical asynchronous hair growth pattern to become synchronous. This can occur from physical or mental stress (high fever, severe infection) or hormonal changes. When the hair growth becomes more synchronous, more hairs enter the telogen (dying) phase at the same time. The patient may present with complaints of significant hair loss, but hair density to the examiner may appear normal. Broken hairs are not observed, and gentle pulling of the hair results in more than four hairs falling
out. Telogen effluvium is reversible without treatment, and this patient has identifiable
stressors that are related to the cause. Reassurance and observation are all that are recommended.
Some medications can cause telogen effluvium. If identified, these should be
discontinued. In addition, both hyper- and hypothyroidism can lead to the condition.
One should consider evaluation for these and other metabolic disorders if the condition
does not reverse or the patient has additional symptoms.

Other causes of nonscarring alopecia include androgenic alopecia, alopecia areata,
tinea capitis, and traumatic alopecia. Androgenic alopecia is the cause of male and female
pattern baldness. It does not typically result from androgen excess. Rather, it is associated
with an increased sensitivity of the affected hairs to the effects of androgens. Androgenic
alopecia can be treated with minoxidil, finasteride, or hair transplants. Alopecia areata
is a condition of focal hair loss measuring about 2–5 cm in diameter. The surrounding
tissue demonstrates increased T lymphocytes, and the treatment includes intralesional
glucocorticoids or topical anthralin or tazarotene. Tinea capitis is also usually a focal area
of hair loss related to an underlying superficial fungal infection. However, in severe cases,
large plaques and pustules can develop. Treatment with oral griseofulvin or terbinafine
with topical selenium sulfide or ketoconazole is usually effective in treating the disease.
Traumatic alopecia presents with multiple broken hairs at sites of increased stress related
to the use of hair care products, including rubber bands, curlers, or chemicals. It can also
result from trichotillomania. Discontinuation of any offending practice or agent is all that
is required to return the hair to normal. Counseling is typically required for those with


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