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The most common causes of hair loss among women
The real or perceived symptom of increased hair loss can be psychologically devastating for female patients. This article is intended as a brief review of the most common causes of adult female alopecia and a thorough introduction to the evaluation of this complaint in the primary-care setting. Bear in mind that many women who experience hair loss will still require referral to a dermatology practice. ©
Hair follicles constantly cycle through three phases: (1) anagen the growth phase; (2) catagen the phase transitioning between growth and resting; and (3) telogen the resting phase. It is normal to lose as many as 100 hairs per day.
Women who present with excessive hair loss must undergo a detailed and extensive history and thorough examination of the hair, with the clinician paying special attention to the pattern of loss and how easily the hair pulls out. The clinician also must order blood tests and examine the scalp. In some cases, pathologic analysis of a scalp biopsy may be necessary. © ©
The initial examination ©
The following information should be obtained as part of the patient history of a woman who is experiencing hair loss: © ©
A thorough physical examination should discern the pattern and distribution of hair loss. Assess all areas of body hair, including eyebrows, eyelashes, arm hair and pubic hair. The scalp should be assessed for erythema, flaking, or scaring. Firmly grasp approximately 60 hairs and pull. If fewer than six hairs come out, this is considered normal shedding (or a negative pull test); six hairs or more is considered a positive pull test.
Special attention should be paid to how easily the hairs break. Easily breakable hair may suggest hair damage caused by overprocessing. Overprocessing can include heat damage from curling irons, straightening, perms, or hair coloring. The diagnosis for this type of hair loss is traumatic alopecia. Pulling from braids, tight hair buns, ponytails, or hair extensions can cause traction alopecia. The treatment for such hair loss is discontinuation of the beauty regimen, addition of biotin supplementation, and adoption of a healthy diet. Other forms of female hair loss to be considered in the differential are listed in Table 1. ©
In searching for an underlying endocrine abnormality, such as hyperandrogenemia or thyroid dysfunction, blood work should include a complete blood count with differential, serum iron, serum ferritin, thyroid-stimulating hormone (TSH), free thyroxine (T[suB]4[/suB]), antinuclear antibodies, free testosterone, prolactin, 17-hydroxy progesterone, cortisol level, and dehydroepiandrosterone sulfate. © ©
Androgenic alopecia ©
The terms androgenic alopecia and female pattern hair loss may be preferable to female pattern baldness. The word "baldness" may lead to unnecessary panic on the part of the patient. Androgenic alopecia describes hair loss caused by genetically determined sensitivity of hair follicles in the scalp to adult levels of androgens.
Androgenic alopecia is the most common cause of hair loss in adult women.[suP]1[/suP] The diagnosis is made by ruling out other possible diagnoses through lab work, recognition of the distinctive pattern of hair loss (Figure 1), and pathologic analysis of a punch biopsy. The biopsy should be full-thickness (at least 4 mm) sectioned horizontally.
Include the differential on the requisition slip that you want to distinguish (e.g., "androgenic alopecia rule out telogen effluvium or alopecia areata"). A sample of at least 6 mm is required to ensure that hair follicles at several stages of the growth cycle are present. Ideally, a dermatopathologist as well as a clinician who is experienced in analyzing hair biopsies should read the hair pathology. For this reason, it may preferable to have the biopsy performed by a local dermatologist who has a working relationship with different pathologists.
The pathology is particularly important because androgenic alopecia has a classic presentation of miniaturization of terminal pigmented anagen hairs to fine hypopigmented vellus hairs. ©
Treatment options include topical OTC minoxidil 2% (Rogaine, Theroxidil) applied twice a day[suP]1[/suP] or hair transplanation. Minoxidil increases the length of time follicles spend in anagen, wakes up follicles in catagen, and enlarges the actual follicles. The most common side effect associated with minoxidil is irritant dermatitis, which is most likely attributable to the vehicle and stabilizers rather than the active ingredient. Unwanted hair growth may be seen in other places on the body. Women who are pregnant or breastfeeding should not use minoxidil, as it can cause hypertrichosis in infants.
Patients must use minoxidil for at least four to six months to evaluate efficacy. Many patients report that minoxidil does not lead to new hair growth but simply slows the rate of hair loss. Use of the product must be continued for as long as the patient wishes to sustain the results. ©
Hair transplantation is a cosmetic procedure performed in the office under local anesthesia. Hair from the uninvolved area is transplanted to the area with loss. Disadvantages of this treatment option include cost and the appearance of the final result. © ©
Telogen effluvium ©
Hairs are normally shed in the telogen phase. Telogen effluvium is a scalp disorder characterized by increased shedding of undamaged hairs in the telogen phase in response to a change in health status. The process that tells the hair when to enter the anagen, telogen, and catagen phase is complex.
In individuals with telogen effluvium, some external factor instructs an abnormally large number of hairs to enter the telogen phase and subsequently be shed (Figure 2). These external factors include, but are not limited to, medications, pregnancy, malnutrition and stress (Table 2).[suP]2[/suP] Since it can take up to three months for the hair loss to start or become noticeable, a thorough medical, psychological and surgical history must cover at least the past six months. ©
The diagnosis of telogen effluvium is one of exclusion combined with analysis of the hair-loss pattern, lab results, and patient history. Laboratory work should include thyroid and chemistry panels, erythrocyte sedimentation rate, antinuclear antibody, and a complete blood count with differential, hematocrit, and ferritin tests. If possible, stop the offending agent/medication or correct the underlying abnormality.
Consider recommending counseling and or medication if psychological stress is the underlying cause. The "tincture of time" (that is, waiting for the body to normalize) may be the best bet for a patient recovering from a change in his or her health status. Make sure the patient is otherwise healthy, eating a balanced diet, taking a multivitamin containing very little or no vitamin A (too much vitamin A can cause hair loss), and 5 mg/day of OTC biotin, which has been shown to accelerate hair growth and thicken existing hair. © ©
Trichotillomania ©
Individuals with trichotillomania pull out their own hair, including eyebrows and eyelashes. This condition is more commonly seen in women and may be accompanied by such concomitant psychological disorders as depression, psychosis, impulse-control disorders, personality disorders, anxiety, and body dysmorphic disorder.
The patches of alopecia caused by the hair pulling often have bizarre sharp, irregular borders, and result in hairs of varying lengths (Figure 3). Some describe confirming the diagnosis by shaving the same patch of scalp weekly to show the normal dense regrowth, but I have rarely seen this in practice.
On pathology, distorted follicular anatomy is found, once again supporting the need for a dermatopathologist to read any scalp/hair biopsy. Treatment is a combination of patient realization of the habit, behavior modification, and therapy.
Additional use of pharmacologic agents should be decided on a case-by-case basis. If pharmacotherapy is indicated, clomipramine (Anafranil) is the first-line agent.[suP]3[/suP] Selective serotonin reuptake inhibitors have had limited success. © ©
Alopecia areata ©
Alopecia areata is the most common nonscaring pattern of hair loss that presents as well-circumscribed areas of alopecia. In this hair-specific autoimmune disease, T-lymphocytes interact with follicular antigens. The clinician can differentiate alopecia areata from tinea capitis by the lack of scalp flaking. A simple fungal culture can confirm the diagnosis.
In an adult, a scalp tinea capitis infection is unlikely unless the patient works in a high-risk environment (e.g., an elementary school with a known outbreak) or is immunosuppressed. One out of five patients with alopecia areata report having a family member with the same condition. ©
Classically, alopecia areata presents as round or oval patches of nonscarred hair loss. Short exclamation-point hairs are often seen at the edges of the patch of hair loss. Other patterns of loss include ophiasis (a band of loss around the temporal and occipital scalp), alopecia totalis (loss of all scalp hair), and alopecia universalis (loss of all scalp and body hair).
Patients with alopecia areata may also experience such nail changes as ridges, pitting, brittleness, onycholysis, and koilonychia. Approximately 40% of patients with alopecia areata will have allergic rhinitis, atopic dermatitis, or asthma.[suP]4[/suP] Other associated diseases include autoimmune thyroid disease (e.g., Hashimoto's thyroiditis, Graves' disease), vitiligo, inflammatory bowel disease, HLA associations, and autoimmune polyendocrinopathy syndrome type 1. Type 1 diabetes is more prevalent in the relatives of persons with alopecia areata. ©
Typical treatment of alopecia areata involves a combination of intralesional corticosteroids (a concentration of 5 mg/mL of triamcinolone acetonide injected every four to eight weeks is usually sufficient), topical steroids, topical minoxidil, and oral biotin. Bimatoprost ophthalmic solution (Latisse, Lumigan) is an option for eyelash loss and is used off-label for eyebrow regrowth. Treatment options for ophiasis, alopecia totalis, and alopecia universalis are extremely limited. Alopecia areata is most often chronic and relapsing. © ©
Underlying skin conditions ©
Physical examination will typically reveal such underlying correctable skin conditions as seborrheic dermatitis or psoriasis. Both conditions may have the symptoms of itching and flaking and will impact such other body areas as the face, nasolabial folds, eyebrows, and ears.
Seborrheic dermatitis is more diffuse than psoriasis and can have a greasy yellow appearance, particularly on the face. Psoriasis is characterized by sharply marginated plaques with scale. Frequently, there is a family history of psoriasis. Plaques are often symmetric and are typically found on the elbows, knees, and groin.
Topical steroids are first-line agents for both conditions. Such steroid-sparing agents as ketoconazole shampoo (Nizoral) or cream (Ketozole, Nizoral) are effective for seborrheic dermatitis. For scalp psoriasis, consider OTC coal-tar shampoo and topical calcipotriene (Dovonex, Sorilux). © ©
Underlying endocrine abnormalities ©
Hyperandrogenemia and thyroid dysfunction are the two most common underlying endocrine abnormalities that lead to hair loss in adult females. Patient history, other complaints, review of systems, and a physical examination all contribute to making this diagnosis. Laboratory workup confirms the diagnosis.
Thyroid dysfunction can be evaluated with TSH and T4 tests. Symptoms of hypothyroidism can include fatigue, weight gain, decreased appetite, cold intolerance, dry skin, muscle pain, joint pain, weakness in the extremities, depression, emotional lability, mental impairment, forgetfulness, impaired memory, inability to concentrate, constipation, paresthesias, nerve entrapment syndromes, blurred vision, decreased hearing, fullness in the throat, and hair loss.[suP]5[/suP] Typically, the hair loss associated with thyroid dysfunction is diffuse overall thinning with no scalp changes. The remaining hair can be dry, coarse, and lusterless. ©
Hyperandrogenic disorders include polycystic ovary syndrome (PCOS), adrenal or ovarian tumors, congenital adrenal hyperplasia, hyperprolactinemia, acromegaly, and Cushing syndrome. Signs of PCOS, the most common condition associated with hyperandrogenism, can include irregular menstrual cycle, amenorrhoea, impaired fertility, difficulty getting pregnant, miscarriage, seborrhea, excessive body hair, acne, and obesity.[suP]6[/suP]
The pattern of hair loss seen with hyperandrogenism is typically diffuse and mimics that of androgenic alopecia. Treating hair loss in hyperandrogenic states or thyroid dysfunction requires addressing the underlying abnormality. © ©
Cicatricial alopecia ©
Cicatricial alopecia, also referred to as scarring alopecia, often results in permanent destruction of the hair follicle. In such cases, a scalp biopsy is almost always necessary to identify the form of cicatricial alopecia and to determine whether there is an underlying treatable condition, such as cutaneous lupus erythematosus (CLE).
On pathologic analysis of the biopsy, lymphocytic hair loss can be seen with lichen planopilaris and CLE; neutrophilic hair loss may be associated with folliculitis decalvans or dissecting cellulitis. The hair loss pattern in individuals with CLE presents as background erythema, variable hypopigmentation, and/or follicular plugging. Other skin lesions of CLE may or may not be present. A thorough evaluation of other signs and symptoms, a family history, and blood work are important pieces of the diagnostic puzzle.
Treatments include topical and intralesional steroids, systemic steroids, antimalarials, and thalidomide (Thalomid).[suP]7[/suP] Lichen planopilaris typically shows perifollicular erythema and scarring with a background violaceous discoloration to the scalp. Intralesional steroids and referral to a dermatology practice are essential aspects in appropriate management of lichen planopilaris. © ©
Summary ©
The workup of the chief complaint of hair loss in the adult female patient is neither quick nor simple. A comprehensive personal history and family history, thorough physical examination, and blood work are crucial elements leading to the proper diagnosis.
The real or perceived symptom of increased hair loss can be psychologically devastating for female patients. This article is intended as a brief review of the most common causes of adult female alopecia and a thorough introduction to the evaluation of this complaint in the primary-care setting. Bear in mind that many women who experience hair loss will still require referral to a dermatology practice. ©
Hair follicles constantly cycle through three phases: (1) anagen the growth phase; (2) catagen the phase transitioning between growth and resting; and (3) telogen the resting phase. It is normal to lose as many as 100 hairs per day.
Women who present with excessive hair loss must undergo a detailed and extensive history and thorough examination of the hair, with the clinician paying special attention to the pattern of loss and how easily the hair pulls out. The clinician also must order blood tests and examine the scalp. In some cases, pathologic analysis of a scalp biopsy may be necessary. © ©
The initial examination ©
The following information should be obtained as part of the patient history of a woman who is experiencing hair loss: © ©
- Duration and pattern of hair loss © [/*]
- Whether the lost hair is broken or intact © [/*]
- Current diet and any change in weight within the past six months © [/*]
- Any surgeries in the past six months © [/*]
- All medications (current and taken within the past six months) © [/*]
- Any illnesses or infections within the past six months © [/*]
- Any other symptoms (a full review of systems) © [/*]
- Whether she has ever experienced similar hair loss before © [/*]
- A family history of hair loss and other medical conditions (e.g., metabolic disorders) © [/*]
- Date of most recent menstrual period © [/*]
- Normal hair and beauty routine. © ©
A thorough physical examination should discern the pattern and distribution of hair loss. Assess all areas of body hair, including eyebrows, eyelashes, arm hair and pubic hair. The scalp should be assessed for erythema, flaking, or scaring. Firmly grasp approximately 60 hairs and pull. If fewer than six hairs come out, this is considered normal shedding (or a negative pull test); six hairs or more is considered a positive pull test.
Special attention should be paid to how easily the hairs break. Easily breakable hair may suggest hair damage caused by overprocessing. Overprocessing can include heat damage from curling irons, straightening, perms, or hair coloring. The diagnosis for this type of hair loss is traumatic alopecia. Pulling from braids, tight hair buns, ponytails, or hair extensions can cause traction alopecia. The treatment for such hair loss is discontinuation of the beauty regimen, addition of biotin supplementation, and adoption of a healthy diet. Other forms of female hair loss to be considered in the differential are listed in Table 1. ©
In searching for an underlying endocrine abnormality, such as hyperandrogenemia or thyroid dysfunction, blood work should include a complete blood count with differential, serum iron, serum ferritin, thyroid-stimulating hormone (TSH), free thyroxine (T[suB]4[/suB]), antinuclear antibodies, free testosterone, prolactin, 17-hydroxy progesterone, cortisol level, and dehydroepiandrosterone sulfate. © ©
Androgenic alopecia ©
The terms androgenic alopecia and female pattern hair loss may be preferable to female pattern baldness. The word "baldness" may lead to unnecessary panic on the part of the patient. Androgenic alopecia describes hair loss caused by genetically determined sensitivity of hair follicles in the scalp to adult levels of androgens.
Androgenic alopecia is the most common cause of hair loss in adult women.[suP]1[/suP] The diagnosis is made by ruling out other possible diagnoses through lab work, recognition of the distinctive pattern of hair loss (Figure 1), and pathologic analysis of a punch biopsy. The biopsy should be full-thickness (at least 4 mm) sectioned horizontally.
Include the differential on the requisition slip that you want to distinguish (e.g., "androgenic alopecia rule out telogen effluvium or alopecia areata"). A sample of at least 6 mm is required to ensure that hair follicles at several stages of the growth cycle are present. Ideally, a dermatopathologist as well as a clinician who is experienced in analyzing hair biopsies should read the hair pathology. For this reason, it may preferable to have the biopsy performed by a local dermatologist who has a working relationship with different pathologists.
The pathology is particularly important because androgenic alopecia has a classic presentation of miniaturization of terminal pigmented anagen hairs to fine hypopigmented vellus hairs. ©
Treatment options include topical OTC minoxidil 2% (Rogaine, Theroxidil) applied twice a day[suP]1[/suP] or hair transplanation. Minoxidil increases the length of time follicles spend in anagen, wakes up follicles in catagen, and enlarges the actual follicles. The most common side effect associated with minoxidil is irritant dermatitis, which is most likely attributable to the vehicle and stabilizers rather than the active ingredient. Unwanted hair growth may be seen in other places on the body. Women who are pregnant or breastfeeding should not use minoxidil, as it can cause hypertrichosis in infants.
Patients must use minoxidil for at least four to six months to evaluate efficacy. Many patients report that minoxidil does not lead to new hair growth but simply slows the rate of hair loss. Use of the product must be continued for as long as the patient wishes to sustain the results. ©
Hair transplantation is a cosmetic procedure performed in the office under local anesthesia. Hair from the uninvolved area is transplanted to the area with loss. Disadvantages of this treatment option include cost and the appearance of the final result. © ©
Telogen effluvium ©
Hairs are normally shed in the telogen phase. Telogen effluvium is a scalp disorder characterized by increased shedding of undamaged hairs in the telogen phase in response to a change in health status. The process that tells the hair when to enter the anagen, telogen, and catagen phase is complex.
In individuals with telogen effluvium, some external factor instructs an abnormally large number of hairs to enter the telogen phase and subsequently be shed (Figure 2). These external factors include, but are not limited to, medications, pregnancy, malnutrition and stress (Table 2).[suP]2[/suP] Since it can take up to three months for the hair loss to start or become noticeable, a thorough medical, psychological and surgical history must cover at least the past six months. ©
The diagnosis of telogen effluvium is one of exclusion combined with analysis of the hair-loss pattern, lab results, and patient history. Laboratory work should include thyroid and chemistry panels, erythrocyte sedimentation rate, antinuclear antibody, and a complete blood count with differential, hematocrit, and ferritin tests. If possible, stop the offending agent/medication or correct the underlying abnormality.
Consider recommending counseling and or medication if psychological stress is the underlying cause. The "tincture of time" (that is, waiting for the body to normalize) may be the best bet for a patient recovering from a change in his or her health status. Make sure the patient is otherwise healthy, eating a balanced diet, taking a multivitamin containing very little or no vitamin A (too much vitamin A can cause hair loss), and 5 mg/day of OTC biotin, which has been shown to accelerate hair growth and thicken existing hair. © ©
Trichotillomania ©
Individuals with trichotillomania pull out their own hair, including eyebrows and eyelashes. This condition is more commonly seen in women and may be accompanied by such concomitant psychological disorders as depression, psychosis, impulse-control disorders, personality disorders, anxiety, and body dysmorphic disorder.
The patches of alopecia caused by the hair pulling often have bizarre sharp, irregular borders, and result in hairs of varying lengths (Figure 3). Some describe confirming the diagnosis by shaving the same patch of scalp weekly to show the normal dense regrowth, but I have rarely seen this in practice.
On pathology, distorted follicular anatomy is found, once again supporting the need for a dermatopathologist to read any scalp/hair biopsy. Treatment is a combination of patient realization of the habit, behavior modification, and therapy.
Additional use of pharmacologic agents should be decided on a case-by-case basis. If pharmacotherapy is indicated, clomipramine (Anafranil) is the first-line agent.[suP]3[/suP] Selective serotonin reuptake inhibitors have had limited success. © ©
Alopecia areata ©
Alopecia areata is the most common nonscaring pattern of hair loss that presents as well-circumscribed areas of alopecia. In this hair-specific autoimmune disease, T-lymphocytes interact with follicular antigens. The clinician can differentiate alopecia areata from tinea capitis by the lack of scalp flaking. A simple fungal culture can confirm the diagnosis.
In an adult, a scalp tinea capitis infection is unlikely unless the patient works in a high-risk environment (e.g., an elementary school with a known outbreak) or is immunosuppressed. One out of five patients with alopecia areata report having a family member with the same condition. ©
Classically, alopecia areata presents as round or oval patches of nonscarred hair loss. Short exclamation-point hairs are often seen at the edges of the patch of hair loss. Other patterns of loss include ophiasis (a band of loss around the temporal and occipital scalp), alopecia totalis (loss of all scalp hair), and alopecia universalis (loss of all scalp and body hair).
Patients with alopecia areata may also experience such nail changes as ridges, pitting, brittleness, onycholysis, and koilonychia. Approximately 40% of patients with alopecia areata will have allergic rhinitis, atopic dermatitis, or asthma.[suP]4[/suP] Other associated diseases include autoimmune thyroid disease (e.g., Hashimoto's thyroiditis, Graves' disease), vitiligo, inflammatory bowel disease, HLA associations, and autoimmune polyendocrinopathy syndrome type 1. Type 1 diabetes is more prevalent in the relatives of persons with alopecia areata. ©
Typical treatment of alopecia areata involves a combination of intralesional corticosteroids (a concentration of 5 mg/mL of triamcinolone acetonide injected every four to eight weeks is usually sufficient), topical steroids, topical minoxidil, and oral biotin. Bimatoprost ophthalmic solution (Latisse, Lumigan) is an option for eyelash loss and is used off-label for eyebrow regrowth. Treatment options for ophiasis, alopecia totalis, and alopecia universalis are extremely limited. Alopecia areata is most often chronic and relapsing. © ©
Underlying skin conditions ©
Physical examination will typically reveal such underlying correctable skin conditions as seborrheic dermatitis or psoriasis. Both conditions may have the symptoms of itching and flaking and will impact such other body areas as the face, nasolabial folds, eyebrows, and ears.
Seborrheic dermatitis is more diffuse than psoriasis and can have a greasy yellow appearance, particularly on the face. Psoriasis is characterized by sharply marginated plaques with scale. Frequently, there is a family history of psoriasis. Plaques are often symmetric and are typically found on the elbows, knees, and groin.
Topical steroids are first-line agents for both conditions. Such steroid-sparing agents as ketoconazole shampoo (Nizoral) or cream (Ketozole, Nizoral) are effective for seborrheic dermatitis. For scalp psoriasis, consider OTC coal-tar shampoo and topical calcipotriene (Dovonex, Sorilux). © ©
Underlying endocrine abnormalities ©
Hyperandrogenemia and thyroid dysfunction are the two most common underlying endocrine abnormalities that lead to hair loss in adult females. Patient history, other complaints, review of systems, and a physical examination all contribute to making this diagnosis. Laboratory workup confirms the diagnosis.
Thyroid dysfunction can be evaluated with TSH and T4 tests. Symptoms of hypothyroidism can include fatigue, weight gain, decreased appetite, cold intolerance, dry skin, muscle pain, joint pain, weakness in the extremities, depression, emotional lability, mental impairment, forgetfulness, impaired memory, inability to concentrate, constipation, paresthesias, nerve entrapment syndromes, blurred vision, decreased hearing, fullness in the throat, and hair loss.[suP]5[/suP] Typically, the hair loss associated with thyroid dysfunction is diffuse overall thinning with no scalp changes. The remaining hair can be dry, coarse, and lusterless. ©
Hyperandrogenic disorders include polycystic ovary syndrome (PCOS), adrenal or ovarian tumors, congenital adrenal hyperplasia, hyperprolactinemia, acromegaly, and Cushing syndrome. Signs of PCOS, the most common condition associated with hyperandrogenism, can include irregular menstrual cycle, amenorrhoea, impaired fertility, difficulty getting pregnant, miscarriage, seborrhea, excessive body hair, acne, and obesity.[suP]6[/suP]
The pattern of hair loss seen with hyperandrogenism is typically diffuse and mimics that of androgenic alopecia. Treating hair loss in hyperandrogenic states or thyroid dysfunction requires addressing the underlying abnormality. © ©
Cicatricial alopecia ©
Cicatricial alopecia, also referred to as scarring alopecia, often results in permanent destruction of the hair follicle. In such cases, a scalp biopsy is almost always necessary to identify the form of cicatricial alopecia and to determine whether there is an underlying treatable condition, such as cutaneous lupus erythematosus (CLE).
On pathologic analysis of the biopsy, lymphocytic hair loss can be seen with lichen planopilaris and CLE; neutrophilic hair loss may be associated with folliculitis decalvans or dissecting cellulitis. The hair loss pattern in individuals with CLE presents as background erythema, variable hypopigmentation, and/or follicular plugging. Other skin lesions of CLE may or may not be present. A thorough evaluation of other signs and symptoms, a family history, and blood work are important pieces of the diagnostic puzzle.
Treatments include topical and intralesional steroids, systemic steroids, antimalarials, and thalidomide (Thalomid).[suP]7[/suP] Lichen planopilaris typically shows perifollicular erythema and scarring with a background violaceous discoloration to the scalp. Intralesional steroids and referral to a dermatology practice are essential aspects in appropriate management of lichen planopilaris. © ©
Summary ©
The workup of the chief complaint of hair loss in the adult female patient is neither quick nor simple. A comprehensive personal history and family history, thorough physical examination, and blood work are crucial elements leading to the proper diagnosis.
