What is Hair Loss?
 

Hair loss (alopecia) is the partial or complete absence of hair from areas where it normally grows, characterized broadly as non-scarring/reversible (non-cicatricial) or scarring (cicatricial), where follicles are permanently destroyed.
 

• Pattern Distribution: Androgenetic alopecia presenting as a receding frontal/temporal hairline and vertex thinning in men, or diffuse widening of the central part with frontal hairline preservation in women.

• Patchy Loss: Well-demarcated round or oval patches of sudden hair loss (e.g., alopecia areata) or irregular broken hairs (e.g., tinea capitis, trichotillomania).

• Diffuse Shedding: Generalized hair thinning across the entire scalp (e.g., telogen effluvium or anagen effluvium).

Primary Causes of Hair Loss
 

• Androgenetic Alopecia (Pattern Hair Loss): Genetically predetermined, progressive follicular miniaturization driven by androgens (dihydrotestosterone/DHT).

• Alopecia Areata: An organ-specific autoimmune condition where T-lymphocytes attack anagen hair follicles, causing patchy or total hair loss.

• Scarring Alopecias (Cicatricial): Primary inflammatory conditions destroying follicles, including lichen planopilaris, frontal fibrosing alopecia, discoid lupus erythematosus, and dissecting cellulitis.

• Traction Alopecia: Mechanical hair loss resulting from chronic, tight hairstyling (pulling tension on the follicles).

• Trichotillomania: A psychiatric impulse-control disorder characterized by the compulsive pulling out of one's own hair.

Secondary Causes of Hair Loss
 

• Telogen Effluvium Triggers: Physiological or emotional stress, severe systemic illness, major surgery, high fevers, rapid weight loss, postpartum hormonal shifts, and hemorrhage shifting a large mass of hair prematurely into the resting (telogen) shedding phase.

• Anagen Effluvium Triggers: Cytotoxic chemotherapy, radiation, malnutrition, or heavy metal toxicities that abruptly interrupt rapid growth activity in the hair matrix.

• Endocrine & Metabolic Disorders: Hypothyroidism or hyperthyroidism, and severe insulin resistance/hyperandrogenic states (e.g., Polycystic Ovary Syndrome / PCOS).

• Nutritional Deficiencies: Severe iron deficiency (low serum ferritin), chronic protein malnutrition, zinc deficiency, and deficiencies in essential fatty acids or niacin.

• Infectious & Inflammatory States: Tinea capitis (fungal scalp infection), secondary syphilis, and chronic systemic inflammatory diseases.

• Medication-Induced Hair Loss: Adverse effects from retinoids (isotretinoin, acitretin), anticoagulants (warfarin, heparin), anticonvulsants (divalproex sodium/valproic acid and carbamazepine), and certain antidepressants (SSRIs).

Diagnostics
 

• Clinical History & Physical Examination: Onset and progression speed, review of inciting stressors or systemic symptoms, scalp inspection for erythema, scaling, follicular plugging, or scarring, and pattern mapping.

• Bedside Diagnostic Tests:

  • Hair Pull Test: Gently pulling ~40-60 hairs; extracting more than 10% (over 6 hairs) indicates active pathological shedding (telogen/anagen effluvium or active alopecia areata).

  • Trichoscopy / Dermatoscopy: Non-invasive magnified imaging to evaluate follicular opening patterns, miniaturization ratios, and hair shaft variability.

• Laboratory Testing:

  • Serum ferritin, total iron-binding capacity (TIBC), and iron panel.

  • Thyroid-stimulating hormone (TSH).

  • Complete blood count (CBC).

  • Hormonal evaluations (free/total testosterone, DHEA-S, prolactin) if PCOS or hyperandrogenism is suspected in women.

  • Fungal culture or potassium hydroxide (KOH) prep if tinea capitis is suspected.

• Invasive Diagnostics: Scalp punch biopsy (sent for vertical and horizontal sectioning) to definitively differentiate scarring from non-scarring alopecias or confirm inflammatory disorders.

Management 

Pharmacological Management​

• Topical Minoxidil (2% or 5%): Vasodilator that prolongs the anagen growth phase (applied topically daily/twice daily for androgenetic hair loss in men and women), Off-label oral minoxidil. Off-label for telogen effluvium.

• 5-Alpha-Reductase Inhibitors: Oral finasteride (approved for men) to block conversion of testosterone to DHT.

• Anti-Androgen Therapy: Oral spironolactone used off-label for female-pattern hair loss.

• Corticosteroids: Topical or intralesional corticosteroid injections (e.g., triamcinolone acetonide into bald patches), or short courses of systemic steroids for rapid-onset disease for inflammatory alopecias.

• JAK Inhibitors: Oral Janus kinase inhibitors (e.g., baricitinib, deuruxolitinib, ritlecitinib) approved for severe alopecia areata to block immune-mediated follicle attack.

• Topical Immunotherapy: Contact sensitizers (e.g., squaric acid dibutylester) applied weekly for severe, treatment-refractory alopecia areata.

• Antimicrobial & Anti-inflammatory Agents: Systemic antifungals (e.g., oral griseofulvin or terbinafine) for tinea capitis; targeted topical or systemic anti-inflammatories for scarring alopecias.

Non-Pharmacological Management

• Behavioral & Lifestyle Modifications: Correcting nutritional deficiencies, modifying damaging hair care practices (avoiding high-tension styling, harsh chemical treatments, or excessive heat), and managing psychological stressors.

• Procedural & Device Options: Low-level laser therapy (laser caps/combs), microneedling, platelet-rich plasma (PRP) injections, and surgical hair transplantation.

• Wigs, Scalp Protheses & Camouflage: Utilizing cosmetic concealers, scalp micropigmentation, or custom cranial prostheses for extensive or permanent hair loss.