Question 6#

A 64-year-old woman presents with diffuse hair loss. She says that her hair is “coming out by the handfuls” after shampooing. She was treated for severe communityacquired pneumonia 2 months ago but has regained her strength and is exercising regularly. She is taking no medications. Examination reveals diffuse hair loss. Several hairs can be removed by gentle tugging. The scalp is normal without scale or erythema. Her general examination is unremarkable; in particular, her vital signs are normal, she has no pallor or inflammatory synovitis, and her reflexes are normal with a normal relaxation phase.

What is the best next step in her management? 

a. Reassurance
b. Measurement of serum testosterone and DHEA-S levels
c. Topical minoxidil
d. Topical corticosteroids
e. CBC and antinuclear antibodies

Correct Answer is A


This patient’s diffuse hair loss after a severe illness is caused by telogen effluvium. Normal hair follicles go through a life cycle. Approximately 5% are in the death (telogen) phase where the hair shaft is released. In telogen effluvium, the hair follicles are “shocked” by the systemic stress, and many enter the telogen phase at the same time. The diagnosis is made by careful history and physical examination. CBC, ANA, and hormonal levels will be normal. Topical treatments are ineffective. The patient will recover fully in a month or two, although a wig may be necessary to hide cosmetically troubling alopecia in the meantime.

Diffuse hair loss may be seen with many drugs or with systemic illnesses such as hypothyroidism, systemic lupus, syphilis, or iron deficiency, but there is no evidence of any of these illnesses in this patient. Male pattern baldness (androgen-dependent alopecia) is seen in normal men, in some older women, and in women with androgen excess, but the hair loss affects the crown and frontal region rather than the scalp diffusely. The dramatic and acute hair loss of telogen effluvium does not occur in male pattern baldness.