Management of Hair Loss in Elderly Women
Primary Etiologies
- Female pattern hair loss (FPHL) is the most common cause of hair loss in women over 65, typically presenting as diffuse thinning of the central scalp while preserving the frontal hairline. 1
- FPHL may follow two patterns: (1) centrifugal expansion centered on the mid‑scalp and (2) frontal accentuation producing a “Christmas‑tree” appearance. 1
- Isolated FPHL with normal circulating androgen levels should not be interpreted as evidence of systemic hyperandrogenism. 1
- Scarring alopecias that can mimic FPHL in older women include central centrifugal cicatricial alopecia and pattern‑distribution fibrosing alopecia. 1
- Telogen effluvium, which often co‑exists with FPHL in the elderly, can be precipitated by medications, nutritional deficiencies, systemic illness, or metabolic dysfunction. 2
Mandatory Hormonal Assessment
- Evaluation of circulating androgens (total and free testosterone) is required in every woman presenting with FPHL. High‑precision assays such as liquid‑chromatography tandem mass spectrometry are preferred. [1][3]
Recommended Ancillary Laboratory Testing
| Test | Rationale / Typical Finding in FPHL | |
|---|---|---|
| Thyroid‑stimulating hormone (TSH) | Detects hypothyroidism, a reversible cause of telogen effluvium. | [4] |
| Serum ferritin (iron stores) | Approximately 29 % of FPHL patients have iron deficiency; the causal link remains uncertain. | [4] |
| 25‑hydroxyvitamin D | Low vitamin D levels are found in about 62 % of FPHL patients. | [4] |
| Serum zinc | Mean zinc concentrations are reduced; about 15 % show deficiency. | [4] |
| Prolactin | Elevated prolactin is present in roughly 7 % of FPHL cases. | [4] |
Clinical Assessment Approach
- Pattern recognition during history and physical exam should differentiate central thinning, frontal recession, patchy loss, and diffuse thinning to narrow the differential diagnosis. 1
- The presence of “exclamation‑mark” hairs (broken hairs at the periphery) suggests alopecia areata rather than FPHL. 2
- Examination for scalp inflammation, scaling, or scarring helps identify scarring alopecias. 1
- A thorough medication review is essential because drug‑induced anagen effluvium can mimic diffuse alopecia. 2
Dermoscopic Evaluation
- Trichoscopy can distinguish FPHL from alopecia areata (e.g., yellow dots, dystrophic hairs) and from scarring conditions, aiding non‑invasive diagnosis. 2
- When clinical and dermoscopic findings are inconclusive, a scalp biopsy is reserved for cases with diagnostic uncertainty. [1][3]