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Guideline Summary
Guideline Title
Evaluation of hair loss in adult women.
Bibliographic Source(s)
University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program. Evaluation of hair loss in adult women. Austin (TX): University of Texas at Austin, School of Nursing; 2010 May 21. 18 p. [36 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program. Recommendations to diagnose and treat adult hair loss disorders or alopecia in primary care settings (non pregnant female and male adults). Austin (TX): University of Texas at Austin, School of Nursing; 2004 May. 21 p. [23 references]

Scope

Disease/Condition(s)

Hair loss or alopecia in adult women

Guideline Category
Diagnosis
Evaluation
Clinical Specialty
Dermatology
Endocrinology
Family Practice
Internal Medicine
Nursing
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To identify common causes of hair loss or alopecia in non-pregnant adult women
  • To assist primary care providers or specialists in early identification of hair loss symptoms, and clinical evaluation of hair loss
Target Population

Adult female patients aged 18 and older

Note: This guideline is not intended for evaluation of pregnant, pediatric, or male patients.

Interventions and Practices Considered

Diagnosis/Evaluation

  1. Medical, family and social history
    • Hair loss history, symptoms and nail changes/disease
    • Personal care history
    • Past medical history
      • Physical illness or surgery
      • Psychiatric illness
      • Medications
      • Signs or symptoms of thyroid disorders
      • Malnutrition gastrointestinal, and absorptive disorders
      • Menstrual and reproductive history
    • Risk factors for sexually transmitted infections
    • Family history
  2. Physical examination
    • Scalp and hair shaft exam
    • Tug test
    • Pull test
    • Neck/thyroid assessment
    • Nail examination
    • Hair density
    • Hair shaft examination
  3. Laboratory studies
    • Thyroid-stimulating hormone (TSH), complete blood count (CBC), ferritin, serum iron, total iron binding capacity (TIBC)
    • Antinuclear antibodies (ANA), rheumatoid factors (RF), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), comprehensive metabolic panel (CMP)
    • Total testosterone, free testosterone, dehydroepiandrosterone sulfate (DHEA-S), 17-hydroxyprogesterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, cortisol
    • Skin scraping sample and potassium hydroxide (KOH)
    • Human immunodeficiency virus (HIV) 1 & 2 screen and rapid plasma reagin (RPR) in patients with high-risk sexual practices
    • B12, zinc, albumin levels
  4. Diagnostic procedures
    • Biopsy
Major Outcomes Considered
  • Quality of life
  • Hair density or pattern
  • Hair loss
  • Appropriate management of underlying conditions

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
  • Searches of Electronic Databases: PubMed, CINAHL, Cochrane Review, Clinical Pharmacology Database, Online Journals.
  • Keyword Searches: Alopecia Evaluation, Alopecia Diagnosis, Hair Loss Evaluation, Hair Loss Diagnosis, and Female Pattern Hair Loss.
  • Inclusion Criteria: Female, aged 18 and older, English language, peer reviewed, publication years 2005-2010.
  • Exclusion Criteria: Male gender, pediatric population, and pregnancy; also medications, treatments, and procedures that cause hair loss.
Number of Source Documents

76

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

The U.S. Preventive Services Task Force (USPSTF) grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor).

Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Informal Consensus
Description of Methods Used to Formulate the Recommendations

This guideline is the result of extensive review and synthesis by expert clinicians.

Rating Scheme for the Strength of the Recommendations

The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).

A. The USPSTF strongly recommends that clinicians provide the service to eligible patients. The USPSTF found good evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms.

B. The USPSTF recommends that clinicians provide the service to eligible patients. The USPSTF found at least fair evidence that the service improves important health outcomes and concludes that benefits outweigh harms.

C. The USPSTF makes no recommendation for or against routine provision of the service. The USPSTF found at least fair evidence that the service can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

D. The USPSTF recommends against routinely providing the service to asymptomatic patients. The USPSTF found at least fair evidence that the service is ineffective or that harms outweigh benefits.

I. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service. Evidence that the service is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

A draft of the guideline was developed by a group of family nurse practitioner (FNP) students and submitted for review to the FNP program faculty and two external expert reviewers. Revisions were made after recommendations were received.

Recommendations

Major Recommendations

Strength of recommendations (A, B, C, D, I) and quality of evidence (good, fair, poor) are defined at the end of the "Major Recommendations" field.

Diagnostic Evaluation

The clinician skilled in gathering pertinent details of a history can quickly form a list of likely differentials that aid in guiding the physical examination and laboratory testing to provide optimal care to the patient.

Medical, Family, and Social History

  1. Evaluate patient history of hair loss, including: the onset, pattern (diffuse or focal), rate, and timing (Barankin, 2007; Harrison & Bergfeld, 2009; Mirmirani, 2007; Mounsey & Reed, 2009; Shapiro, 2007; Shrivastava, 2009; Tosti, Bellavista, & Iorizzo, 2006). Also inquire about other scalp symptoms, such as itching, burning, or tingling (Barankin, 2007; Mirmirani, 2007; Mounsey & Reed, 2009; Sarabi & Khachemoune, 2007; Shapiro, 2007; Shrivastava, 2009), and any nail changes or disease (Barankin, 2007; Dombrowski & Bergfeld, 2005; Martinelli et al., 2007; Tosti, Bellavista, & Iorizzo, 2006). Grade B, Fair Evidence.
  2. Obtain information about personal care history:
    • Hair-care routine, hygiene products, physical stress (Barankin, 2007; Harrison & Bergfeld, 2009; Mirmirani, 2007; Mounsey & Reed, 2009; Shapiro, 2007; Shrivastava, 2009). Grade B, Fair Evidence.
    • Dietary changes, diet, and environmental exposures (Barankin, 2007; Bhat et al., 2009; Camacho-Martinez, 2009; Collins, 2009; Harrison & Bergfeld, 2009; Mirmirani, 2007; Mounsey & Reed, 2009; Nagahama et al., 2006; Shapiro, 2007; Shrivastava, 2009). Grade C, Fair Evidence.
  3. Past medical history data should include:
    • Physical illness or surgery (Barankin, 2007; Camacho-Martinez, 2009; Harrison & Bergfeld, 2009; Mirmirani, 2007; Mounsey & Reed, 2009; Shapiro, 2007; Shrivastava, 2009). Grade B, Fair Evidence
    • Psychiatric illness (Willemsen et al., 2009) Grade C, Fair Evidence
    • Medications, including prescriptions, vitamins, and over-the-counter (OTC) medications. (Barankin, 2007; Harrison & Bergfeld, 2009; Mirmirani, 2007; Mounsey & Reed, 2009; Shapiro, 2007; Shrivastava, 2009). Grade B, Fair Evidence
    • Signs or symptoms of thyroid disorders (Barahmani, Schabath, & Duvic, 2009; Barankin, 2007; Harrison & Bergfeld, 2009; Mirmirani, 2007; Shapiro, 2007; Shrivastava, 2009). Grade B, Fair Evidence
    • Malnutrition, gastrointestinal disorders and absorptive disorders (Barahmani, Schabath, & Duvic, 2009; Bhat et al., 2009; Camacho-Martinez, 2009; Collins, 2009; Harrison & Bergfeld, 2009; Nagahama et al., 2006; Wang & Busbey, 2005). Grade C, Fair Evidence
    • Menstrual and reproductive history (Barankin, 2007; Karrer-Voegeli et al., 2009; Mirmirani, 2007; Mounsey & Reed, 2009; Shapiro, 2007; Shrivastava, 2009). Grade B, Fair Evidence
  4. Assess risk factors for sexually transmitted infections such as human immunodeficiency virus (HIV) or syphilis (Gale Group, 2009; Harrison & Bergfeld, 2009; Mounsey & Reed, 2009; Sud et al., 2009). Grade C, Fair Evidence
  5. Any family history of:
    • Alopecia, autoimmune disorders, endocrine disorders, atopy (Barahmani, Schabath, & Duvic, 2009; Barankin, 2007; Harrison & Bergfeld, 2009; Mirmirani, 2007; Mounsey & Reed, 2009; Shapiro, 2007; Shrivastava, 2009; Tosti, Bellavista, & Iorizzo, 2006; Welsh & Guy, 2009). Grade B, Fair Evidence
    • Gastrointestinal disorders (Bhat et al., 2009; Collins, 2009; Harrison & Bergfeld, 2009; Nagahama et al., 2006; Wang & Busbey, 2005). Grade C, Fair Evidence

Physical Examination

  1. Scalp exam for any scars, erythema, scarring, scaling, or inflammation (Barankin, 2007; Fu & Price, 2009; Petros, 2009; Sarabi & Khachemoune, 2007; Shapiro, 2007; Shrivastava, 2009). Grade B, Fair Evidence
  2. Assess the density and distribution of scalp hair (Barankin, 2007; Martinelli et al., 2007; Mirmirani, 2007; Mounsey & Reed, 2009; Shapiro, 2007; Shrivastava, 2009). Grade B, Fair Evidence
  3. Examine the hair shaft for quality, length, shape, and fragility (Mirmirani, 2007; Mounsey & Reed, 2009; Shapiro, 2007). Grade B, Fair Evidence
  4. Perform a tug test which evaluates the fragility of the shaft, and can be done by anchoring a cluster of hair at the scalp line with one hand, and pulling with the other to evaluate the number of shafts that break with pressure. No breakage is considered normal (Fu & Price, 2009; Mirmirani, 2007; Mounsey & Reed, 2009; Shapiro, 2007; Olsen et al., 2005). Grade B, Fair Evidence
  5. Perform a pull test to evaluate hair loss by grasping about 60 hairs between the thumb, the index, and the middle fingers. The hairs are then gently but firmly pulled. A positive test (approximately 6 out of 60 hairs, or 10%) indicates an active hair shedding (Dombrowski & Bergfeld, 2005; Fu & Price, 2009; Harrison & Bergfeld, 2009; Mounsey & Reed, 2009; Olsen et al., 2005; Rebora et al., 2005; Shrivastava, 2009). Grade B, Fair Evidence
  6. Assess the neck, beginning with the thyroid to determine size and if any nodularity is present Grade C, Poor Evidence. Determine if any cervical lymphadenopathy has occurred, which can be an indication of scalp infection (Petros, 2009; Sarabi & Khachemoune, 2007). Grade C, Fair Evidence
  7. Perform a nail examination to assess for pitting, which can be associated with alopecia areata (Barankin, 2007; Dombrowski & Bergfeld, 2005; Martinelli et al., 2007; Mirmirani, 2007). Grade C, Fair Evidence
  8. Examine hair density in other areas such as the face and extremities. A female patient who presents with thinning scalp hair and demonstrates increased facial, thigh, chin, or chest hair may have excess androgen (Harrison & Bergfeld, 2009; Karrer-Voegeli et al., 2009; Mirmirani, 2007; Mounsey & Reed, 2009; Shapiro, 2007; Shrivastava, 2009; Olsen et al., 2005). Grade B, Fair Evidence

Diagnosis

Routine laboratory tests help to determine the presence of underlying causes and risk factors associated with hair loss. Which tests to perform are based on findings obtained in the history and physical examination.

Laboratory Studies

  1. For all female hair loss patients with diffuse hair loss and in whom an underlying cause is not readily apparent, consider the measurement of thyroid-stimulating hormone (TSH) concentration to rule out thyroid disease; a complete blood count (CBC) for anemia and infection; along with a ferritin, serum iron, and total iron binding capacity (TIBC) level (Barankin, 2007; Camacho-Martinez, 2009; Collins, 2009; Harrison & Bergfeld, 2009; Mirmirani, 2007; Mounsey & Reed, 2009; Olsen et al., 2005; Rulon, Safranek, & Gauer, 2009; Shapiro, 2007; Shrivastava, 2009; Trost, Bergfeld, & Calogeras, 2006). Grade B, Fair Evidence

    If initial screening tests are unrevealing, or there is a strong history of autoimmune disorders, consider adding an antinuclear antibodies (ANA), rheumatoid factors (RF), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) to rule out an inflammatory cause or autoimmune disease (Barankin, 2007; Mirmirani, 2007; Mounsey & Reed, 2009; Olsen et al., 2005; Shrivastava, 2009). A comprehensive metabolic panel (CMP) can be done to rule out liver and renal disease (Harrison & Bergfeld, 2009). Grade B, Fair Evidence

  2. Women who have symptoms of hyperandrogenism, such as menstrual irregularities, infertility, cystic acne, virilization, or galactorrhea, will need to have their total testosterone, free testosterone, and dehydroepiandrosterone sulfate (DHEA-S) levels checked initially (Camacho-Martinez, 2009; Harrison & Bergfeld, 2009; Karrer-Voegeli et al., 2009; Mirmirani, 2007; Mounsey & Reed, 2009; Olsen et al., 2005; Rulon, Safranek, & Gauer, 2009; Shapiro, 2007; Shrivastava, 2009). Be sure to stop exogenous hormones at least one month prior to testing and consider referring to endocrinology early in the evaluation. Further testing may include 17-hydroxyprogesterone, luteinizing Hormone (LH), follicle-stimulating hormone (FSH), prolactin, and cortisol levels (Camacho-Martinez, 2009; Harrison & Bergfeld, 2009; Karrer-Voegeli et al., 2009; Mirmirani, 2007; Mounsey & Reed, 2009; Olsen et al., 2005; Shrivastava, 2009). Grade B, Fair Evidence
  3. For female hair loss patients with localized hair loss consider taking a skin scraping sample and utilizing potassium hydroxide (KOH) to rule out tinea capitis (Mounsey & Reed, 2009; Sarabi & Khachemoune, 2007; Shapiro, 2007). Grade B, Fair Evidence
  4. For female hair loss patients with high risk sexual practices, a human immunodeficiency virus (HIV) 1 & 2 screen should be run, along with an rapid plasma reagin (RPR) test to rule out syphilis (Gale Group, 2009; Harrison & Bergfeld, 2009; Mirmirani, 2007; Mounsey & Reed, 2009; Shapiro, 2007; Sud et al., 2009). Grade C, Fair Evidence
  5. For hair loss with symptoms of malnutrition, gastrointestinal or absorptive disorder, consider obtaining vitamin B12, zinc, and albumin levels (Barankin, 2007; Bhat et al., 2009; Collins, 2009; Harrison & Bergfeld, 2009; Nagahama et al., 2006; Olsen et al., 2005; Wang & Busbey, 2005). The longer a patient has experienced alopecia, the more likely serum deficiencies will be detected (Bhat et al., 2009). Grade C, Fair Evidence

Diagnostic Procedures

When evaluation necessitates a specialty referral, one of the primary procedures to have done is a routine and immuno biopsy of the scalp from two separate biopsy sites. This can be used with localized or diffuse hair loss to differentiate chronic telogen effluvium, diffuse alopecia areata, female pattern hair loss (FPHL), systemic lupus erythematosus (SLE), scarring alopecia, or rarer dermatologic conditions (Harrison & Bergfeld, 2009; Lin et al., 2007; Mirmirani, 2007; Mounsey & Reed, 2009; Shapiro, 2007; Shrivastava, 2009). Grade C, Fair Evidence

Definitions:

Strength of Recommendation (Based on U.S. Preventive Services Task Force [USPSTF] Ratings)

A. The USPSTF strongly recommends that clinicians provide the service to eligible patients. The USPSTF found good evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms.

B. The USPSTF recommends that clinicians provide the service to eligible patients. The USPSTF found at least fair evidence that the service improves important health outcomes and concludes that benefits outweigh harms.

C. The USPSTF makes no recommendation for or against routine provision of the service. The USPSTF found at least fair evidence that the service can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

D. The USPSTF recommends against routinely providing the service to asymptomatic patients. The USPSTF found at least fair evidence that the service is ineffective or that harms outweigh benefits.

I. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service. Evidence that the service is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

Quality of Evidence (Based on USPSTF Ratings)

Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of evidence is identified and graded for all recommendations (see "Major Recommendations").

These recommendations are the result of a comprehensive review of many sources, including case studies, clinical trials, and reviews. In order to formulate the guideline, group consensus was used when the information contained in the above sources was inconclusive.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Early identification of causes of hair loss in adult women
  • Identification of possible concomitant disorders and appropriate referrals
  • Improvement of psychological well-being and body image
  • Avoidance of expensive, ineffective, and time-consuming therapeutic interventions
Potential Harms
  • Psychological stress
  • Unnecessary, invasive, and often time-consuming testing
  • Subgroups most likely to be harmed: patients with underlying causes of hair loss that remains undetected
  • Use caution when performing punch or scrape biopsies in patients undergoing anticoagulation therapies or immunocompromised patients.

Qualifying Statements

Qualifying Statements
  • This document is not intended to guide the evaluation of pregnant, pediatric, or male patients.
  • This document is intended as a guideline only and should not supersede the clinical judgment of the health care provider. It is provided for discussion, educational purposes, and as a decision making tool for both clinicians and patients. It should not be used or relied upon without supervision of a qualified health care provider.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program. Evaluation of hair loss in adult women. Austin (TX): University of Texas at Austin, School of Nursing; 2010 May 21. 18 p. [36 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2004 May (revised 2010 May 21)
Guideline Developer(s)
University of Texas at Austin School of Nursing, Family Nurse Practitioner Program - Academic Institution
Source(s) of Funding

University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program

Guideline Committee

Practice Guidelines Committee

Composition of Group That Authored the Guideline

Authors: Olivia Blankenship, RN, BSN; Darla Grimes, RN, BS, MSN; Christine Kremer, RN-C, BA, MSN; Sally Reese, RN, BSN

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program. Recommendations to diagnose and treat adult hair loss disorders or alopecia in primary care settings (non pregnant female and male adults). Austin (TX): University of Texas at Austin, School of Nursing; 2004 May. 21 p. [23 references]

Guideline Availability

Electronic copies: None available.

Print copies: Available from the University of Texas at Austin, School of Nursing. 1700 Red River, Austin, Texas, 78701-1499, Attn: Nurse Practitioner Program

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on August 25, 2004. The information was verified by the guideline developer on November 12, 2004. This summary was updated by ECRI Institute on October 3, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium). This summary was updated by ECRI Institute on November 6, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This summary was updated by ECRI Institute on May 5, 2009, following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium). This NGC summary was updated by ECRI Institute on October 21, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which may be subject to the guideline developer's copyright restrictions.

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