Transcript: Approach to Hair Loss for New Nurse Practitioners

​Liz Rohr:                                              

Well, hey, there. It's Liz Rohr from Real World NP. You are watching the Real World NP YouTube channel, where I share weekly episodes to help save you time, learn faster, and help you take the best care of your patients. In this week's episode, we are going to be talking about hair loss as a chief complaint in primary care.                                                  

So this is a tricky one. I just want to normalize that. Because when it comes to this chief complaint, the differentials are really actually broad. In this episode, I'm going to focus on breaking it down with a kind of quick and dirty approach in primary care. And what are the red flags of what not to miss and things to think about as an initial approach.

And in this episode, I'm actually going to work backwards. So I usually start with like history questions, exam, things like that and then I get to differentials and plan. But I'm going to start actually with differentials. And I've said this before, but as I've become more experienced as a nurse practitioner, when I encounter a chief complaint, I get more of the differentials in the front of my mind, such that when I ask the history, HPI questions, I can ask those history questions specific to the differentials. So we're going to practice it in this video. Who knows? I think it'll make more sense for this particular topic because it will really frame what it is you're asking for and what you're looking for.

 So let's start with a couple of differentials. So like I said, hair loss has a very broad differential. And so these are the main ones I want you to keep in mind. So on the one hand, there are systemic illnesses. So I'll talk about that in a second. And then the other thing is like is this a scalp or hair disorder compared to the systemic illnesses?

So let's talk about some of those. So what are some systemic illnesses we need to think about? One is hyper or hypothyroidism can cause hair loss. Another one is iron deficiency anemia, or B12 deficiency anemia. Another one is actually in kind of like a broader category. So there's something called telogen effluvium, which is a really fancy word to make you feel real fancy when you use that in your notes or when you're discussing with colleagues. But basically what it's referring to is that in hair, there are three general phases. Anagen, catagen, and telogen, meaning growth, development through rest. And about at any one time on the average person's head, 90% of them are in the first two phases, anagen, catagen. I hope I'm saying them right. I'm really good at mispronouncing things. And then telogen is that resting phase. So about 10% of hair is in that telogen phase, that resting phase, and that's when it falls out, right? Because there's continual growth, shedding, all that stuff.

There are certain states that lead to telogen effluvium. It is a whole can of worms. But long and short of it, for the purposes of this video and your first approach to hair loss and primary care is major changes in the body can lead to kind of like a general amount of hair loss. That is almost like when you pull on your hair, a whole bunch comes out at once. It's not like patchy. It's not specific bald spots, things like that.

So I believe that can come with, that is how it's shown in hyper or hypothyroidism and iron deficiency as well. But the other thing that can cause that is things like major stress, whether it's emotional stress, physiologic stress, chronic illness, or acute illnesses, hospitalizations. And the other thing is pregnancy. So postpartum, it's actually a specific name called telogen gravidarum, I believe. Anyway, that's just being real fancy. But that happens, predictably, after childbirth.

So there are certain states that can have this telogen effluvium state, and it tends to happen two to three months after the inciting incident. Kind of one or two other things that can cause it that's pretty important to remember, because I see this all the time, is sudden decreases in caloric intake or vitamin intake. So for example, when somebody goes on a very strict diet or caloric restriction, anorexia nervosa, perhaps after bariatric surgery, those things, and again, having a surgery as well, that decrease in nutrition can trigger that to happen. And then that can either get better over time or when the calories are reinstated, then less of an issue.

One other thing can be there's some correlation with vitamin D deficiency and hair loss, that general hair loss, not like specific patches. So that would be one to consider as well. So those are kind of the more systemic related issues that we want to keep front of mind with hair loss.

The other ones are scalp specific disorders and/or hair shaft follicle disorders. And like I said, it's a big chunk of stuff, so we'll keep it at that. But the main kind of skin ones we want to think about in primary care, do we have any seborrheic dermatitis? Do we have any tinea capitis? And then one other kind of very, like on the more common side one, is traction alopecia, which has to do with pulling on the hair from various hairstyles that can lead to spots of thinning hair.

So you want to ask, leading into the next section of history and exam and pearls of practice, but you of course want to ask about how patients take care of their hair, what they do for it. Do they have tighter hairstyle, things like that. Other things as it relates to kind of like hair specific or scalp specific, you want to think about is there any type of, like what is the pattern?

Okay, so this is getting into the next section of like history and exam. So let's just jump in. So when we're talking about history, we want to ask, whenever there's a chief complaint, regardless of what it is and especially if you're not comfortable with the full differential diagnosis, you want to go back to your acronyms of OLDCART or whichever one you use, PQRST, I think some other people use. But what are the questions that we can ask to get a full history regardless of the differentials?

Specific to hair loss though, we want to ask about duration. How long has this been going on for? Did it just start? Is it progressing? Is it getting worse, better or the same? Any sort of major stressors. Again, going back to the differential, I would want to know, is there a risk of telogen effluvium? Are there patches, is it specific areas on their scalp? Is there a pattern? And if you're listening, instead of watching, I'm pointing to my hairline, but is there a receding of a hairline, or is there loss by the crown or in the part? And you want to ask about do they have any physical symptoms associated with it, is there any itching, is there any pain, is there any drainage, things like that?

And one other differential I forgot to mention related to the hair loss patterns is that people can have androgen excess. And whether or not for some patients that might have PCOS for example, excess androgens or other conditions can lead to increased hair loss. And then there's some genetic components of genetic related hair loss.

So again, just to recap and tie it back into those differentials, do they have any recent weight loss, any diets, any recent surgeries, major stressors. And then of course, we always want to ask about medications that they take. Even if we're not familiar with all the medications that can contribute to hair loss, we want to have that full history so it can be part of our investigation.

So again, the next part is the exam. So even if you don't feel super comfortable with this, you can generally speaking examine and palpate the scalp and the hair. So you want to see, again, if they can point you to where the issues are, you can determine is it patches versus general hair loss versus is there a rash, signs of dandruff, seborrheic dermatitis, tinea capitis, et cetera, et cetera. Again, huge differential, but just start there, and use your clinical judgment to determine is there a risk for some sort of systemic illness, is this local, things like that.

 When it comes to diagnostics, so again, I'm really focusing on the main triage-related stuff in primary care, and then you're kind of deciding from there do they need to see dermatology. So we're thinking about, again, those differentials. Do we want to assess for their TSH? Do they have signs of androgen excess? Do we want to test for that? Iron deficiency? Do we want to do a CBC, ferritin, iron studies, B12? Because again, if you've been a part of the lab course, we talk about how you might not see on a CBC that there's anemia, but your iron stores reflected in your ferritin can becoming very close to iron deficient and you just haven't caught it on the CBC yet. So you want to think about do you want to do a ferritin, again, or a B12.

And then one other kind of, I didn't mention this in the differential, but syphilis can cause patchy hair loss. Epidemiologically, not a huge necessarily population risk, but something you want to consider based on their history and their exam. And so really your end result and your treatment is dependent on those factors. And like I said, there's so many things that it could be. But if there's any risk for seborrheic dermatitis or tinea, you could trial four to six weeks of ketoconazole if it seems like it's something related to that. You can do their blood tests and see if there's any risk for any of those factors. And then if it really looks like something that is outside of that scope, that's when you get the assistance of dermatology.

 So hopefully this video is helpful. Let us know what questions you have and thank you so very much for watching. If you haven't grabbed the Ultimate Resource Guide for the New NP, head over to https://www.realworldnp.com/guide. You'll get these videos sent straight to your inbox every week with notes from me, patient stories and bonuses. I really just don't share anywhere else. Thank you so much again for watching. Hang in there. I'll see you soon.