Alopecia Management in Primary Care: Expert Insights from ACP 2025

At the American College of Physicians Internal Medicine Meeting 2025, April 3-5, 2025, in New Orleans, William Lewis, MD, instructor, department of dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, presented on the management of nonspecific hair loss, emphasizing the importance of careful assessment and patient communication.

Dr Lewis opened his presentation by underscoring the fact that alopecia presents several challenges in a busy primary care clinic. Patients often experience significant emotional distress regarding their hair loss, which can complicate management. Responses to treatment may be slow, making it difficult to reassure patients about their progress. In some cases, referrals to dermatological specialists may be necessary for effective management, and addressing alopecia often requires comprehensive counseling and lengthy discussions to help patients navigate their concerns.

Key Insights on Management:

1. Assessment Protocol: Physicians were encouraged to ask targeted questions during patient evaluations regarding the specific nature of hair loss. And Dr Lewis noted that distinguishing between shedding and thinning is crucial for diagnosis as shedding often indicates telogen effluvium, while thinning suggests different underlying causes. Physicians should also ask whether hair loss is symptomatic as itching or pain suggests an inflammatory process.
2. Take Pictures: Alopecia treatments may work slowly, so patients may not notice even an excellent treatment response. Dr Lewis stressed that taking pictures can serve as a powerful tool in reassuring patients and encouraging them to adhere to treatment protocols. A study of standardized scalp photography in 119 people seen for follow-up at a hair specialty clinic showed that 98.3% of participants reported they were more motivated to continue treatment after seeing images, and 52.9% rated alopecia as less severe after seeing images.¹
3. Referral Indicators: Identifying red flags such as atypical patterns of hair loss, active inflammation, or noticeable post-inflammatory changes is vital for determining when to refer patients to dermatological specialists.
4. Effective Counseling: Dr Lewis urged physicians to educate patients on the causes and triggers of hair loss, establishing realistic expectations surrounding treatment timelines and outcomes.

Treatment Modalities

Dr Lewis also discussed both FDA-approved and off-label treatment options, with topical minoxidil and oral finasteride being highlighted for androgenetic alopecia. He also covered emerging nonpharmaceutical treatments, such as low-level light therapy and platelet-rich plasma injections, which are gaining traction as viable options for hair regrowth. In discussing laboratory testing, physicians were advised to consider a panel of evaluations, including iron studies, vitamin D levels, TSH, and hormonal assessments in patients demonstrating virilizing signs, particularly in women.

References:

1. Pathoulas JT, Flanagan KE, Walker CJ, et al. Evaluation of standardized scalp photography on patient perception of hair loss severity, anxiety, and treatment. J Am Acad Dermatol. 2021;85:1640-1641. doi:10.1016/j.jaad.2020.12.059