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Endgames Case Report

Recurrent episodes of hair loss in a 37 year old woman

BMJ 2012; 345 doi: (Published 09 October 2012) Cite this as: BMJ 2012;345:e6798
  1. Carol Cunningham, specialist registrar in dermatology1,
  2. Ralf Paus, professor of cutaneous medicine2,
  3. Matthew Harries, dermatology consultant1
  1. 1Dermatology, Salford Royal Foundation Trust, Manchester M6 8HD, UK
  2. 2University of Manchester, Stopford Building, Manchester
  1. Correspondence to: C Cunningham car.cunningham{at}

A 37 year old woman presented with recurrent episodes of hair shedding that led to reduced hair volume. The first episode of hair loss had occurred three months after the death of her father. Her scalp hair had become dry and of poor quality, and soon after her hair started “falling out by the roots.” After four months of serious hair shedding the hair loss slowed. Unfortunately, she then had a miscarriage, which resulted in a flare of the shedding. Investigations at this time identified low iron stores (ferritin 24.7 pmol/L, reference range 54-674 for men and 34-690 for women; 1 pmol/L=0.45 ng/mL). With increased iron consumption the shedding settled and was associated with improvements in hair quality and volume. A few months later she started a combined oral contraceptive (cyproterone acetate and ethinylestradiol), but within a month she developed side effects so stopped the treatment. Within six weeks she developed a further episode of increased hair shedding with loss of hair density.

On first attendance she reported a reduction in the rate of hair shedding, with evidence of hair regrowth. However, she thought that her hair volume was still subnormal and felt self conscious about it. She had no medical history of note, no allergies, and had been taking multivitamin and iron supplements for the past seven months. She had not used any topical treatments, had not changed the frequency of shampooing, and denied any traumatic hair care practices. On examination there was no evidence of scarring or inflammation of the scalp skin. Short regrowing hairs were seen, the vertex hair part width was normal compared with the occipital hair part width, and a pull test to assess for active hair shedding was negative.


  • 1 What is the most likely diagnosis?

  • 2 List four possible differential diagnoses

  • 3 How …

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