Alopecia and hair loss — diagnosing the cause first, then treating it honestly

In brief

• Hair loss has several different causes, and the treatment depends on the type. Most “nothing works” stories are the wrong treatment for the cause, or the right treatment stopped too soon.
• Pattern hair loss responds to minoxidil and, in men, finasteride. Expect the first benefit at 3–4 months and the full effect at 6–12 months.
• Shedding after illness, childbirth or stress usually regrows once the trigger is corrected, often with iron or thyroid treatment.
• Patchy hair loss (alopecia areata) often regrows by itself; injections can speed it up.
• Redness, scaling, itch or tenderness on the scalp can mean scarring hair loss, which needs prompt referral.

We assess hair loss at our Punggol and Joo Chiat clinics, with blood tests where useful and trichoscopy at Punggol when the clinical situation warrants it. Book a skin and hair appointment.

Why diagnosing the type matters

The common types of hair loss look similar (less hair) but are different conditions with different treatments and outlooks. When the diagnosis and treatment don’t match:

• A hair-growth product applied to telogen effluvium does little, when correcting the trigger would have allowed natural regrowth in 3–6 months.
• A supplement bought for pattern hair loss does nothing for early scarring alopecia, while months pass that specialist treatment could have used.
• A costly “restoration” treatment for alopecia areata misses that the condition often regrows on its own.

What we do at the diagnostic visit

History

• When it started: sudden or gradual; recent stress, illness, surgery, major weight change or pregnancy
• Pattern: diffuse, frontal or temporal recession, central thinning, patches, or along the hairline
• Scalp symptoms: itch, burning, tenderness, scaling or redness, which suggest a scarring or inflammatory cause
• Medications: many can contribute, including some chemotherapy, anticoagulants, beta-blockers, lithium, ACE inhibitors, starting or stopping oral contraceptives, some antidepressants, isotretinoin and other retinoids
• Diet: extreme dieting, anorexia, recent major weight loss, or restrictive diets without supplementation
• Family history, particularly for pattern hair loss
• Hair care: tight ponytails or braids, frequent chemical processing, heat styling
• For women: menstrual cycle, pregnancy, the months after birth, menopause and hormonal contraception

Examination

• Pattern of loss: graded on the Norwood scale for men and the Ludwig or Sinclair scale for women
• Density, overall and in specific areas
• Scalp surface: redness, scaling, scarring, and whether follicle openings are preserved
• Hair pull test: gentle traction on a small bundle; more than 2–3 hairs coming out easily suggests active shedding
• Broken, miniaturised or exclamation-mark hairs, the last being specific to alopecia areata
• Trichoscopy: a dermatoscope magnifies the scalp to show follicle openings, miniaturised hairs and scarring patterns. We use it at our Punggol clinic when the clinical situation warrants it.

Blood tests

We usually check:

• Ferritin (iron stores). Low iron is a common contributor. For hair growth we aim for ferritin above 50 µg/L, higher than the threshold for general iron deficiency.
• TSH (thyroid function). An under- or overactive thyroid can both cause shedding.
• Full blood count, for anaemia and other clues.
• Vitamin D, which is commonly low locally.
• Sometimes: vitamin B12, folate or zinc; in women with signs of excess androgens (acne, irregular periods, excess hair), testosterone and DHEAS; and selected autoimmune markers such as ANA if an autoimmune cause is suspected.

We don’t order broad supplement panels or “hair mineral analysis”. They are popular, but the evidence that they guide treatment is weak.

When we refer

We refer to a dermatologist for scarring alopecia (lost follicle openings, redness or scaling around follicles) for scalp biopsy and specialist treatment, because these conditions can cause permanent loss if not treated promptly. We also refer extensive or complex alopecia areata, hair loss still unexplained after a full primary care work-up, and anyone who prefers specialist-led care.

Androgenetic alopecia — the most common type

Also called male-pattern baldness or female-pattern hair loss. It is hereditary and gradual, driven by the sensitivity of hair follicles to the hormone dihydrotestosterone (DHT).

What it looks like

Men: recession at the temples and front hairline, with thinning at the crown. The two areas often progress and eventually meet. The Norwood scale grades this from 1 to 7.

Women: diffuse thinning over the crown with a preserved front hairline, which distinguishes it from frontal fibrosing alopecia, a scarring condition. A widening central parting, the “Christmas tree” pattern, is typical. The Ludwig scale grades this from I to III.

Treatment in primary care — what works

Three medications have good evidence. We order them through an online pharmacy when prescribed, with delivery usually in 1–3 working days, because they are not routinely stocked in our dispensary.

1. Topical minoxidil

• Men: 5% solution or foam, twice daily on the scalp
• Women: 2% solution or 5% foam, once or twice daily
• Available over the counter in Singapore as Regaine and generic brands
• First benefit at 3–4 months; full response at 6–12 months. Don’t judge it earlier.
• It must be continued. Stopping leads to loss of the regained hair within about 6 months.
• Side effects: scalp irritation (switching from solution to foam can help); unwanted facial hair, mainly with 5% in women, so we usually start women at 2%; and extra shedding in the first 4–6 weeks as new growth pushes out old hairs. That early shedding is a sign it is working.

2. Oral finasteride 1 mg daily (men only)

• Lowers DHT in the scalp. It is the most effective medical treatment for male pattern hair loss.
• We prescribe it in primary care after discussing:
  • Sexual side effects (reduced libido, erectile dysfunction, lower ejaculate volume) in a small minority, probably 1–3% in trials and possibly more in real-world reports. Usually reversible on stopping. We review at 3 and 6 months.
  • Mood changes: a possible link with low mood and depression, which we monitor.
  • Long-term use: benefit needs continued use; stopping leads to gradual loss of regained hair over 6–12 months.
  • Pregnancy in a partner: finasteride can harm a male fetus. A pregnant partner, or one trying to conceive, should not handle crushed or broken tablets. Intact tablets are safe to handle.
• Not used in women who could become pregnant, outside specific specialist settings.

3. Low-dose oral minoxidil (off-label)

• 2.5 mg once daily, or 1.25 mg in women and sometimes more in men. Off-label, but increasingly mainstream internationally.
• More effective than topical minoxidil for many people, and easier to keep up: one tablet instead of twice-daily application.
• Side effects to know about:
  • Extra body and facial hair: common and manageable
  • A small fall in blood pressure: usually not significant at low doses; we check blood pressure first
  • Fluid retention or mild ankle swelling: uncommon at low doses, and settles with a lower dose
  • A faster heart rate: possible, rarely a problem
• We check blood pressure and history before starting, and review at 1 month.
• Often used together with finasteride.

Combination treatment

For men, topical minoxidil with oral finasteride is the best-evidenced combination and works clearly better than either alone. Oral minoxidil with finasteride is increasingly used. We choose based on severity, your preferences, side effects and what you can keep up.

Procedures we do not offer

• Platelet-rich plasma (PRP) injections: the evidence is mixed and any benefit is modest and inconsistent. We do not offer PRP; aesthetic dermatologists can discuss it with you.
• Hair transplant: a separate surgical specialty, and we have no established referral pathway. If you are considering it, look for a doctor with specific surgical training in the procedure, and ask about technique (FUE or FUT), expected graft yield and realistic results. We are happy to discuss whether your pattern of loss suits transplant.

Realistic expectations

• The best outcome is to stop or slow further loss and partly regrow thinned hairs. Medical treatment alone will not restore teenage density at 50.
• Earlier treatment works better. Keeping existing hair is easier than regrowing lost hair.
• Treatment is long-term. Stopping any of these medicines leads to loss of regained hair within 6–12 months.
• Cost matters, and we discuss it openly. Topical minoxidil is the most affordable; finasteride and oral minoxidil are also relatively affordable, but costs add up over years.

Telogen effluvium — shedding after a trigger

Diffuse shedding, noticed as more hair on the pillow, in the brush or in the shower drain, usually 2–4 months after a trigger.

Common triggers:

• Major illness, surgery or a hospital stay
• Childbirth: affects many women 2–6 months after delivery and usually resolves over 6–12 months
• Significant unintended weight loss
• Severe psychological stress, such as bereavement
• Iron deficiency or another nutritional deficiency
• Thyroid disease, under- or overactive
• Some medications (see the history list above)
• Recent COVID-19 or another significant infection

The trigger pushes hair follicles early from the growing phase into the shedding phase. The shedding can be dramatic, but the follicles are not damaged, and regrowth is the normal outcome once the trigger is corrected.

What we do

• Find and correct the trigger: replace iron if low, treat thyroid disease, address nutrition and stress
• Replace deficiencies: most often iron (target ferritin above 50 µg/L), sometimes vitamin D, occasionally B12 or zinc
• Reassure: regrowth usually starts within 3–6 months of the trigger being addressed, with full recovery over 6–12 months
• Avoid adding hair-growth products that don’t address the cause; the regrowth would have happened anyway

Sometimes two causes overlap, most often shedding after childbirth together with new pattern hair loss. Then both need treating, for example iron replacement plus topical minoxidil.

Alopecia areata — autoimmune, patchy

Sudden round or oval patches of complete hair loss, often coin-sized. The skin in the patch looks normal: no scaling, redness or scarring, and follicle openings are preserved.

Fine dents in the nails (nail pitting) sometimes occur. Exclamation-mark hairs, short broken hairs that taper towards the scalp at the edge of an active patch, are characteristic.

Course

Very variable. Many people have a single small patch that regrows on its own over 6–12 months. Others get recurrent patches, and a smaller group progress to loss of all scalp hair (alopecia totalis) or all body hair (alopecia universalis). Which path a person will take is hard to predict.

Treatment in primary care

For mild, localised alopecia areata:

• Steroid injections into the patch (intralesional triamcinolone) every 4–6 weeks, effective for many people with localised disease. We do these in clinic when appropriate.
• A potent steroid cream or lotion, under overnight occlusion where practical
• Topical minoxidil as an add-on
• Reassurance: many patches regrow without treatment. Treatment may speed regrowth but is not always needed for limited disease.

When we refer

• Extensive disease: a large area, multiple patches or rapid progression
• Alopecia totalis or universalis
• No response to localised treatment
• Significant distress

Specialist treatment now includes JAK inhibitors (baricitinib, ritlecitinib), oral medicines licensed for severe alopecia areata that have transformed outcomes for many people with extensive disease. They are dermatologist-led, expensive and need monitoring.

Scarring alopecia — permanent, and we refer

A group of conditions in which the hair follicle itself is destroyed, so the loss is permanent. They include:

• Lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA): autoimmune, often at the front hairline. FFA particularly affects women after menopause, with frontal recession and loss of eyebrows.
• Central centrifugal cicatricial alopecia (CCCA): affects the crown, more common with Afro-textured hair
• Folliculitis decalvans: chronic inflammation with pustules
• Discoid lupus affecting the scalp

Signs to watch for

• Loss of follicle openings in the affected area
• Redness and scaling around follicles
• Itch, burning or scalp tenderness, often prominent
• A change in hairline shape: frontal recession (FFA) or a patch spreading from the crown (CCCA)
• Loss of eyebrows (FFA)

When we refer

Any suspicion of scarring alopecia needs prompt referral to a dermatologist for assessment and scalp biopsy, the diagnostic test. Treatment with anti-inflammatory medicines aims to stop progression, because a scarred follicle cannot regrow hair. Time matters: early treatment protects the follicles not yet affected, so we do not delay referral.

Things that may not help

• “Hair growth” shampoos and conditioners: most have no meaningful effect. Some contain low doses of minoxidil or ketoconazole that may help slightly, but medical-grade products work better.
• Most supplements, unless you have a proven deficiency. Hair supplement bundles often contain biotin (rarely lacking, rarely the cause), iron (helpful only if low), zinc and plant extracts. Treating a real ferritin or thyroid problem works far better than blanket supplements.
• Biotin without a deficiency: no benefit, and high doses can distort blood tests, particularly thyroid and troponin results.
• Scalp massage on its own: gentle massage while applying minoxidil is fine and helps you keep it up; massage alone has weak evidence.
• “Detox” and chemical scalp treatments: limited evidence, and some can worsen scalp inflammation.
• PRP: inconsistent evidence, as above; we do not offer it.
• Laser and LED caps: modest evidence in some studies, expensive, and no substitute for proven treatment. Some people add them if budget allows.
• Shampooing more or less often: neither causes nor treats hair loss.
• Cutting hair short “to make it grow stronger”: hair grows from the follicle under the scalp, so cutting the shaft doesn’t change growth or thickness.

If something has clearly helped you, tell us. We would rather know.

When to come and see us

Book a visit if:

• You are losing more hair than usual and it has gone on for more than 4–6 weeks
• You notice a patch of complete hair loss, particularly if it appeared suddenly
• Your hairline is receding and you want to discuss treatment
• Your scalp is red, scaly, itchy or tender, which should be assessed promptly
• Hair loss after childbirth is severe or hasn’t started to recover by 6–9 months after delivery
• You have been on treatment for 6–12 months without much improvement
• Hair loss comes with other symptoms, such as tiredness, weight change or menstrual changes, that suggest a wider cause

Same-day attention

• Sudden hair loss with marked scalp inflammation, pustules, fever or feeling unwell. Uncommon, but it should be seen the same day.

Get in touch

Punggol — 658 Punggol East, #01-04, Singapore 820658 · Tel 6312 4589

Joo Chiat — 172 Joo Chiat Road, #01-01, Singapore 427443 · Tel 6920 1952

Email — admin@ktmc.sg

References

Guidelines and reviews — androgenetic alopecia

• Kanti V, Messenger A, Dobos G, et al. Evidence-based (S3) guideline for the treatment of androgenetic alopecia in women and in men — short version. European Academy of Dermatology and Venereology. J Eur Acad Dermatol Venereol. 2018;32(1):11–22.
• Sinclair R, Patel M, Dawson TL Jr, et al. Hair loss in women: medical and cosmetic approaches to increase scalp hair fullness. Br J Dermatol. 2011;165(Suppl 3):12–18.
• Vañó-Galván S, Pirmez R, Hermosa-Gelbard A, et al. Safety of low-dose oral minoxidil for hair loss: A multicenter study of 1404 patients. J Am Acad Dermatol. 2021;84(6):1644–1651.

Telogen effluvium

• Malkud S. Telogen effluvium: A review. J Clin Diagn Res. 2015;9(9):WE01–WE03.

Alopecia areata

• Strazzulla LC, Wang EHC, Avila L, et al. Alopecia areata: Disease characteristics, clinical evaluation, and new perspectives on pathogenesis. J Am Acad Dermatol. 2018;78(1):1–12.
• King BA, Senna MM, Ohyama M, et al. Defining severity in alopecia areata: Current perspectives and a proposed framework. J Am Acad Dermatol. 2024;90(2):359–364.

Scarring alopecia

• Olsen EA, Bergfeld WF, Cotsarelis G, et al. Summary of North American Hair Research Society (NAHRS)-sponsored Workshop on Cicatricial Alopecia. J Am Acad Dermatol. 2003;48(1):103–110.

Finasteride safety

• Mella JM, Perret MC, Manzotti M, et al. Efficacy and safety of finasteride therapy for androgenetic alopecia: a systematic review. Arch Dermatol. 2010;146(10):1141–1150.

This information is for general education only and is not a substitute for medical advice. Hair loss treatment is individualised — please attend a consultation for assessment. v1.1 · October 2026 (v1.0 April 2026) · Review due April 2028.