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

About this guide

Hair loss is one of the conditions where patients most commonly arrive at the clinic having already tried several things — supplements, “hair growth” shampoos, perhaps an over-the-counter topical, sometimes treatments from a beauty salon — and concluded that “nothing works.” The honest reading is usually different: the wrong treatment was being applied to the wrong cause, or the right treatment wasn’t given enough time, or both.

The single most important step in hair loss is diagnosing the type of hair loss correctly. The treatment depends on the cause, and the wrong treatment for the right condition is just as ineffective as the right treatment for the wrong condition.

This guide covers:

• The main types of hair loss we see — and how to tell them apart
• What we do at the diagnostic visit — history, examination, blood tests
• Androgenetic alopecia (male and female pattern) — what genuinely works and what doesn’t
• Telogen effluvium — the diffuse shedding that follows illness, surgery, or pregnancy
• Alopecia areata — the autoimmune patchy hair loss
• Scarring alopecia — when it’s permanent and we refer
• Things that may not help — including some popular and expensive options
• When to come and see us

This is also one of the conditions where being honest about what we offer and what we don’t is especially important. We are happy to discuss the full landscape; we will tell you clearly what we do in clinic, what we order via online pharmacy, and what we refer for.

Why diagnosing the type matters

The four most common types of hair loss in adults look superficially similar (less hair) but are completely different conditions with different treatments and different outlooks. Mismatch the diagnosis and treatment, and:

• A topical hair-growth product applied to telogen effluvium does little, when identifying and correcting the underlying trigger would have allowed natural regrowth in 3–6 months
• A supplement marketed for androgenetic alopecia applied to early scarring alopecia does nothing for the scarring while valuable months pass without specialist intervention
• A “hair restoration treatment” sold for alopecia areata misses that the condition often regrows spontaneously and that the right step might simply be reassurance and time

Getting the diagnosis right is the single biggest lever. The rest follows.

What we do at the diagnostic visit

A structured visit, typically including:

History

• When did it start? Sudden vs gradual; recent stressor; recent illness, surgery, severe weight change, or pregnancy
• Pattern — diffuse all over, frontal/temporal recession, central thinning, patches, edges of hairline
• Symptoms — itch, burning, tenderness, scaling, redness on the scalp (suggests scarring or inflammatory cause)
• Medications — many drugs can contribute (some chemotherapy, anticoagulants, beta-blockers, lithium, ACE inhibitors, oral contraceptives starting or stopping, some antidepressants, isotretinoin, retinoids in general)
• Diet and lifestyle — extreme dieting, anorexia, recent significant weight loss, vegan or restrictive diets without supplementation
• Family history — particularly for androgenetic alopecia
• Hair styling and treatments — tight ponytails, braids, frequent chemical processing, heat styling
• For women — menstrual cycle, pregnancy, postpartum, menopause, hormonal contraception

Examination

• Pattern of loss — Norwood scale for men, Ludwig or Sinclair scale for women
• Density — overall and in specific areas
• Scalp surface — redness, scaling, scarring, follicular orifices preserved or lost
• Hair pull test — gentle traction on a small bundle; if more than 2–3 hairs come out easily, suggests active shedding (telogen effluvium or active alopecia areata)
• Examination of broken hairs, miniaturised hairs, exclamation-mark hairs (specific to alopecia areata)
• Trichoscopy — using a dermatoscope to examine the scalp at higher magnification, to look for follicular orifices, miniaturised hairs, perifollicular changes, and scarring patterns. We are currently in the process of procuring a dermatoscope — once it arrives (over the next few weeks), trichoscopy will be part of our standard hair-loss assessment. In the meantime, we use careful clinical examination, which is sufficient for most diagnoses.

Blood tests

We typically check:

• Ferritin (iron stores) — low iron is a common contributor; we aim for ferritin above 50 µg/L for hair growth, which is higher than the threshold for general iron deficiency
• TSH (thyroid function) — both hypothyroidism and hyperthyroidism can cause diffuse hair shedding
• Full blood count (FBC) — looks for anaemia and other clues
• Vitamin D — common deficiency locally; replete if low
• Sometimes added — vitamin B12, folate, zinc; for women — testosterone and DHEAS if signs of androgen excess (acne, irregular periods, hirsutism); for suspected autoimmune alopecia — ANA and other markers selectively

We don’t routinely order extensive supplement panels or “hair mineral analysis” — these are popular but the evidence base for guiding treatment is weak.

When we refer

For scarring alopecia (loss of follicular orifices, perifollicular redness or scaling) we refer to a dermatologist for scalp biopsy and specialist management — these conditions require specific systemic treatments and can cause permanent hair loss if not treated promptly. We also refer for complex or extensive alopecia areata, persistent unexplained alopecia despite a full primary care workup, and any patient who would prefer specialist-led care.

Androgenetic alopecia — the most common type

Also called male-pattern baldness or female-pattern hair loss. Hereditary, hormonally driven (sensitivity of hair follicles to dihydrotestosterone, DHT), gradual.

What it looks like

Men: Recession at the temples and frontal hairline, with thinning at the vertex (crown). The two areas often progress together, eventually meeting. Norwood scale grades 1–7 from minimal recession to extensive loss.

Women: Diffuse central thinning at the crown with preserved frontal hairline (an important distinguishing feature from frontal fibrosing alopecia, which is a scarring condition). Ludwig scale grades I–III. The “Christmas tree” pattern of widening at the central parting is characteristic.

Treatment in primary care — what genuinely works

Three medications have meaningful evidence and are what we use. All three are generally not stocked in our dispensary — we order them via online pharmacy when prescribed, with typical delivery 1–3 working days. This is a normal workflow at our clinic for medications used in defined patient cohorts.

1. Topical minoxidil

• Men: 5% solution or foam, applied twice daily to the scalp
• Women: 2% solution or 5% foam, applied once or twice daily
• Available over the counter in Singapore as Regaine (and several generic brands)
• First sign of benefit at 3–4 months; full response at 6–12 months. Don’t judge before then.
• Continued use is required — stopping leads to gradual loss of the gained hair within 6 months.
• Side effects: scalp irritation (sometimes managed by switching solution to foam), unwanted facial hair (mainly the 5% in women — we usually start at 2% in women), occasional initial increased shedding in the first 4–6 weeks (the existing miniaturised hairs being pushed out by new growth) — push through it; this is a sign it’s working.

2. Oral finasteride 1 mg once daily (men only)

• A 5-alpha-reductase inhibitor that lowers DHT levels in the scalp
• The most effective medical treatment for male androgenetic alopecia
• We prescribe in primary care, with appropriate counsel:
  • Sexual side effects — reduced libido, erectile dysfunction, ejaculatory volume changes — affect a small minority (probably 1–3% in trials, possibly more in real-world reports). Usually reversible on stopping. Discuss honestly before starting; review at 3 and 6 months.
  • Mood changes — possible association with low mood and depression; we monitor.
  • Long-term use — continued use is needed for sustained benefit; stopping leads to gradual loss of the gained hair over 6–12 months.
  • Pregnancy in partner — finasteride is a teratogen for male fetuses. Pregnant or trying-to-conceive partners should not handle crushed or broken tablets. Intact tablets are safely handled.
  • Not used in women of child-bearing potential outside specific specialist settings.

3. Oral minoxidil — low-dose (off-label)

• Oral minoxidil at 2.5 mg once daily (or 1.25 mg in women, sometimes higher in men) is off-label but increasingly mainstream internationally for androgenetic alopecia
• More effective than topical for many patients, with better adherence (one tablet vs twice-daily application)
• Side effects to discuss:
  • Excess body and facial hair (hypertrichosis) — common; manageable but worth knowing
  • Mild blood pressure drop — usually not clinically significant at low doses; we screen pre-treatment
  • Fluid retention / mild ankle swelling — uncommon at low doses; resolve on dose reduction
  • Heart rate changes — mild tachycardia possible; rarely problematic
• We screen blood pressure and history before initiating, then check at 1 month
• Often used alongside finasteride for synergistic benefit

What about combination treatment?

For men, topical minoxidil + oral finasteride is the most evidenced and widely-used combination, with clearly better outcomes than either alone. Oral minoxidil + finasteride is increasingly used. We discuss the combination based on severity, patient preference, side-effect tolerance, and adherence likelihood.

Procedures we do not offer

• Platelet-rich plasma (PRP) scalp injections — evidence is mixed; benefit (where present) is modest and inconsistent. We do not offer PRP at our clinic. Patients interested in PRP can discuss it with private aesthetic dermatologists.
• Hair transplant — a separate, surgical specialty. We do not have an established referral pathway for hair transplant. If you are considering transplant, look for a doctor with specific surgical training in the procedure, ideally with an aesthetic surgery or dermatology background, and ask carefully about technique (FUE vs FUT), expected graft yield, and realistic outcomes. We are happy to discuss whether transplant is likely to be appropriate for your particular pattern of loss.

Realistic expectations

For androgenetic alopecia treatment overall:

• The best outcome is to halt or slow further loss and partially regrow miniaturised hairs. Expecting a return to teenage hair density at age 50 is not realistic with medical treatment alone.
• Earlier treatment works better — preserving existing hair is easier than regrowing fully lost hair.
• Treatment is long-term — stopping causes gradual loss of gained hair within 6–12 months for any of these agents.
• Cost matters and we will discuss it openly. Topical minoxidil is the most affordable; oral finasteride is also relatively affordable; oral minoxidil similar. The cost adds up over years.

Telogen effluvium — diffuse shedding after a trigger

A common pattern of diffuse hair shedding — typically seen 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 hospitalisation
• Childbirth (post-partum) — affects many women 2–6 months after delivery; usually resolves over 6–12 months
• Significant unintentional weight loss
• Severe psychological stress (bereavement, major life event)
• Iron deficiency (low ferritin) or other nutritional deficiency
• Thyroid disease — both directions
• Some medications (see history above)
• Recent COVID-19 or other significant infection

The hair follicles are pushed prematurely from the growing (anagen) phase to the shedding (telogen) phase by the trigger. Shedding is dramatic and distressing, but the follicles are not damaged, and regrowth is the normal outcome once the trigger is corrected.

What we do

• Identify and correct the underlying trigger — replace iron if low, treat thyroid disease, address nutritional gaps, manage stress, ensure adequate nutrition during weight loss
• Reassure — diffuse shedding from telogen effluvium is alarming but regrowth typically begins within 3–6 months of the trigger being addressed, with full recovery over 6–12 months
• Replace any nutritional deficiency — most commonly iron (target ferritin > 50 µg/L), sometimes vitamin D, occasionally B12 or zinc if levels are low
• Avoid overlaying topical hair-growth products — they don’t address the cause, and the natural regrowth would have happened anyway

A patient pattern we sometimes see: postpartum telogen effluvium combined with new androgenetic alopecia — both contribute, both need attention, and the treatment may include both addressing iron stores and starting topical minoxidil for the androgenetic component.

Alopecia areata — autoimmune, patchy

Sudden onset of one or more well-circumscribed round or oval patches of complete hair loss, often the size of a coin. Skin in the patches looks normal — no scaling, no redness, no scarring — and the follicular orifices are preserved.

Sometimes accompanied by nail pitting (fine surface dents). Exclamation-mark hairs (short broken hairs that taper towards the scalp) at the edge of an active patch are characteristic.

Course

Highly variable. Many patients have a single small patch that regrows spontaneously over 6–12 months. Others have recurrent patches; a smaller proportion progress to alopecia totalis (entire scalp) or alopecia universalis (entire body). Predicting which path a given patient will take is difficult.

Treatment in primary care

For mild, localised alopecia areata:

• Intralesional triamcinolone injection — small injections into the affected patch at 4–6 week intervals. Effective for many patients with localised disease. We do this in clinic when appropriate.
• Potent topical corticosteroid — under occlusion overnight where practical
• Topical minoxidil — adjunct
• Reassurance — many patches regrow without specific treatment; treatment may speed up the process but is not always essential for limited disease

When we refer

• Extensive alopecia areata (large area, multiple patches, rapid progression)
• Alopecia totalis or universalis
• Failure to respond to localised treatment
• Significant psychological impact

Specialist treatment options now include JAK inhibitors (baricitinib, ritlecitinib) — oral medications licensed for severe alopecia areata that have transformed outcomes for many patients with extensive disease. These are dermatology-led, expensive, and require monitoring.

Scarring alopecia — when it’s permanent and we refer

A group of conditions where the hair follicle itself is destroyed, leading to permanent loss. Includes:

• Lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) — autoimmune, often affects the frontal hairline (FFA particularly affects post-menopausal women, with recession at the front and loss of eyebrows)
• Central centrifugal cicatricial alopecia (CCCA) — affects the crown, more common in patients with Afro-textured hair
• Folliculitis decalvans — chronic inflammatory, with pustules
• Discoid lupus erythematosus scalp involvement

Signs to watch for

• Loss of follicular orifices — the small visible openings of hair follicles disappear in affected areas
• Perifollicular redness and scaling
• Itch, burning, or scalp tenderness — often present and prominent
• Changes in hairline shape — receding frontal hairline (FFA), patchy expansion at vertex (CCCA)
• Loss of eyebrows (FFA)

When we refer

Any suspicion of scarring alopecia warrants prompt referral to a dermatologist for assessment and scalp biopsy (the diagnostic test). Treatment involves topical and sometimes systemic anti-inflammatory medications to halt progression — once a follicle is scarred, the hair is lost permanently.

Time matters — early treatment can preserve unaffected follicles. We do not delay referral if scarring is suspected.

Things that may not help

• “Hair growth” shampoos and conditioners marketed at consumer prices — most have no clinically significant effect on hair regrowth. Some contain low-dose ingredients (minoxidil, ketoconazole) that may help marginally, but the medical-grade products work better.
• Most supplements unless you have a documented deficiency. Hair-growth supplement bundles often contain biotin (rarely deficient; rarely the cause), iron (helpful only if low), zinc, and various plant extracts. Treating an actual ferritin or thyroid abnormality is much more effective than blanket supplementation.
• Biotin supplements without deficiency — no benefit; high-dose biotin can interfere with several blood tests (particularly thyroid and troponin) and cause misleading results.
• Scalp massage as a primary treatment — gentle scalp massage with minoxidil application is fine and increases compliance; massage alone has weak evidence.
• “Detox” hair treatments and chemical scalp treatments — limited evidence; some can worsen scalp inflammation.
• PRP (as discussed above) — evidence inconsistent; we do not offer.
• Hair-growth lasers and LED caps — modest evidence in some studies; expensive; not a substitute for proven medical therapy. Some patients use them adjunctively if budget allows.
• Frequent shampooing or stopping shampooing — neither causes or treats hair loss meaningfully.
• Cutting hair shorter “to make it grow stronger” — hair grows from the follicle below the scalp; cutting the visible shaft has no effect on growth rate or thickness.

If you’ve used something that has clearly helped, please tell us — we’d rather hear about it than have you stop mentioning it.

When to come and see us

Worth a clinic visit if:

• You’re losing more hair than usual and it’s been going on for more than 4–6 weeks
• You have noticed a patchy area of complete hair loss — particularly if it appeared suddenly
• Your hairline is receding (men or women) and you’d like to discuss whether to start treatment
• You have any redness, scaling, itch, or tenderness on the scalp — particularly important to assess promptly
• You have post-partum hair loss that is severe or hasn’t started to recover by 6–9 months after delivery
• You’ve been on hair-loss treatment without much improvement after 6–12 months — we should review
• You have hair loss along with other symptoms — fatigue, weight changes, menstrual changes — that suggest a systemic cause

Urgent — same-day attention

• Sudden hair loss with significant scalp inflammation, pustules, or systemic features (fever, unwell) — uncommon but worth same-day review

Get in touch

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

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

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. v1.0 · April 2026 · Review due April 2028.