Diagnosing and Treating Crown Hair Loss in a 36-Year-Old Female with Suspected Trichotillomania
Hair loss can be challenging to diagnose—especially when the pattern doesn’t align perfectly with typical alopecia types. At Reena Jogi MD Dermatology, we see many patients who’ve experienced years of distress from undiagnosed or mistreated scalp conditions. This case features a 36-year-old woman with crown-centered hair loss that required careful clinical judgment to narrow the diagnosis and tailor the treatment plan.
Chief Complaint: Longstanding Generalized Hair Loss
The patient presented with moderate hair loss that began suddenly several years ago. She had been self-managing her symptoms with Nutrafol supplements and an iRestore red light therapy helmet, but with minimal improvement. Notably, she denied scalp pain, flaking, or itching, and had no systemic symptoms.
Examination Findings and Diagnostic Considerations
On exam, we noted patchy hair thinning on the crown and posterior parietal scalp, which did not match the typical pattern of androgenetic alopecia (AGA). Other differentials included:
Trichotillomania: The patient admitted to childhood hair pulling in the same region.
Alopecia Areata (AA): Autoimmune-related patchy loss could not be ruled out.
Nonspecific Dermatitis (L30.9): Possible scalp inflammation.
Despite previous success with intralesional Kenalog (ILK) injections, the atypical presentation warranted consideration of a scalp punch biopsy. We thoroughly discussed the biopsy procedure, but the patient opted to defer it and proceed with empiric treatment.
Treatment Plan: ILK Injections and Topical Minoxidil
Given the patient’s history and preferences, we initiated:
✅ 1. Intralesional Kenalog (ILK) Injection
17 focal lesions were injected using 2.5 mg/cc diluted Kenalog
Total volume: 3.0cc
Risks of skin atrophy were reviewed and accepted by the patient
✅ 2. Topical Minoxidil 5% Solution
The patient was prescribed minoxidil with detailed instructions for safe and effective application:
Dosage: 1 mL twice daily to affected areas
Expectations: Results may take 3–6 months
Important Notes: Initial shedding is normal; continued use is necessary to maintain regrowth
Androgenetic Alopecia Consideration
Although the pattern was not clearly androgenetic, the patient may still have female pattern hair loss (L64.8) contributing to her symptoms. Treatment options discussed for future escalation included:
Spironolactone
Scalp biopsy if symptoms persist or worsen
Conclusion: Holistic Management for Complex Hair Loss in Houston and Katy
This case highlights the importance of individualized care when facing atypical scalp presentations. By respecting patient preferences while offering evidence-based solutions, we empowered this 36-year-old woman to take charge of her hair restoration journey.
If you’re struggling with crown hair loss, scarring alopecia, or unexplained shedding, schedule a consultation with Reena Jogi MD in Houston or Katy today.
