Case Report: Hair Loss, Skin Lesion Evaluation, and Comprehensive Care in a 50-Year-Old Male
At our dermatology clinic in Houston and Katy, Texas, we often see patients who present with multiple skin and hair concerns that require careful evaluation and treatment planning. This case highlights the management of diffuse hair loss, benign skin growths, and sun-related pigmentation changes in a middle-aged man.
Patient Presentation
A 50-year-old male presented as a new patient with two primary concerns:
Diffuse hair loss on the scalp, moderate in severity, with sudden onset over the past 6 months.
Skin lesions on the upper back and chest, present for years, prompting evaluation for suspicious growths and education regarding sun protection.
Clinical Examination
A full-body skin exam was performed, including scalp, face, trunk, extremities, nails, and genital area, with dermoscopy utilized for closer evaluation.
Key findings included:
Benign nevi: regular, evenly pigmented moles
Lentigines: light brown sunspots on sun-exposed areas
Seborrheic keratoses: stuck-on, waxy growths on the trunk
Skin tags: small pedunculated papules on the clavicular area
Genital warts: cauliflower-like papules on the scrotum and suprapubic skin
Androgenetic alopecia: diffuse thinning of the scalp consistent with male pattern hair loss
Diagnosis & Treatment Plan
1. Hair Loss (Androgenetic Alopecia)
The patient was diagnosed with male pattern hair loss, a genetic and progressive condition.
Started on oral minoxidil 2.5 mg daily with counseling on possible side effects (e.g., ankle swelling, dizziness, unwanted hair growth).
Discussed other options including finasteride, PRP (platelet-rich plasma), AlmaTED treatments, supplements, laser therapy, and hair transplantation.
Advised that initial shedding may occur in the first 8–10 weeks, followed by gradual improvement with consistent use.
2. Benign Nevi & Lentigines
Reassured patient that current moles appeared benign.
Recommended monthly self-skin checks and annual full-body skin exams.
For lentigines, discussed cosmetic treatments such as bleaching creams, retinoids, chemical peels, and laser therapy.
Emphasized daily use of broad-spectrum sunscreen SPF 30+ and sun-protective clothing.
3. Seborrheic Keratoses & Skin Tags
Explained these are benign and do not require treatment unless irritated.
Four skin tags on the neck and clavicular area were removed cosmetically with excision after informed consent.
4. Genital Warts (Condyloma)
Diagnosed as HPV-related lesions.
Seven warts treated with liquid nitrogen cryotherapy.
Provided education on transmission prevention, recurrence risk, and partner evaluation.
Patient Counseling & Education
The patient was counseled extensively on:
Sun safety: daily SPF 30+, reapplication every 2 hours, using sun-protective clothing and lip balm with SPF.
Hair loss management: realistic expectations, possible need for combination therapies, and importance of follow-up.
HPV counseling: importance of partner testing and gynecological follow-up for female partners due to cervical cancer association.
Conclusion
This case demonstrates the importance of comprehensive dermatologic evaluation, where both medical and cosmetic concerns can be addressed in a single visit. By tailoring treatments for androgenetic alopecia, benign lesions, and viral skin infections, we help patients achieve improved health, appearance, and confidence.
If you are concerned about hair loss, skin growths, or sun damage in Houston or Katy, Texas, our clinic offers expert diagnosis and personalized treatment plans.
