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A 42-year-old woman presents with concern regarding excessive hair growth on her face. She reports a history of regular menstrual periods and reports that at her most recent annual gynecologic examination, she was told that her ovaries were normal in size. What is the most logical next step?

A. Check serum androstenedione and testosterone

B. Check 21-hydroxylase level

C. Skin biopsy

D. Referral to endocrinology

E. CT abdomen

A. In the case of idiopathic hirsutism, women will present with the clinical signs of androgen excess, however, with normal menses, normal-sized ovaries, normal adrenal function, and no evidence of adrenal or ovarian tumors. They may often have a slightly elevated level of plasma androstenedione and testosterone, making this the next logical step in workup.

A 24-year-old woman is seen with gradual hair thinning over the past few years. On examination her frontal hairline is retained but the central part is widened, and there are many hairs of varied length and caliber. The follicular markings are intact and there is no scaling or erythema of the scalp. A pull test is negative. A scalp biopsy will likely show:

A. Peribulbar lymphocytic inflammation

B. An increased catagen/telogen ratio

C. Premature desquamation of the inner root sheath

D. Miniaturized hair follicles with preserved sebaceous glands

D. The description of hair loss fits best with a clinical diagnosis of androgenetic alopecia. The histologic findings seen in androgenetic alopecia are miniaturized follicles with retained sebaceous glands.

A 6-year-old girl is sent home from school for having “lice” and presents to you for evaluation and treatment. On examination, there are freely mobile structures noted along the hair shaft. What is the most likely diagnosis?

A. Pediculosis

B. Hair casts

C. Trichoptilosis

D. Monilethrix

E. Pili annulati

B. Hair casts present most commonly in young girls between 2 and 8 years old. These casts are nonadherent and thus slide freely along the hair shaft in contrast to the nits from pediculosis capitis which are adherent to the hair and do not slide. Trichoptilosis is the result of chemical or physical damage to the hair and are commonly referred to as “split ends.”

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