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Chronic telogen effluvium or early androgenetic alopecia?

A 16‐year‐old girl presented with a 12‐month history of generalized hair shedding from the scalp. The onset of shedding coincided with the development of Hashimoto's thyroiditis and iron deficiency. At the time of initial presentation, the Hashimoto's thyroiditis had been treated with Neo‐Mercazole and she was euthyroid. Her iron stores were low, with a ferritin level of 13 µg/L. As she was vegetarian, oral iron replacement therapy was commenced without further investigation. On follow‐up 6 months later, her iron stores were normal (ferritin, 36 µg/L), but the hair shedding had continued. On examination, there was a positive hair pull test from both the vertex of the scalp and the occipital scalp. There was mild bitemporal recession, but no widening of the central part, and she appeared to have a full, thick head of hair ( Fig. 1 ). Additional investigations at that time revealed normal thyroid function and negative antinuclear antibody (ANA) and syphilis serology. She was on no medication other than Neo‐Mercazole. Serum testosterone, dihydroepiandosterone sulphate (DHEAS) and sex hormone binding globulin (SHBG) were normal. Two 4‐mm punch biopsies were taken from the vertex of the scalp; one was sectioned horizontally and the other vertically. The vertical section was unremarkable. On the horizontal section, there were 32 hair follicles in total, 30 of which were terminal hairs and two of which were vellus hairs. One hair was in telogen. The ratio of terminal to vellus hairs was 15 : 1.