Comprehensive Skin Exam and Hair Loss Evaluation in a 40-Year-Old Female: Sun Damage, Anti-Aging, and Androgenetic Alopecia Management
by: Dr. Caroline Vaughn
Case Overview
A 40-year-old female presented to Village Dermatology in Katy, Texas for a full-body skin examination. The patient denied any family history of melanoma but undergoes annual skin cancer screenings as part of her routine preventive care. Her main concerns included sun-related pigmentation, aging skin, and gradual hair thinning over the past several years.
Clinical Examination
A full skin examination was performed, including the scalp, face, neck, trunk, extremities, and nails.
The patient was well-developed, alert, and in no distress. A dermatoscope was used throughout the exam.
Findings revealed benign skin lesions and mild photoaging changes. No suspicious lesions for malignancy were noted.
Assessment and Plan
1. Benign Nevi (D22.5)
Multiple symmetrical, evenly pigmented moles were found on the upper back and abdomen.
Counseling:
No treatment necessary
Perform monthly self-skin checks for changes in size, color, or shape
Use broad-spectrum SPF 30+ sunscreen daily
2. Seborrheic Keratoses (L82.1)
Pigmented, waxy, stuck-on papules were observed on the periumbilical area and thoracic spine.
These are benign skin growths that often appear with age.
Plan: Observation and reassurance; optional cosmetic removal if desired.
3. Lentigines (L81.4)
Light tan, reticulated macules consistent with sun-induced lentigines were distributed on the upper sternum and left upper back.
Plan:
Sun protection: Apply SPF 30+ 15 minutes before sun exposure and reapply every 2 hours
Consider chemical peels, retinoids, or laser for cosmetic improvement
Encourage daily use of lip balm with SPF and sun-protective clothing
4. Cherry Angiomas (D18.01)
Bright red vascular papules noted on the mid-back and periumbilical skin.
Counseling:
These are benign vascular growths that can be treated with laser or electrodesiccation for cosmetic reasons.
5. Aging Skin (L90.8)
The patient expressed interest in improving fine lines and photoaging. She had previously obtained tretinoin 0.025% from an online dermatologist and planned to initiate treatment.
Plan:
Continue tretinoin 0.025% at bedtime (pea-sized amount, 2–3 nights weekly, increasing as tolerated)
Use Skinceuticals A.G.E. Eye Complex or SkinBetter AlphaRet Eye Cream for under-eye rejuvenation
Continue broad-spectrum SPF 30+ sunscreen daily
Counseling:
Discussed the role of retinoids in stimulating collagen, improving skin tone, and reducing fine lines.
Reviewed potential dryness or irritation and how to minimize side effects by introducing use gradually.
6. Androgenetic Alopecia (L64.8)
The patient reported gradual hair thinning consistent with female pattern hair loss. She is currently family planning and opted to avoid oral medications such as finasteride or dutasteride.
Plan:
Start topical minoxidil 5% foam daily to the scalp
Consider Nutrafol supplements or PRP (Platelet-Rich Plasma) therapy in the future
Monitor for improvement over the next 4–6 months
Counseling:
Discussed that androgenetic alopecia is genetically determined and slowly progressive. Early treatment can slow shedding and thicken existing hair.
Patient instructed to contact the office if hair loss worsens or if irritation develops from topical minoxidil.
Discussion
This case highlights the importance of annual dermatologic exams in women for early detection of benign and precancerous skin lesions while addressing aesthetic and hair health concerns.
At Village Dermatology, we combine medical dermatology and cosmetic expertise to manage conditions like photoaging, lentigines, and androgenetic alopecia comprehensively.
Patients in Katy and Houston, Texas can benefit from personalized skincare routines and advanced treatment options to maintain healthy, youthful skin and hair.
Conclusion
Comprehensive dermatologic care addresses both skin health and appearance. Through preventive screenings, sun protection, retinoid therapy, and targeted hair loss treatments, patients can achieve long-term skin and scalp wellness.
Residents in Katy and Houston, TX are encouraged to schedule annual full-body skin exams with Village Dermatology for expert evaluation and customized treatment.
