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Hair Disorders

Last updated 1 Jun 2026 · Dermatology

📋 Key Information Summary

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  • Hair disorders affect approximately 49% of women and 76% of men over their lifetime; androgenetic alopecia (AGA) is the most prevalent cause in both sexes.
  • Classify hair loss as non-scarring vs scarring and diffuse vs focal before considering aetiology — this diagnostic model guides all subsequent investigation and management.
  • The hair pull test is a simple bedside tool: ≥6 hairs extracted with gentle traction from multiple scalp sites indicates active shedding (positive test).
  • Androgenetic alopecia presents with progressive miniaturisation of hair follicles — vertex and frontal recession in men (Hamilton–Norwood scale), diffuse central thinning in women (Ludwig scale).
  • First-line pharmacotherapy for AGA: topical minoxidil 5% (men) or 2% (women) applied BD, and finasteride 1 mg daily (men only, not PBS-listed for alopecia).
  • Alopecia areata is a T-cell–mediated autoimmune condition presenting with well-circumscribed patches of non-scarring alopecia; may progress to totalis (scalp) or universalis (body-wide).
  • For patchy alopecia areata, intralesional triamcinolone acetonide 5–10 mg/mL every 4–6 weeks is first-line; extensive disease requires systemic therapy.
  • Baricitinib 2 mg daily (Olumiant®) is TGA-approved and PBS-listed (Authority Required) for severe alopecia areata in adults — a landmark JAK inhibitor option.
  • Telogen effluvium presents as diffuse hair shedding 2–3 months after a physiological or psychological trigger; usually self-limiting within 6 months.
  • All scarring (cicatricial) alopecias require urgent dermatology referral — irreversible follicular destruction demands early aggressive treatment to prevent permanent hair loss.
  • Always check serum ferritin, TFTs, zinc, vitamin D, and FBC in diffuse hair loss; target ferritin ≥30 µg/L for optimal hair regrowth.
  • ATSI populations face barriers including remote access to dermatology, cultural factors affecting health-seeking behaviour, and higher rates of nutritional deficiency contributing to hair loss.

Introduction & Australian Epidemiology

Hair disorders encompass a broad spectrum of conditions ranging from benign, self-limiting shedding to progressive scarring alopecia resulting in permanent hair loss. Hair loss carries significant psychosocial morbidity — studies consistently demonstrate reduced quality of life, impaired self-esteem, increased anxiety and depression, and social withdrawal in affected individuals.

In Australia, hair loss is a common presenting complaint in general practice. Androgenetic alopecia accounts for the majority of consultations, affecting approximately 50% of men by age 50 and up to 30% of Caucasian women by age 70. Alopecia areata has a lifetime prevalence of approximately 2% in the Australian population, while telogen effluvium is among the most frequent causes of acute diffuse hair loss in women of reproductive age.

Condition Prevalence (Australia) Peak Demographic Key Feature
Androgenetic alopecia ~50% men by age 50; ~30% women by age 70 Men 20–50; Women post-menopausal Progressive miniaturisation
Alopecia areata ~2% lifetime prevalence Bimodal: 20–40 and <10 years Well-circumscribed patches
Telogen effluvium Common; exact prevalence unknown Women 30–60 Diffuse shedding post-trigger
Scarring alopecia ~3–7% of alopecia referrals Middle-aged women (LPP/FFA) Permanent follicular loss
Anagen effluvium Variable (treatment-related) Cancer patients on chemotherapy Rapid onset during anagen phase

The psychosocial burden of hair loss is frequently underestimated. General practitioners play a central role in early recognition, classification, initial investigation, and referral when indicated. A systematic approach — classifying hair loss by pattern (diffuse vs focal), presence or absence of scarring, and associated features — is essential before initiating management.

Hair Loss Diagnostic Model & Hair Pull Test

Diagnostic Framework

A structured approach to hair loss begins with distinguishing four key features: pattern (diffuse vs focal/patchy), scalp changes (scarring vs non-scarring), onset and course (acute vs chronic), and hair shaft abnormalities (if present). This classification narrows the differential diagnosis and guides investigation.

1
Scarring vs Non-Scarring
Examine scalp for loss of follicular ostia (scarring — smooth, shiny patches). Non-scarring retains follicular openings and potential for regrowth. Dermoscopy is invaluable here.
2
Pattern: Diffuse vs Focal
Diffuse thinning suggests AGA, telogen effluvium, or drug-related loss. Focal/patchy suggests alopecia areata, tinea capitis, or trichotillomania.
3
Hair Pull Test
Grasp 40–60 hairs between thumb and forefinger; pull firmly along the shaft from base to tip. ≥6 hairs extracted = positive test, indicating active shedding.
4
Trichoscopy (Dermoscopy of Scalp)
Identify specific patterns: yellow dots (alopecia areata), peripilar casts (lichen planopilaris), hair shaft variability, vellus hairs (AGA), and arborising vessels.

Hair Pull Test — Technique & Interpretation

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Technique: The patient should not wash their hair for 24–48 hours before testing. Grasp a lock of 40–60 hairs firmly at the base between the thumb and index finger. Apply steady traction while sliding the fingers along the hair shaft. Perform at 3–4 different sites across the scalp (frontal, vertex, occipital, temporal).

Interpretation: Extracting ≥6 hairs per pull at one or more sites = positive (active shedding phase). Anagen hairs have dark, bulbous roots; telogen hairs have small, depigmented, club-shaped roots. Examine the roots under magnification or send for pathology.

Hair Pull Result Root Appearance Suggests Next Step
Positive — telogen roots Small, white club-shaped Telogen effluvium, early AGA, drug-induced Bloods: FBC, ferritin, TFTs, zinc, vitamin D
Positive — anagen roots Dark, elongated, may be tapered/dystrophic Anagen effluvium (chemotherapy), alopecia areata Correlate medication/chemotherapy history
Negative No significant extraction Stable AGA, scarring alopecia, resolved effluvium Dermoscopy; consider biopsy if scarring suspected
Positive — broken shafts Fractured mid-shaft, no root Tinea capitis, trichorrhexis nodosa, hair abuse Fungal culture, shaft examination

When to Refer to Dermatology

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Urgent referral indications: Suspected scarring alopecia (loss of follicular ostia), rapidly progressive alopecia areata involving >50% of the scalp, alopecia totalis/universalis, hair loss with systemic features (rash, joint pain, oral ulcers suggesting lupus/lichen planus), and any diagnostic uncertainty requiring scalp biopsy.

Androgenetic Alopecia & Anagen Effluvium

Androgenetic Alopecia (AGA)

Androgenetic alopecia is the most common form of hair loss, driven by the effects of dihydrotestosterone (DHT) on genetically predisposed hair follicles. DHT binds to androgen receptors in dermal papilla cells, leading to progressive follicular miniaturisation — terminal hairs are replaced by vellus hairs over successive hair cycles. The condition has a strong polygenic inheritance pattern with variable expressivity.

Clinical Classification

Male Pattern Hair Loss (Hamilton–Norwood Scale)
  • Type I–II: Minimal frontal recession
  • Type III: Deep frontal-temporal recession
  • Type III vertex: Vertex thinning begins
  • Type IV–V: Significant frontal and vertex loss, bridge of hair separating the two areas thins
  • Type VI–VII: Extensive loss, only a band of hair remains laterally and occipitally
Female Pattern Hair Loss (Ludwig Scale)
  • Grade I: Mild central thinning, frontal hairline preserved
  • Grade II: Moderate widening of the central part, visible scalp through hair
  • Grade III: Extensive diffuse thinning over the crown with frontal hairline preservation
  • Occipital and temporal hair typically spared
  • Savin scale also used in some Australian dermatology practices

Pharmacological Management

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Minoxidil Topical
Regaine® · Kirkland® · Vasodilator
Adult dose Men: 5% foam or solution 1 mL BD to affected areas. Women: 2% solution 1 mL BD or 5% foam once daily.
Paediatric dose Not routinely used in children <18 years
Duration Lifelong; benefits lost within 3–6 months of cessation. Initial shedding expected in first 1–2 months.
Renal adjustment No adjustment required (minimal systemic absorption)
Hepatic adjustment No adjustment required
Key side effects Scalp irritation, contact dermatitis, facial hypertrichosis (more common with 5% in women), initial telogen shedding
PBS status ✘ Not PBS-listed — available OTC from pharmacies (approx. –60/month)
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Finasteride
Propecia® · Generic · 5α-Reductase Inhibitor (Type II)
Adult dose 1 mg PO once daily. Allow 6–12 months for efficacy assessment.
Paediatric dose Contraindicated in children and adolescents
Duration Lifelong; hair loss resumes within 12 months of cessation
Renal adjustment No adjustment required (CrCl ≥9 mL/min)
Hepatic adjustment Use with caution; reduce dose in hepatic impairment
Key side effects Decreased libido (1–2%), erectile dysfunction, decreased ejaculate volume. Post-finasteride syndrome (rare, controversial). Contraindicated in women of childbearing potential (teratogenic — 5α-reductase inhibition causes ambiguous genitalia in male foetus).
PBS status ✘ Not PBS-listed for alopecia — private prescription (approx. –30/month generic)
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Spironolactone
Aldactone® · Generic · Aldosterone Antagonist / Anti-androgen
Adult dose Women: 100–200 mg PO daily (off-label for FPHL). Titrate from 50 mg over 2–4 weeks.
Paediatric dose Not indicated for alopecia in children
Duration Minimum 6–12 months; long-term use common
Renal adjustment Avoid if eGFR <30 mL/min (hyperkalaemia risk)
Hepatic adjustment Use with caution; avoid in severe hepatic impairment
Key side effects Hyperkalaemia (monitor K⁺), menstrual irregularity, breast tenderness, dizziness. Contraindicated in pregnancy (anti-androgenic effects).
PBS status ✔ PBS General Benefit (for approved indications; off-label for FPHL — private cost applies)
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Dutasteride
Avodart® · Generic · 5α-Reductase Inhibitor (Type I & II)
Adult dose Men: 0.5 mg PO once daily (off-label for AGA in Australia). More potent DHT suppression than finasteride.
Duration Lifelong; assess at 6–12 months
Renal adjustment No adjustment required
Hepatic adjustment Contraindicated in severe hepatic impairment
Key side effects Similar to finasteride: decreased libido, erectile dysfunction, gynaecomastia. Long half-life (~5 weeks) — effects persist after cessation. Contraindicated in women of childbearing potential.
PBS status ⚑ PBS Authority Required (for BPH; off-label for AGA — private prescription)
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Combination therapy: Combining topical minoxidil with oral finasteride (men) or spironolactone (women) provides superior outcomes compared with monotherapy. Low-level laser therapy (LLLT) devices (e.g., HairMax®) have TGA clearance and may provide modest additive benefit as adjunctive therapy.

Anagen Effluvium

Anagen effluvium results from abrupt cessation of mitotic activity in the hair matrix during the anagen (growth) phase, most commonly due to chemotherapy agents. The hallmark is rapid, diffuse hair loss occurring within days to 2–3 weeks of initiating cytotoxic therapy. Hair loss is often severe and may involve the entire scalp, eyebrows, eyelashes, and body hair.

Chemotherapy Agent Hair Loss Risk Typical Onset Reversibility
Doxorubicin Near 100% 2–4 weeks Regrowth 3–6 months post-cessation
Cyclophosphamide High (dose-dependent) 2–4 weeks Usually complete regrowth
Docetaxel / Paclitaxel Near 100% 2–3 weeks Regrowth 3–6 months
Vincristine Moderate–High 4–8 weeks Usually complete
5-Fluorouracil Low–Moderate Variable Complete
Targeted therapy (e.g., erlotinib) Low–Moderate Weeks to months Reversible

Management of Anagen Effluvium

  • Scalp cooling (cryotherapy): Reduces chemotherapy delivery to hair follicles. Available at many Australian cancer centres (e.g., DigniCap®, Paxman®). Reduces hair loss severity by 50% with taxane-based regimens. Funded by some private health insurers and available at select public hospitals.
  • Wigs and head coverings: State-based programs (e.g., Wig Library services through Cancer Council Australia) provide free or subsidised wigs. A prescription from a GP or oncologist may be required for insurance rebates.
  • Topical minoxidil 5%: May accelerate regrowth after chemotherapy cessation (limited evidence); typically started 2–4 weeks after completing chemotherapy.
  • Psychosocial support: Refer to Cancer Council 13 11 20 or oncology social work for counselling and support regarding body image changes.
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Differential — alopecia areata post-immunotherapy: Immune checkpoint inhibitors (nivolumab, pembrolizumab, ipilimumab) can trigger alopecia areata rather than anagen effluvium. This presents with patchy, non-scarring hair loss with positive pull test (anagen roots). Dermatology referral is recommended for appropriate management (often requires immunosuppression rather than supportive care alone).

Alopecia Areata, Totalis & Universalis

Pathophysiology

Alopecia areata (AA) is a T-cell–mediated autoimmune condition targeting hair follicles in the anagen phase. CD8+ cytotoxic T lymphocytes surround the hair bulb in a characteristic "swarm of bees" pattern on histopathology. There is collapse of the immune privilege of the hair follicle bulb, with upregulation of MHC class I and II antigens and interferon-γ signalling. Genetic susceptibility is strongly associated with HLA class II alleles (particularly HLA-DRB1), and there is an association with other autoimmune conditions including thyroid disease, vitiligo, and atopic dermatitis.

Classification & Severity

Mild
Patchy AA (<50% scalp)
One or more well-circircumscribed, smooth, non-scarring patches of alopecia. "Exclamation mark" hairs at the periphery (short, broken hairs tapering proximally). May spontaneously resolve in 6–12 months.
Setting: GP management with intralesional steroids
Moderate
Extensive AA (>50% scalp)
Multiple coalescing patches affecting >50% of the scalp. "Ophiasis" pattern (band-like loss along temporal and occipital margins) carries poorer prognosis. Nail pitting in ~10–60% of cases.
Setting: Dermatology-led, combination therapy
Severe
Alopecia Totalis / Universalis
Totalis: Complete scalp hair loss. Universalis: Complete body hair loss (scalp, eyebrows, eyelashes, body). Spontaneous regrowth rate <10%. Significant psychosocial impact. Consider systemic therapy including JAK inhibitors.
Setting: Dermatology specialist, systemic therapy

Investigations

Essential TSH, free T4, thyroid antibodies Associated autoimmune thyroiditis in 10–25% of AA patients
Essential FBC, serum ferritin, vitamin D, zinc Exclude concurrent nutritional deficiencies that may impair regrowth
Available Dermoscopy (trichoscopy) Yellow dots (empty follicular infundibula), black dots (cadaverised hairs), short vellus hairs (sign of regrowth), exclamation mark hairs. MBS item 105 may apply for specialist dermoscopy.
Specialist Scalp biopsy (4 mm punch) When diagnosis uncertain, especially to exclude scarring alopecia. Shows peribulbar lymphocytic infiltrate and increased catagen/telogen hairs in AA.
Available ANA, ESR/CRP, coeliac serology If systemic autoimmune features suspected or extensive/refractory disease

Pharmacological Management

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Triamcinolone Acetonide (Intralesional)
Kenalog® · Corticosteroid (injection)
Adult dose 5–10 mg/mL injected into subcutaneous tissue of active patches. Use a 30-gauge needle, 0.1 mL per injection site spaced 1 cm apart. Maximum 20–30 mg per session per scalp.
Frequency Every 4–6 weeks. Assess response after 3 sessions.
Paediatric dose 2.5–5 mg/mL. Can be used from age 10+ with adequate counselling. May require procedural sedation in younger children.
Key side effects Localised cutaneous atrophy (most common, usually reversible), depigmentation at injection site, pain during injection
PBS status ✔ PBS General Benefit (injection kit). GP consultation under MBS item 23 (standard) or 36 (prolonged).
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Clobetasol Propionate 0.05%
Dermovate® · Generic · Superpotent Topical Corticosteroid
Adult dose Apply thin layer to affected areas BD for 2–4 weeks, then taper. Use under occlusion for resistant patches. Limit to 50 g/week to reduce systemic absorption risk.
Paediatric dose Use with caution; prefer potent (not superpotent) agents such as betamethasone valerate 0.1% in children <12 years.
Key side effects Skin atrophy, telangiectasia, striae with prolonged use. Avoid on face and skin folds.
PBS status ✔ PBS General Benefit
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Minoxidil Topical 5%
Regaine® · Vasodilator (adjunct)
Adult dose 1 mL BD to affected areas. Used as adjunct to corticosteroid therapy to stimulate regrowth during treatment.
PBS status ✘ Not PBS-listed — OTC (approx. –60/month)
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Baricitinib
Olumiant® · JAK1/JAK2 Inhibitor
Adult dose 2 mg PO once daily. For severe alopecia areata (≥50% scalp involvement) in adults. Response assessment at 36 weeks — continue if adequate regrowth achieved.
Paediatric dose Not approved for use in children <18 years for alopecia areata in Australia
Duration Continue for ≥36 weeks to assess efficacy. Relapse common upon discontinuation.
Renal adjustment eGFR 30–60: 1 mg daily. eGFR <30: avoid.
Hepatic adjustment Contraindicated in severe hepatic impairment (Child-Pugh C)
Key side effects Acne, upper respiratory infections, elevated CPK, elevated LDL cholesterol, thrombocytosis. Screen for latent TB, hepatitis B/C, and VZV before initiation. Avoid live vaccines during treatment.
PBS status ⚑ PBS Authority Required — for severe alopecia areata in adults who have failed or are intolerant to systemic corticosteroids. Initial authority via dermatologist.
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JAK inhibitor safety monitoring (baricitinib): Baseline FBC, LFTs, lipid profile, renal function, hepatitis B/C serology, and TB screening (IGRA or Mantoux) are mandatory before initiation. Repeat FBC, LFTs, and lipids at 4 weeks, 12 weeks, then every 3 months. Counsel patients regarding thromboembolic risk (DVT/PE) and increased infection susceptibility. Baricitinib carries a TGA boxed warning regarding thromboembolic events and major adverse cardiovascular events observed in the RA safety population — discuss risk-benefit with patients.

Non-Pharmacological Management

  • Cosmetic camouflage: Scalp micropigmentation, hair fibres (e.g., Toppik®), and strategic hairstyling can reduce psychosocial impact.
  • Wigs: The Australian Alopecia Areata Foundation (AAAF) provides a wig subsidy program and peer support networks nationally.
  • Psychological support: Cognitive-behavioural therapy (CBT) has demonstrated benefit in improving quality of life in AA patients. Refer to clinical psychologist as needed. Beyond Blue (1300 22 4636) and AAAF (alopecia.org.au) are valuable Australian resources.
  • Contact immunotherapy (DPCP/diphencyprone): Available at some specialist dermatology centres in Australia. Topical sensitiser applied weekly to induce allergic contact dermatitis, redirecting the immune response. Requires specialist supervision.

Telogen Effluvium & Scarring Alopecia

Telogen Effluvium (TE)

Telogen effluvium is a reactive, non-scarring diffuse hair loss triggered by an event that shifts a large proportion of anagen hairs prematurely into the telogen phase. The latent period between the inciting event and onset of shedding is typically 2–3 months, corresponding to the time for telogen club hairs to be released. TE may be acute (<6 months duration) or chronic (>6 months).

Common Triggers

Category Examples Mechanism
Physiological Postpartum (3–6 months post-delivery), cessation of OCP, menopause Oestrogen withdrawal shifts anagen to telogen
Nutritional Iron deficiency (ferritin <30 µg/L), crash dieting, zinc deficiency, vitamin D deficiency, protein malnutrition Impaired hair matrix cell proliferation
Psychological stress Major life events, bereavement, surgery, illness, COVID-19 infection Cortisol-mediated follicular signalling disruption
Medications β-blockers, anticoagulants (heparin, warfarin), anticonvulsants (valproate, carbamazepine), lithium, retinoids, ACE inhibitors Direct follicular toxicity or metabolic disruption
Systemic illness Thyroid dysfunction (hypo- and hyperthyroidism), systemic lupus erythematosus, chronic renal failure, malignancy Multifactorial
Post-infectious COVID-19 (reported 2–3 months post-infection), influenza, high febrile illness Systemic inflammatory stress response

Diagnosis

  • History: Diffuse hair shedding (increased hair on pillow, in shower drain, on clothing), with identifiable trigger 2–3 months prior.
  • Examination: Diffuse thinning more apparent at the vertex and frontal scalp. Positive hair pull test (telogen club roots). No scalp inflammation, erythema, or scarring. Frontal hairline typically preserved.
  • Dermoscopy: Predominantly empty follicular ostia, short regrowing vellus hairs (indicating recovery), no specific disease pattern.
  • "Christmas tree" pattern: On parting, widening of the central part in a characteristic triangular pattern is typical of chronic TE in women.

Management

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Acute telogen effluvium is self-limiting. Reassurance is the cornerstone of management — patients must understand that shedding will cease and full regrowth is expected within 6–12 months. The psychosocial impact should not be underestimated; validate the patient's distress and provide written information and support resources.

  • Treat underlying cause: Iron supplementation (ferrous sulfate 325 mg PO daily if ferritin <30 µg/L, taken with vitamin C to enhance absorption), thyroid replacement, medication review.
  • Optimise nutrition: Balanced diet with adequate protein (1.0–1.2 g/kg/day), iron-rich foods, and zinc. Consider supplementation: zinc 30 mg daily, vitamin D if deficient (<50 nmol/L).
  • Minoxidil 2–5% topical: May be considered in chronic TE (>6 months) to support regrowth and mask thinning. Not typically required in acute TE.
  • Chronic TE (>6 months): Investigate for overlapping AGA, nutritional deficiency, and thyroid disease. Dermatology referral recommended. May require scalp biopsy to distinguish from early AGA.
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Ferrous Sulfate
Ferro-Gradumet® · Generic · Iron Supplement
Adult dose 325 mg PO daily (105 mg elemental iron) with food or vitamin C 200 mg. Recheck ferritin at 3 months; target ≥30 µg/L (ideally 50–70 µg/L).
Paediatric dose 3–6 mg/kg/day elemental iron in divided doses
Key side effects Constipation, nausea, dark stools. Take alternate-day for improved fractional absorption per current evidence.
PBS status ✔ PBS General Benefit

Scarring (Cicatricial) Alopecia

Scarring alopecias are a group of disorders characterised by irreversible destruction of hair follicles and replacement with fibrous tissue. They account for approximately 3–7% of hair loss referrals in Australia. Early recognition and aggressive treatment are critical — once follicles are destroyed, regrowth is impossible. All suspected scarring alopecias require urgent dermatology referral.

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Critical red flags for scarring alopecia: Loss of visible follicular ostia (smooth, shiny scalp patches), perifollicular erythema and scale, permanent hair loss in focal areas, symptoms of burning, tenderness or pruritus on the scalp. If any of these features are present, refer to dermatology urgently — do not delay for empirical treatment.

Classification

Type Key Features Demographics First-Line Treatment
Lichen Planopilaris (LPP) Perifollicular erythema and scale, particularly at the frontal hairline. Follicular hyperkeratosis. May be itchy/tender. Women 40–60 years Topical/intralesional corticosteroids + hydroxychloroquine
Frontal Fibrosing Alopecia (FFA) Band-like recession of the frontotemporal hairline (1–5 cm). Loss of eyebrows. Perifollicular erythema at the leading edge. Variant of LPP. Post-menopausal women (increasing incidence in Australia) Topical corticosteroids + 5α-reductase inhibitors (finasteride/dutasteride) + hydroxychloroquine
Discoid Lupus Erythematosus (DLE) Disc-shaped plaques with follicular plugging, dyspigmentation, atrophy, and scale. DLE may co-exist with systemic lupus (1–5%). Women 20–40; higher prevalence in ATSI and darker-skinned populations Photoprotection + potent topical corticosteroids + hydroxychloroquine
Central Centrifugal Cicatricial Alopecia (CCCA) Progressive scarring from the vertex outward. Associated with hair grooming practices (heat, chemicals). Women of African descent Cessation of chemical/heat treatments + topical corticosteroids + doxycycline
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Hydroxychloroquine
Plaquenil® · Generic · Antimalarial / Immunomodulator
Adult dose 200–400 mg PO daily (≤5 mg/kg actual body weight). Onset of effect 2–3 months.
Duration Long-term; stabilisation of disease rather than regrowth. Monitor for retinal toxicity.
Key side effects Retinal toxicity (screen with OCT annually after 5 years or sooner with risk factors), GI upset, skin pigmentation, QT prolongation (rare)
PBS status ⚑ PBS Authority Required (for connective tissue / autoimmune conditions)
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Doxycycline
Doryx® · Generic · Tetracycline Antibiotic / Anti-inflammatory
Adult dose 100 mg PO BD (anti-inflammatory dose). Used for LPP, CCCA, and folliculitis decalvans.
Duration 3–6 months; taper to 50 mg daily for maintenance
Key side effects Photosensitivity, GI upset, oesophageal ulceration (take with water, remain upright). Avoid in pregnancy and children <8 years.
PBS status ✔ PBS General Benefit
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Mycophenolate Mofetil
CellCept® · Generic · Immunosuppressant
Adult dose 500–1000 mg PO BD. Second-line for refractory scarring alopecia (LPP, DLE) when hydroxychloroquine fails.
Key side effects GI upset, myelosuppression, increased infection risk, teratogenicity (absolute contraception required)
Monitoring FBC fortnightly × 2 months then monthly; LFTs monthly; pregnancy test before initiation
PBS status ⚑ PBS Authority Required (for approved transplant/autoimmune indications; specialist-initiated)

Investigations

Investigation is guided by the clinical pattern of hair loss. The following provides a framework for first-line and specialist investigations available in Australian general practice and pathology services.

Essential Full Blood Count (FBC) Anaemia of iron deficiency, haematinic deficiency. MBS item 66551.
Essential Serum Ferritin Target ≥30 µg/L for hair growth; optimal 50–70 µg/L. MBS item 66551.
Essential Thyroid Function Tests (TSH, fT4) Hypo- and hyperthyroidism both cause diffuse hair loss. MBS item 66719.
Essential Serum Zinc Zinc deficiency is an under-recognised cause of hair loss, especially in ATSI and malnourished populations. MBS item 66815.
Essential Serum Vitamin D (25-OH) Vitamin D deficiency prevalent in Australia (particularly southern states, elderly, darker-skinned individuals). MBS item 66824.
Available Testosterone, DHEAS, SHBG If clinical features of hyperandrogenism in women (hirsutism, acne, irregular menses, virilisation). Rule out PCOS or adrenal/ovarian tumour. MBS item 66658.
Available Antinuclear Antibody (ANA), Anti-dsDNA If discoid lupus or systemic lupus suspected (scarring alopecia with photosensitivity, oral ulcers, rash). MBS item 66629.
Available Coeliac Serology (tTG-IgA) If associated GI symptoms, refractory iron deficiency, or extensive alopecia areata.
Specialist Scalp Biopsy (4 mm punch) Vertical and horizontal sections. Essential for diagnosing scarring alopecia subtypes. Performed by dermatologist. MBS item 30071 (skin biopsy).
Specialist Dermoscopy (Trichoscopy) Dermatoscopic examination of scalp. Distinguishes AA (yellow dots, exclamation mark hairs), AGA (hair shaft variability, miniaturisation), LPP (peripilar casts, absence of follicular ostia). MBS item 105 may apply in specialist setting.

Monitoring & Follow-Up

Baseline
Clinical photography (standardised frontal, vertex, lateral views). Hair pull test. Laboratory investigations (FBC, ferritin, TFTs, zinc, vitamin D). Severity scoring (Hamilton–Norwood, Ludwig, or SALT score for AA).
3 months
Reassess hair pull test (should become negative in effluvium). Review compliance with topical/oral therapy. Early side effect monitoring. Repeat FBC/ferritin if on iron supplementation.
6 months
Assess for clinical response (photographic comparison). Minoxidil — initial regrowth may be visible. Finasteride — early stabilisation of hair loss. If no response, consider dose optimisation or combination therapy.
12 months
Full efficacy assessment. Continue maintenance therapy if responding. If inadequate response on current regimen, consider: adding adjunctive agents, switching therapies, or specialist referral (dermatology, endocrinology if hyperandrogenism suspected).
Ongoing
Lifelong treatment for AGA. Annual review for medication side effects. JAK inhibitors: FBC, LFTs, lipids at 4 weeks, 12 weeks, then 3-monthly. Hydroxychloroquine: annual ophthalmological review (OCT) after 5 years or sooner with risk factors. Psychosocial wellbeing review at each visit.

Special Populations

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Pregnancy

Minoxidil Contraindicated — Category C. Discontinue at least 1 month before conception. Teratogenic in animal studies.
Finasteride / Dutasteride Absolutely contraindicated — Category X. Exposure in male foetus causes ambiguous genitalia. Women must not handle crushed or broken tablets.
Spironolactone Contraindicated — anti-androgenic effects on male foetus. Discontinue before conception.
Hydroxychloroquine Generally considered safe in pregnancy (benefits outweigh risks for active autoimmune disease). Continue per rheumatology/dermatology advice.
Postpartum TE Expect onset at 3–6 months postpartum. Self-limiting (resolves within 6–12 months). Reassurance is key. Minoxidil can be used postpartum but not during breastfeeding without discussion of risk.
Intralesional triamcinolone Can be used cautiously for AA in pregnancy — minimal systemic absorption. Discuss risk-benefit.
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Paediatrics

Alopecia areata in children AA is the most common cause of acquired non-scarring alopecia in children. Onset <10 years and extensive disease carries a poorer prognosis. Associated with atopy and nail changes. Referral to paediatric dermatology recommended.
Topical corticosteroids First-line: betamethasone valerate 0.1% or mometasone furoate 0.1% (moderate-potency preferred over superpotent in children). Clobetasol 0.05% limited to short courses in children >12 years.
Intralesional triamcinolone Can be used from age 10+ (2.5–5 mg/mL). May require procedural sedation/anxiolysis in younger children. Efficacy similar to adults.
Finasteride / Dutasteride Not approved for use in children. Absolute teratogenic risk in pubertal females.
Baricitinib Not approved for AA in patients <18 years. Limited safety data in paediatric AA.
Tinea capitis Important differential in children — presents with patchy hair loss, scaling, lymphadenopathy. Treat with oral griseofulvin (15–20 mg/kg/day for 6–8 weeks) or terbinafine (weight-based dosing). Topical therapy alone is insufficient. MBS: Fungal culture (66095).
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Elderly

Age-related hair changes Senescent alopecia (generalised thinning with ageing) is physiological. Differs from AGA by absence of follicular miniaturisation on biopsy. Reduced treatment responsiveness expected.
Drug-induced TE Polypharmacy increases risk. Review medications: β-blockers, anticoagulants, anticonvulsants, ACE inhibitors, and lithium are common culprits.
Frontal fibrosing alopecia Increasing incidence in post-menopausal women. Requires specialist management. Sunscreens (titanium dioxide-based) and oral finasteride may be protective per emerging evidence.
Nutritional deficiencies Iron, zinc, and vitamin D deficiency are more prevalent in elderly populations due to reduced dietary intake, malabsorption, and reduced sun exposure. Screen proactively.
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Renal Impairment

Chronic kidney disease CKD is associated with chronic TE due to anaemia, metabolic derangements, and uraemia. Hair loss may be an early clinical clue to undiagnosed renal disease.
Baricitinib eGFR 30–60: dose-reduce to 1 mg daily. eGFR <30: avoid use.
Iron supplementation Oral iron absorption may be impaired in CKD. IV iron (ferric carboxymaltose) may be required under nephrology guidance. Target ferritin >100 µg/L in CKD.
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Hepatic Impairment

Finasteride / Dutasteride Metabolised hepatically. Use with caution in hepatic impairment; avoid in severe liver disease. Monitor LFTs if chronic use.
Methotrexate (for refractory AA/scarring alopecia) Hepatotoxic — contraindicated in significant hepatic fibrosis or cirrhosis. Monitor LFTs and consider FibroScan/liver biopsy with prolonged use.
Mycophenolate Metabolised hepatically. Monitor LFTs regularly. Dose adjustment not well defined — use with caution.
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Immunocompromised

JAK inhibitors (baricitinib) Increased risk of herpes zoster, serious infections, and malignancy. Screen for latent TB (IGRA) and hepatitis B/C before initiation. Avoid in active serious infection. Avoid live vaccines.
Immunosuppressive agents Methotrexate, mycophenolate, and cyclosporine used for refractory scarring alopecia — increased infection and malignancy risk. Requires specialist supervision and regular monitoring.
HIV-associated hair loss AA may be more severe and treatment-refractory in HIV. TE may be related to HIV itself or antiretroviral therapy. Coordinate management with infectious diseases specialist.
Aboriginal and Torres Strait Islander Health Considerations

Hair and scalp conditions are a significant but under-recognised health concern in Aboriginal and Torres Strait Islander communities. Culturally safe, trauma-informed care is essential when addressing hair disorders in this population.

Tinea capitis and scalp infections
Tinea capitis (scalp ringworm) has a significantly higher prevalence in remote Aboriginal and Torres Strait Islander communities, particularly among children. Trichophyton tonsurans and Microsporum species are common causative organisms. Crowded living conditions and shared personal items (brushes, pillows) facilitate transmission. Oral antifungal therapy (griseofulvin or terbinafine) is required — topical therapy alone is insufficient. Community-based screening and treatment programs are essential.
Nutritional deficiency
Iron, zinc, and vitamin D deficiency are more prevalent in remote communities due to food insecurity (limited access to fresh fruit, vegetables, and protein-rich foods), "food desert" conditions, and chronic disease burden. Serum ferritin and zinc should be checked proactively in any ATSI patient presenting with hair loss. Addressing food security (through community stores, Outback Stores programs, and the National Strategy for Food Security in Remote Indigenous Communities) is a public health priority.
Access to dermatology
Specialist dermatology services are extremely limited in remote and very remote areas of Australia. Telehealth dermatology services (e.g., through the Australian Specialist Outreach Service, Northern Territory Dermatology, and state-based Aboriginal health services) are critical for assessment, trichoscopy, and biopsy planning. Support the use of store-and-forward teledermatology with clinical photography where available.
Discoid lupus erythematosus
DLE has a higher prevalence in darker-skinned populations, including Aboriginal and Torres Strait Islander peoples. DLE can cause significant scarring alopecia and dyspigmentation. Photoprotection is essential — provide culturally appropriate sun-safety counselling and ensure access to broad-spectrum SPF 50+ sunscreen. Coordinate screening for systemic lupus (ANA, renal function) with rheumatology/renal medicine.
Cultural considerations
Hair has deep cultural and spiritual significance in many Aboriginal and Torres Strait Islander communities. Hair loss may carry additional psychosocial and cultural distress beyond the physical impact. Engage Aboriginal and Torres Strait Islander health workers and liaison officers in consultations. Use culturally safe communication — avoid medicalised language without explanation, allow time for yarning, and involve family where appropriate. Respect cultural practices around hair management.
Pharmacy access and PBS affordability
Access to pharmacies may be limited in remote communities. OTC products like minoxidil may be unavailable or unaffordable. Ensure patients on PBS-listed medications (e.g., hydroxychloroquine, iron supplements) are aware of Closing the Gap PBS co-payment (currently .70 per script for eligible patients). Refer to Aboriginal Community Controlled Health Organisations (ACCHOs) for medication supply and chronic disease management support.

📚 References

  1. 1. Messenger AG, McKillop J, Farrant P, McDonagh AJ, Sladden M. British Association of Dermatologists' guidelines for the management of alopecia areata 2012. Br J Dermatol. 2012;166(5):916–926.
  2. 2. King BA, Ohyama M, Kwon O, et al. Two phase 3 trials of baricitinib for alopecia areata. N Engl J Med. 2022;386(18):1687–1699.
  3. 3. Blume-Peytavi U, Atkin S, Shapiro J, Lai S, Tosti A. Female pattern hair loss — update on diagnosis and management. J Dtsch Dermatol Ges. 2023;21(3):264–277.
  4. 4. Pratt CH, King LE Jr, Messenger AG, Christiano AM, Sundberg JP. Alopecia areata. Nat Rev Dis Primers. 2017;3:17011.
  5. 5. Dhurat R, Mathapati S. Trichoscopy in alopecia areata: A reappraisal. Int J Trichology. 2023;15(1):1–8.
  6. 6. Strazzulla LC, Wang EHC, Avila L, et al. Alopecia areata: Disease characteristics, clinical evaluation, and new perspectives on pathogenesis. J Am Acad Dermatol. 2018;78(1):1–12.
  7. 7. Ramaswamy P, Mendese G, Engasser H, Gathers RC. Lichen planopilaris and frontal fibrosing alopecia: Update on diagnosis and management. J Am Acad Dermatol. 2021;85(6):1417–1429.
  8. 8. Australian Institute of Health and Welfare. Skin conditions in Australia. AIHW Cat. No. PHE 301. Canberra: AIHW; 2023.
  9. 9. Rossi A, Anzalone A, Fortuna MC, et al. Multi-therapies in androgenetic alopecia: Review and clinical experiences. Dermatol Ther. 2016;29(6):424–432.
  10. 10. Guo EL, Katta R. Diet and hair loss: Effects of nutrient deficiency and supplement use. Dermatol Pract Concept. 2017;7(1):1–10.
  11. 11. Royal Australian College of General Practitioners (RACGP). Hair loss assessment and management in general practice. Aust Fam Physician. 2022;51(8):580–586.
  12. 12. Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Health Survey. ABS Cat. No. 4715.0. Canberra: ABS; 2019.
  13. 13. Asghar F, Shamim N, Farooque U, Sheikh H, Aqeel R. Telogen effluvium: A review of the literature. Cureus. 2020;12(5):e8320.
  14. 14. Skin Health Cancer Foundation Australia. Report on skin and hair conditions in Australia. 2023.
for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.
Preventive health
Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction
Paracetamol ± NSAID; manual therapy
2–6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; ± calcitonin; DXA + osteoporosis Rx
6–12 weeks healing
Elderly; osteoporosis; acute onset
ACS (posterior MI)
Aspirin 300 mg, GTN, heparin; urgent PCI
Time-critical
ECG, troponin; CV risk factors
Aortic dissection
IV labetalol; urgent CT aortogram; surgery (Type A)
Time-critical
Tearing pain; BP differential >20 mmHg
Vertebral osteomyelitis
IV antibiotics (vancomycin + ceftriaxone initially); ID consult
6 weeks IV antibiotics
Fever, elevated CRP, IV drug use
Biliary colic / cholecystitis
Paracetamol ± morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

📚 References

  1. 1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
  2. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
  3. 3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  4. 4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
  5. 5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
  6. 6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
  7. 7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
  8. 8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
  9. 9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
  10. 10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
  11. 11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
  12. 12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).