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Adult patients presenting with hair loss may have a variety of underlying aetiologies. The first step to treating patients with hair loss is to identify the most likely cause. This is easier said than done, however, there are several techniques that you can employ in your general practice to aid in diagnosis.

Take a good history

History can give you some clues as to what type of hair loss you may be dealing with. Ask about hair practices including tight ponytails, hot-combing and tight braids as some styling practices are associated with scarring alopecia. Ask how long this has been going on and whether the patient has experienced any recent serious stressor or illness.

The nature of how the hair is lost can also indicate aetiology. Some hair loss disorders result in diffuse shedding whereas others are lost in uneven patches. Genetic factors also play a role, so a family history of male or female pattern baldness may be a risk factor. It can be helpful to let patients know that it is normal to lose 100-150 hairs every day.

The physical exam and other tests

Clues in your physical exam include loss of follicular ostia on the scalp as well as atrophy or skin changes. The hair pull test is an easily employed test that can be used in the clinic as well. To perform this, you simply grab approximately 40 hairs and tug to see how many hairs are lost. More than 10 hairs lost indicates a pathological cause for hair loss.

A skin biopsy may also help you distinguish whether or not scarring is involved. It may also be helpful to evaluate the patient for underlying anemia, thyroid disease, and vitamin deficiencies to rule out potential secondary causes of hair loss. as well.

We can think of hair loss in two main categories: non-scarring and scarring hair loss. Here, we will briefly review the most commonly encountered alopecias in each of these two categories.

Non-scarring alopecias

Telogen effluvium

Telogen effluvium is a very common type of hair loss that usually starts several months after a significant stressor. This could be a serious illness or even significant emotional stress that the patient has experienced. Patients often complain of diffuse hair loss all over their scalp, and physical exam shows diffuse thinning without evidence of scarring. There is no treatment for telogen effluvium except to reverse the underlying trigger if possible. The process is reversible.

Alopecia areata

Alopecia areata is an autoimmune process that results in ovoid patches of alopecia on the scalp. The process is non-scarring and thought to be due to the loss of immune privilege in the hair follicle. The patient’s own immune cells attack the hair follicle inducing hair loss clinically. Common treatment options for alopecia areata includes topical and intralesional steroids. This autoimmune process can run in families and may coexist with other autoimmune disorders.

Androgenic alopecia

Androgenic alopecia is also known as male-pattern baldness or female-pattern baldness. It is incredibly common and tends to run in families. Hair loss is progressive and chronic, worsening with age. Most men complain of alopecia at the vertex of their scalp while women have hair loss of the frontotemporal and midline scalp. Treatment includes topical minoxidil 5% twice daily or oral 5α-reductase inhibitors such as finasteride or dutasteride. Usually, it takes at least 4-5 months of daily use of minoxidil topically to evaluate treatment efficacy.

Scarring alopecias

Central centrifugal cicatricial alopecia

Central centrifugal cicatricial alopecia is most common in patients of African descent. Pathogenesis is partially explained by styling practices such as tight ponytails, braids, hot combing, and the use of pomades. Diffuse scarring and chronic disease are often irreversible, however, treatment with oral tetracycline may provide benefit by slowing or halting the process.

Frontal fibrosing alopecia

This type of scarring alopecia presents most often as scarring hair loss along the anterior hairline. It is more common in women and more prevalent in Caucasians. Diagnosis must be confirmed with histology so a biopsy is always recommended when this diagnosis is suspected. Treatment involves intralesional steroids and oral antimalarials like hydroxychloroquine, though many cases may be recalcitrant.

Learn more in the Professional Diploma program in General Dermatology.

Sources

Sperling LC, Sinclair RD, and Shabrawi-Caelen LE. Alopecia. In: Dermatology. 4th ed. Philadelphia, PA: Elsevier Saunders; 2018:1171-1181

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