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Alopecia areata

This page teaches you diagnosis and evaluation of people with hair loss meant for medical professionals

History and Physical Examination


Patient history of alopecia: onset of hair loss, hair loss pattern (diffuse or focal), rate and timing of hair loss, other scalp symptoms (itching, burning, tingling)
Personal history: dietary changes, diet, hair-care routine, hygiene products, medications (prescription medications, vitamins, over-the-counter [OTC] medications, and herbal remedies), stress (causes disease by suppressing immune functions), major illness
Female patient: menstrual and reproductive histories
Any family history of alopecia, patient's concurrent systemic/chronic illness, physical stress, medication, environmental exposure, psychiatric disorders, hairstyle, signs and symptoms of hormonal abnormalities

Physical examination:
Scalp exam for any scars, erythema, scaling, or inflammation
Density and distribution of hair
Hair shaft exam for caliber, length, shape, and fragility
Thyroid palpation to determine thyroid size, nodularity, or vascularity
Use "pull test" technique for hair loss. Grasp about 60 hairs between the thumb, the index, and the middle fingers. The hairs are then gently but firmly pulled. A positive test (210 hairs obtained) indicates an active hair shedding.
If a patient demonstrates positive hair-pull tests all over the scalp, he/she may be warned he/she will most likely lose all of their hair. Next, provide anticipatory guidance during the period of extensive hair loss as the cycle reestablishes and regrowth begins.

Finally, determine if eyebrow, eyelash, axillary, or body hair is affected. Examine hair density in other areas such as the face and extremities. A female patient who presents with thinning scalp hair and demonstrates increased facial, thigh, chin, or chest hair may have an androgen excess.

Laboratory Studies

Once other causes such as malnutrition, androgenetic, hereditary conditions (by history, progression, and presentation), trauma (trichotillomania, traction alopecia), and drugs (telogen effluvium) have been ruled out, consider labs for secondary conditions:

For female alopecia with symptoms of hyperandrogenism (such as menstrual irregularities, infertility, cystic acne, virilization, or galactorrhea), check total testosterone, free testosterone, dehydroepiandrosterone sulfate (DHEA-S), or prolactin levels.
For male and female alopecia without symptoms of hyperandrogenism, consider measurement of serum thyroid stimulating hormone concentration to rule out thyroid disease; venereal disease research laboratory (VDRL) technique to rule out syphilis; serum ferritin to rule out anemia; antinuclear antibody test (ANA), RF (rheumatoid factor) to rule out autoimmune disease; potassium hydroxide (KOH) examination to rule out tinea capitis; swab a wound culture to rule out infections; and scalp biopsy as needed to rule out neoplasm.

Disorders Causing Hair Loss in Adults

Androgenetic alopecia
Male: Hereditary. Dihydrotestosterone compels follicles into perpetual telogen phase. The earlier oral or topical treatment is started, the better results one may expect.
Female: Female androgenetic pattern incidence increases with age. Incidence is approximately 6% in women under 50, but increases to 38% in women over 70. Female pattern hair loss typically demonstrates a lower density of hair but maintains a relatively even distribution, known as "Ludwig" distribution. Even thinning across the crown is typical, while the frontal line maintains position.



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