Alopecia

Aka: Alopecia, Hair Loss

1. See Also
   1. Hair
2. Causes: Focal
   1. Diffuse
      1. Androgenetic Alopecia
         1. Male-Patterned Hair Loss (M-patterned hair thinning)
         2. Female-Patterned Hair Loss (central hair thinning)
      2. Telogen Effluvium
      3. Anagen Effluvium
      4. Systemic conditions (e.g. Hypothyroidism, Iron Deficiency Anemia, nutritional deficiency)
      5. Alopecia Totalis
   2. Focal or patchy - Nonscarring Alopecia (non-cicatrical Alopecia)
      1. Tinea Capitis
      2. Trichotillomania
      3. Traction Alopecia (e.g. tight braiding)
      4. Alopecia Areata
      5. Secondary Syphilis (Alopecia syphilitica with moth-eaten appearance)
   3. Focal or patchy - Scarring Alopecia (Cicatricial Alopecia, uncommon)
      1. Congenital defects
      2. Trauma
         1. Chemical agents (caustic substances)
         2. Burns
         3. Radiation
      3. Inflammatory dermatoses
         1. Discoid Lupus Erythematosis
         2. Sarcoidosis
         3. Lichen Planus follicularis
         4. Necrobiosis Lipoidica diabeticorum
      4. Infection
      5. Neoplasm
         1. Basal Cell Carcinoma
         2. Squamous Cell Carcinoma
         3. Metastases
         4. Lymphoma
3. History
   1. Duration of Hair Loss
   2. Pattern of Hair Loss (see below)
   3. Progression of Hair Loss
   4. Family History of Hair Loss
      1. Androgenetic Alopecia
      2. Alopecia Areata
   5. Hair Loss type
      1. Broken hairs: Tinea Capitis, Trichotillomania
      2. Hairs lost by roots
   6. Concurrent systemic symptoms (e.g. weight loss, Fatigue) or systemic illness or endocrinopathy (e.g. Hypothyroidism)
      1. Alopecia Areata
      2. Telogen Effluvium
   7. Concurrent psychiatric illness or significant stress, pregnancy or febrile illness (with abrupt onset)
      1. Telogen Effluvium
      2. Trichotillomania
   8. Recent medication changes
      1. Telogen Effluvium
   9. Hyperandrogenism in women
      1. Androgenetic Alopecia
   10. Excessive hair care product use (straightening agents, Shampoos)
       1. Trichorrhexis Nodosa
4. Exam: Hair
   1. Hair distribution and areas of thinning
   2. Hair Pull Test
   3. Scalp scarring
      1. Inflammation
      2. Scaling
      3. Loss of Hair Follicles in non-scarring Alopecia
   4. Hair Shaft exam
      1. Hair length and caliber
      2. Hair fragility
   5. Scalp with Scaling, Pustules, crusts, erosions or erythema or local adenopathy
      1. Infection
   6. Dry, broken hair
      1. Trichorrhexis Nodosa
5. Signs: Patterns of Hair Loss
   1. M-Pattern in Men (bi-temporal, frontal, vertex) or central and vertex thinning (with spared frontal hair) in women
      1. Androgenetic Alopecia
   2. Diffuse Hair Loss
      1. Alopecia Areata (or if involves the entire body, Alopecia Totalis or universalis)
      2. Telogen Effluvium
      3. Toxin or Chemotherapy exposure
      4. Endocrinopathy
   3. Focal Hair Loss
      1. Traction Alopecia
      2. Trichotillomania
      3. Tinea Capitis
      4. Alopecia Areata
      5. Systemic Lupus Erythematosus
      6. Syphilis
6. Labs
   1. Potassium Hydroxide (KOH) of scalp scraping
   2. Consider additional labs based on Alopecia type
      1. See Alopecia Areata
      2. See Androgenetic Alopecia
      3. See Telogen Effluvium
   3. Scalp Biopsy Indications (4 mm Punch Biopsy)
      1. Scarring Alopecia (not diagnostic if Trauma related)
      2. Unusual Hair Loss pattern
7. Management
   1. Refer cicatrical Alopecia (scarring Alopecia)
   2. See specific Alopecia types for management
8. Resources
   1. National Alopecia Areata Foundation
      1. http://www.alopeciaareata.com
9. References
   1. Nielson (1995) Am Fam Physician 51:1513-28 [PubMed]
   2. Phillips (2017) Am Fam Physician 96(6): 371-8 [PubMed]
   3. Price (1999) N Engl J Med 341:964-73 [PubMed]
   4. Shapiro (2000) Can Fam Physician 46:1469-77 [PubMed]
   5. Sperling (1998) Med Clin North Am 82:1155-69 [PubMed]
   6. Springer (2003) Am Fam Physician 68(1):93-102 [PubMed]