Physical Examination for Increased Hair Loss
A thorough physical examination for hair loss should include dermoscopy, hair pull test, and detailed scalp assessment to identify the pattern, distribution, and characteristics of hair loss, which is essential for accurate diagnosis and treatment planning. 1
Initial Scalp Assessment
Examine the entire scalp systematically, noting:
- Pattern of hair loss (diffuse vs. patchy)
- Distribution (vertex, frontal, bitemporal, or generalized)
- Presence of inflammation, scaling, or scarring
- Hair density in affected areas compared to unaffected areas
Look for specific diagnostic features:
- Exclamation mark hairs (tapered proximal end) - suggestive of alopecia areata 2
- Broken hairs - may indicate trichotillomania or traction alopecia
- Miniaturized hairs - common in androgenetic alopecia
- Scaling or erythema - may suggest tinea capitis or inflammatory conditions
Diagnostic Tests During Physical Examination
1. Hair Pull Test
- Grasp 50-60 hairs between thumb and index finger
- Apply gentle traction and pull away from the scalp
- Interpretation:
- Normal: 1-2 hairs extracted
- Positive: >6 hairs extracted (indicates active shedding)
- Assess extracted hairs for telogen bulbs (club-shaped) or anagen roots
2. Dermoscopy
- Essential non-invasive diagnostic tool with high accuracy 1
- Look for specific features:
- Yellow dots - common in alopecia areata
- Black dots - broken hairs at scalp level
- Exclamation mark hairs - characteristic of alopecia areata
- Hair shaft diameter variation - androgenetic alopecia
- Perifollicular scaling/erythema - inflammatory conditions
3. Hair Shaft Examination
- Examine individual hair shafts under magnification
- Assess:
- Hair shaft diameter (uniform vs. variable)
- Structural abnormalities (fractures, nodes)
- Pigmentation changes
- Root morphology (anagen vs. telogen)
Extended Physical Examination
1. Scalp Palpation
- Feel for:
- Tenderness or pain
- Nodules or masses
- Induration or scarring
- Temperature changes
2. Other Body Areas
- Examine:
- Eyebrows and eyelashes for loss
- Body hair distribution
- Nail changes (pitting, ridging) - may accompany alopecia areata 2
- Facial hair in women - may indicate hormonal issues
3. Signs of Systemic Disease
- Look for:
- Thyroid enlargement
- Lymphadenopathy
- Skin manifestations of autoimmune diseases
- Signs of nutritional deficiencies
Differential Diagnosis Assessment
During the physical exam, consider these key diagnostic distinctions 2, 1:
- Alopecia areata: Smooth, non-inflamed patches with exclamation mark hairs
- Trichotillomania: Incomplete hair loss with broken hairs firmly anchored
- Tinea capitis: Subtle inflammation, scaling, broken hairs
- Telogen effluvium: Diffuse thinning without scalp abnormalities
- Androgenetic alopecia: Pattern-dependent thinning with hair miniaturization
- Scarring alopecia: Loss of follicular ostia, skin texture changes
Documentation
- Photograph affected areas for baseline comparison
- Map the distribution of hair loss
- Document hair density measurements and terminal-to-vellus hair ratio
- Record specific dermoscopic findings
Common Pitfalls to Avoid
- Failing to distinguish between scarring and non-scarring alopecia
- Overlooking subtle signs of tinea capitis
- Misdiagnosing trichotillomania as alopecia areata
- Not considering systemic causes of hair loss
- Inadequate dermoscopic examination
When physical examination findings are inconclusive or suggest scarring alopecia, a scalp biopsy may be necessary for definitive diagnosis 1.
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