What is the recommended initial workup for a patient presenting with alopecia?

Recommended Workup for Alopecia

The diagnosis of alopecia is usually straightforward and requires minimal investigation in most cases, with specific tests only indicated when the diagnosis is in doubt. 1

Initial Diagnostic Approach

Clinical Evaluation

• Detailed history:

  • Duration and pattern of hair loss
  • Family history (especially for androgenetic alopecia)
  • Recent stressors or illness
  • Medication use
  • Hair care practices and styling

• Physical examination:

  • Pattern of hair loss (diffuse, patchy, or patterned)
  • Presence of scalp inflammation or scarring
  • Examination for "exclamation mark" hairs (characteristic of alopecia areata)
  • Pull test to assess hair fragility and shedding
  • Examination of nails (may show changes in 10% of alopecia areata cases) 1

Dermoscopy

• Essential diagnostic tool that can aid in differentiating between types of alopecia
• Key findings in alopecia areata:
  • Regular round yellow dots
  • Dystrophic hairs with fractured tips (exclamation mark hairs)
  • Cadaverized hairs (fractured before emergence from scalp) 1

Laboratory Testing

Laboratory investigations are unnecessary in most cases of alopecia unless the diagnosis is uncertain 1. When indicated, consider:

• For suspected alopecia areata with diagnostic uncertainty:

  • Fungal culture (to rule out tinea capitis)
  • Serology for lupus erythematosus
  • Serology for syphilis 1

• For other types of alopecia:

  • Thyroid function tests (for suspected telogen effluvium)
  • Complete blood count
  • Iron studies (though routine testing for iron status in alopecia areata is not recommended) 1, 2

Advanced Diagnostic Procedures

• Scalp biopsy:
  • Indicated primarily when scarring alopecia is suspected
  • Should be an early step in evaluation of any case with suspected scarring 3
  • Can help differentiate between non-scarring and scarring forms 4

Common Diagnostic Pitfalls

Several conditions may cause diagnostic difficulties when evaluating alopecia areata:

1. Trichotillomania - most common source of confusion; look for incomplete hair loss and firmly anchored broken hairs
2. Tinea capitis - may have subtle inflammation
3. Early scarring alopecia
4. Telogen effluvium
5. Anagen effluvium (drug-induced)
6. Systemic lupus erythematosus
7. Secondary syphilis 1

Psychological Assessment

• Evaluate psychological impact of hair loss
• Assess for anxiety and depression, which are more common in patients with moderate to severe hair loss 2
• Consider referral for psychological support when indicated 1, 5

Follow-up Recommendations

• Photography to document baseline and monitor progression
• Regular follow-up to assess treatment response
• Quality of life measures to evaluate impact of condition and treatment 5

Remember that alopecia can have significant psychological effects despite not directly impacting general health. Early diagnosis and appropriate management are essential for improving patient outcomes and quality of life 1, 6.