What questions should be asked when evaluating a patient with alopecia?

Essential Questions When Evaluating a Patient with Alopecia

When evaluating alopecia, focus your history on distinguishing between non-scarring versus scarring patterns, identifying autoimmune triggers, assessing psychological impact, and ruling out systemic causes through targeted questioning about disease characteristics, family history, medications, and associated symptoms.

Clinical Presentation and Pattern Recognition

Hair Loss Characteristics

• Ask about the pattern of hair loss: Is it patchy, diffuse, or localized to specific areas like the scalp margin (ophiasis pattern)? 1
• Determine the time course: Was onset sudden or gradual? How long has the hair loss been present? 1
• Assess completeness: Is the hair loss complete in affected areas or incomplete with broken hairs? 1
• Inquire about exclamation mark hairs: Does the patient notice short broken hairs around the margins of bald patches? 1

Scalp Examination Findings

• Ask if the scalp appears normal or inflamed: Redness or inflammation suggests tinea capitis rather than alopecia areata 1
• Question about scalp symptoms: Is there itching, pain, scaling, or irritation? 1
• Determine if hair can be easily pulled out: Firmly anchored broken hairs suggest trichotillomania, while easily removable hairs may indicate alopecia areata 1

Family and Personal Medical History

Genetic and Autoimmune Factors

• Ask about family history of hair loss: Approximately 20% of alopecia areata patients have affected family members 1, 2
• Screen for autoimmune diseases: Does the patient have thyroid disease, vitiligo, lupus, or other autoimmune conditions? 1, 2
• Inquire about atopic disease: History of eczema, asthma, or allergies may indicate poorer prognosis 1

Age-Related Considerations

• Document age of onset: Childhood onset carries a worse prognosis than adult onset 1, 3
• For children specifically: Ask parents if they notice behavioral changes, withdrawal, low self-esteem, or school performance issues 1

Medication and Exposure History

Drug-Induced Causes

• Review all current medications: Certain drugs can cause anagen effluvium mimicking diffuse alopecia areata 1
• Ask about recent chemotherapy or systemic treatments: These can cause anagen effluvium 1
• Question about topical scalp products: Hair dyes, relaxers, or styling products may cause irritation 4

Behavioral and Traumatic Factors

• Screen for hair pulling behaviors: Trichotillomania often coexists with or mimics alopecia areata 1
• Ask about hairstyling practices: Tight braiding, extensions, or chemical treatments can cause traumatic alopecia 5

Systemic and Nutritional Assessment

Infectious and Systemic Diseases

• Ask about recent infections or illnesses: Fungal infections (tinea capitis) require specific questioning 1, 2
• Screen for syphilis risk factors: Secondary syphilis can present with patchy hair loss 1, 3
• Inquire about lupus symptoms: Joint pain, rash, photosensitivity suggest systemic lupus erythematosus 1

Hormonal and Metabolic Factors

• For women, ask about menstrual irregularities: Polycystic ovary syndrome can cause hair loss 2
• Question about signs of androgen excess: Acne, hirsutism, or irregular periods warrant hormonal evaluation 2
• Screen for thyroid symptoms: Weight changes, fatigue, or temperature intolerance suggest thyroid disease 2

Nutritional Deficiencies

• Ask about dietary habits: Poor nutrition may indicate vitamin D, zinc, or folate deficiency 2, 3
• Question about recent weight loss or restrictive diets: These can trigger telogen effluvium 1

Psychological and Quality of Life Impact

Emotional Assessment

• Directly ask how the hair loss affects them emotionally: Patients may feel self-conscious, conspicuous, angry, rejected, or embarrassed 1
• Screen for behavioral changes: Do they behave in a shy, cautious, aggressive, retreating, evasive, or defensive (SCARED) manner? 1
• Assess coping strategies: How are they managing the altered body image? 1
• Inquire about social impact: Has hair loss affected work, relationships, or social activities? 1

Support Systems

• Ask about disclosure: Have they told family and friends about their condition? Many struggle with this 1
• Determine if they need psychological support: Some patients are profoundly upset and require formal counseling 1
• For children, assess school impact: Are there signs of bullying or academic decline? 1, 6

Prognosis-Related Questions

Disease Severity Indicators

• Quantify extent of hair loss: Less than 25% scalp involvement has better prognosis than extensive loss 1, 3
• Ask about nail changes: Nail involvement occurs in approximately 10% of referred patients 1
• Determine if this is first episode or recurrence: Almost all patients experience multiple episodes 1
• Ask about previous treatment responses: History of treatment resistance suggests poorer prognosis 1

Common Diagnostic Pitfalls to Avoid

Critical distinction: The incomplete nature of hair loss and firmly anchored broken hairs in trichotillomania versus exclamation mark hairs in alopecia areata is the key differentiating feature 1, 3. Subtle scalp inflammation may indicate tinea capitis rather than alopecia areata 1. Diffuse presentations of alopecia areata are particularly challenging and may require biopsy for definitive diagnosis 1.

Important caveat: While investigations are unnecessary in most cases of alopecia areata, when diagnosis is uncertain, consider fungal culture, skin biopsy, lupus serology, or syphilis serology 1, 2. Dermoscopy looking for yellow dots, exclamation mark hairs, and cadaverized hairs can aid diagnosis non-invasively 1, 2, 3.