What initial questions should be asked to a patient presenting with alopecia (hair loss) and pale, yellowish skin?

Initial Assessment of Hair Loss with Pale, Yellowish Skin

Ask first about symptoms of hypothyroidism, including cold intolerance, fatigue, weight gain, and constipation, as this presentation strongly suggests thyroid dysfunction causing both hair loss (including eyebrow loss) and carotenemia or myxedema.

Critical First Questions

Thyroid-Related Symptoms

The combination of hair loss (particularly involving eyebrows) and yellowish, pale skin is highly suggestive of hypothyroidism. While the provided guidelines focus on alopecia areata, this specific presentation requires immediate consideration of systemic causes:

• Cold intolerance - a hallmark symptom of hypothyroidism
• Fatigue and lethargy - common metabolic manifestations
• Weight changes - typically weight gain despite poor appetite
• Constipation - reflecting slowed metabolism
• Dry skin - beyond the yellowish discoloration noted

Hair Loss Characteristics

Following the British Association of Dermatologists' approach, obtain specific details about the hair loss pattern 1:

• Onset and duration - sudden vs. gradual hair loss 2
• Distribution pattern - diffuse thinning vs. patchy loss 1
• Progression rate - stable, worsening, or improving 2
• Eyebrow involvement - lateral third loss is classic for hypothyroidism, though full eyebrow loss occurs in alopecia universalis 1

Family and Medical History

• Family history of hair loss - present in approximately 20% of alopecia areata cases 1, 2
• Personal or family history of autoimmune disease - alopecia areata associates with other autoimmune conditions 1
• Medication review - drugs causing anagen effluvium 1, 2

Skin Changes Beyond Hair Loss

• Yellowish discoloration - determine if this is carotenemia (hypothyroidism, dietary) or jaundice (hepatic/hemolytic)
• Pallor characteristics - anemia vs. decreased perfusion
• Texture changes - dry, coarse skin suggests hypothyroidism
• Presence of scaling or inflammation - tinea capitis shows subtle scalp inflammation 1

Physical Examination Priorities

Scalp Assessment

• Look for exclamation mark hairs - short broken hairs with fractured tips indicating alopecia areata 1, 2
• Check for erythema or inflammation - subtle in tinea capitis 1, 2
• Assess for scaling - suggests fungal infection 1, 2
• Perform dermoscopy if available - yellow dots indicate active alopecia areata progression 1

Systemic Examination

• Nail examination - involved in approximately 10% of alopecia areata patients 1, 2
• Thyroid palpation - assess for goiter
• Lymph node examination - occipital and cervical nodes 2
• Skin texture assessment - myxedematous changes

Common Diagnostic Pitfalls to Avoid

• Misdiagnosing diffuse alopecia areata as telogen effluvium - both can present with diffuse thinning 1, 2
• Overlooking systemic disease - the yellowish, pale skin is a red flag that distinguishes this from typical alopecia areata 3
• Failing to recognize trichotillomania - broken hairs remain firmly anchored unlike exclamation mark hairs 1, 2
• Missing subtle tinea capitis - inflammation may be minimal 1, 2

When to Investigate Further

While investigations are unnecessary in most typical alopecia areata cases 1, this presentation with systemic features (yellowish, pale skin) warrants:

• Thyroid function tests - TSH, free T4 for suspected hypothyroidism
• Complete blood count - assess for anemia causing pallor
• Liver function tests - if jaundice suspected rather than carotenemia
• Serology for lupus or syphilis - only when diagnosis is uncertain 1
• Fungal culture - if tinea capitis suspected 1

Note: Routine screening for autoimmune disease or iron deficiency is not recommended for typical alopecia areata 1, but the presence of systemic symptoms (yellowish, pale skin) changes this calculus and mandates targeted investigation of underlying systemic disease.