What is the evaluation for alopecia (hair loss)?

From the Guidelines

A thorough hair loss evaluation should begin with a detailed medical history and physical examination, followed by targeted laboratory tests and potentially a scalp biopsy, as outlined in the British Association of Dermatologists' guidelines for the management of alopecia areata 2012 1. When evaluating hair loss, it is essential to consider the patient's medical history, including onset and progression of hair loss, family history, medical conditions, medications, and recent life stressors.

• The physical examination should assess the pattern of hair loss, scalp condition, and hair characteristics.
• Laboratory tests may include complete blood count, thyroid function tests, iron studies (ferritin, TIBC), vitamin D levels, and sometimes hormone panels (testosterone, DHEAS) for women.
• A pull test may be performed to assess active shedding, and dermoscopy can evaluate the scalp and hair follicles in detail.
• In some cases, a scalp biopsy may be necessary to determine the specific type of hair loss, such as alopecia areata, which can be treated with intralesional corticosteroids, including triamcinolone acetonide, as reported by Porter and Burton 1. The evaluation process helps distinguish between common causes like androgenetic alopecia, telogen effluvium, alopecia areata, or scarring alopecias, and early evaluation is crucial as many hair loss conditions respond better to treatment when addressed promptly, and some causes may indicate underlying health issues requiring separate treatment.
• Intralesional corticosteroids, such as triamcinolone acetonide, can stimulate hair regrowth at the site of injection in some patients with alopecia areata, with a response rate of 62% in patients with fewer than five patches of < 3 cm in diameter, as reported in a study from Saudi Arabia 1.
• The use of a needleless device, such as the Dermajet, can also administer intralesional corticosteroids, with a reported regrowth of hair at 12 weeks in 62% of patients 1.

From the FDA Drug Label

For use by men only. Do not use if • your amount of hair loss is different than that shown on the side of this carton or your hair loss is on the front of the scalp. Minoxidil topical solution 5% is not intended for frontal baldness or receding hairline • you have no family history of hair loss • your hair loss is sudden and/or patchy • you do not know the reason for your hair loss

The evaluation of hair loss for minoxidil topical solution 5% should consider the following key points:

• Family history of hair loss: Minoxidil topical solution 5% is intended for men with a family history of hair loss.
• Pattern of hair loss: The product is not intended for frontal baldness or receding hairline.
• Sudden or patchy hair loss: Minoxidil topical solution 5% is not recommended for sudden or patchy hair loss.
• Known reason for hair loss: The product is intended for men who know the reason for their hair loss. It is essential to consult a doctor before using minoxidil topical solution 5% to evaluate the hair loss and determine if the product is suitable for use 2.

From the Research

Hair Loss Evaluation

Hair loss, also known as alopecia, is a common condition that affects millions of people worldwide. The evaluation of hair loss involves a comprehensive history, physical examination, and targeted laboratory testing to determine the underlying cause.

Types of Hair Loss

• Nonscarring alopecias, which include:
  • Diffuse alopecias (e.g., telogen and anagen effluvium) 3, 4, 5
  • Patterned hair loss (e.g., androgenetic alopecia) 3, 4
  • Focal hair loss (e.g., alopecia areata, tinea capitis, traction alopecia) 3, 4
• Scarring alopecias, which are best evaluated by a dermatologist 4

Diagnosis and Treatment

• A comprehensive history and physical examination can help elucidate the underlying cause of hair loss, including malnutrition, autoimmune diseases, and endocrine disease 3
• Targeted laboratory testing may be necessary to confirm the diagnosis 3
• Treatment options vary depending on the underlying cause, but may include:
  • Minoxidil for androgenetic alopecia 3, 4
  • Oral finasteride for male patients with androgenetic alopecia 3
  • Intralesional corticosteroid or oral immunosuppressant therapy for alopecia areata 3, 4
  • Oral antifungals for tinea capitis 3, 4
  • Decreasing tension on the hair for traction alopecia 3, 4

Special Considerations

• Hair loss can have a significant impact on a patient's quality of life, including anxiety, depression, and lower work productivity and quality-of-life scores 3
• Educating patients about expected hair changes, treatment options, and realistic outcomes can help patients feel that they are being listened to and that their hair loss is being taken seriously 3
• In children, hair loss can be caused by infection, autoimmune conditions, nutrition, medications, trauma/traction, or underlying genetic disorders, and diagnosis begins with a good history, physical examination, and use of dermoscopy or trichoscopy 6