What is the best way to document a patient's symptoms and medical history when describing hair loss with bald spots, considering their age, sex, and relevant medical history, including previous diagnoses or treatments for hair loss or scalp conditions, such as autoimmune disorders or skin conditions like lupus (Systemic Lupus Erythematosus), rheumatoid arthritis, psoriasis, or eczema?

Documenting Hair Loss with Bald Spots in Clinical Notes

When documenting hair loss with bald spots, describe the pattern as "patchy hair loss" or "focal alopecia" and specify key clinical features including the presence or absence of exclamation mark hairs, scalp inflammation, scaling, and nail changes, while noting relevant patient demographics and associated autoimmune conditions. 1, 2

Essential Documentation Elements

Pattern Description

• Document whether the hair loss is scarring or non-scarring, as this fundamentally directs all diagnostic and therapeutic decisions 2
• For patchy hair loss, specify the location (e.g., "multiple well-demarcated patches on vertex and occipital scalp") and estimate the percentage of scalp involvement 1, 3
• Note whether the pattern is diffuse, patterned, or focal, as these categories guide differential diagnosis 4

Critical Physical Examination Findings

• Exclamation mark hairs (short broken hairs with tapered bases around expanding patches) are pathognomonic for alopecia areata and must be documented if present 1, 2, 3
• Document scalp appearance within bald spots: normal-appearing skin suggests alopecia areata, while scaling or inflammation raises concern for tinea capitis or scarring alopecia 2, 3
• Nail changes (pitting, ridging, or dystrophy) occur in approximately 10% of alopecia areata patients and should be documented 1
• Perform and document a gentle hair pull test at patch margins—easily removed hairs indicate active, expanding disease 1, 3

Patient Demographics and Context

• Age and sex are critical, as androgenetic alopecia patterns differ by gender, and childhood onset of alopecia areata carries poorer prognosis 1, 3
• Family history of hair loss or autoimmune disease should be documented, as approximately 20% of alopecia areata patients have affected family members 1
• Document duration of current episode, as this affects prognosis (34-50% of limited patchy alopecia areata resolves within one year) 1, 3

Associated Medical Conditions

• Autoimmune diseases including thyroid disease, lupus erythematosus, vitiligo, and rheumatoid arthritis associate with alopecia areata and must be documented 5, 1
• Systemic lupus erythematosus can cause both scarring and non-scarring alopecia 1
• Document any medications that may cause hair loss, including chemotherapy, anticoagulants, and beta-blockers 1

Differential Diagnosis Considerations to Document

Key Distinguishing Features

• Trichotillomania shows incomplete patches with firmly anchored broken hairs that remain in anagen phase, unlike exclamation mark hairs 1, 2
• Tinea capitis presents with scalp inflammation and scaling requiring fungal culture 1, 3
• Telogen effluvium typically shows diffuse thinning triggered by physiologic or emotional stress 1, 6
• Secondary syphilis presents with patchy "moth-eaten" hair loss 1

Recommended Documentation Template

Document using this structure:

• Chief complaint: "Patchy hair loss for [duration]"
• Pattern: Focal/patchy vs. diffuse; scarring vs. non-scarring
• Physical findings: Presence/absence of exclamation mark hairs, scalp inflammation, scaling, nail changes
• Pull test result: Positive (active disease) or negative at patch margins
• Extent: Percentage of scalp involvement, specific locations
• Associated findings: Autoimmune disease history, family history, medication use
• Dermoscopic findings (if performed): Yellow dots, exclamation mark hairs, cadaverized hairs, black dots 1

Common Documentation Pitfalls to Avoid

• Do not use vague terms like "some hair loss"—quantify the extent and specify the pattern 2
• Do not omit the pull test, as this simple bedside test indicates disease activity 1, 3
• Do not fail to document nail examination, as nail changes support the diagnosis of alopecia areata 1
• Do not overlook psychological impact—document mental health screening, as alopecia can cause considerable psychological and social disability 1, 2, 4