How should I manage a pruritic, tender scalp with associated hair loss?

Management of Pruritic, Tender Scalp with Hair Loss

The most critical first step is to clinically distinguish between alopecia areata (autoimmune patchy hair loss) and inflammatory scalp conditions like tinea capitis, seborrheic dermatitis, or scalp psoriasis, as this fundamentally determines your treatment approach. 1, 2

Immediate Diagnostic Approach

Key Clinical Features to Identify

Alopecia Areata (Non-Inflammatory):

• Round or oval patches of complete hair loss with smooth scalp 2, 3
• Exclamation mark hairs (short broken hairs with tapered ends) at patch margins—pathognomonic for active disease 2, 3
• Yellow dots visible on dermoscopy 2, 3
• Minimal to no scalp inflammation or scaling 1
• Nail pitting or ridging in approximately 10% of cases 2, 3

Inflammatory Scalp Conditions (More Likely with Tenderness/Itching):

• Tinea capitis: Scalp inflammation with scaling, though signs may be subtle; requires fungal culture for diagnosis 1, 4
• Seborrheic dermatitis/Psoriasis: Sharply demarcated erythematous plaques with silver-white scaling, significant pruritus 5, 6
• Scalp dysesthesia: Burning/itching without visible cutaneous disease, often neuropathic 7

Dermoscopy as First-Line Diagnostic Tool

Perform dermoscopy immediately—it is the single most useful non-invasive diagnostic tool. 2

• Yellow dots + exclamation mark hairs = alopecia areata 2
• Absence of these features suggests telogen effluvium, androgenetic alopecia, or inflammatory conditions 2

Laboratory Testing Algorithm

For clinically evident alopecia areata, no laboratory testing is needed. 1, 3

Order targeted tests only when:

• Diagnosis is uncertain after clinical examination and dermoscopy 1, 2
• Inflammatory scalp conditions are suspected 1

Specific tests to consider:

• Fungal culture: Mandatory if tinea capitis suspected (scalp inflammation + scaling) 1, 2
• Skin biopsy: For diffuse alopecia areata or early scarring alopecia when diagnosis remains unclear 1, 2
• Serum ferritin: If diffuse hair loss suggests telogen effluvium (most common nutritional deficiency) 2
• Vitamin D level: 70% of alopecia areata patients are deficient (<20 ng/mL) versus 25% of controls, with inverse correlation to disease severity 2
• TSH: To exclude thyroid disease as cause of hair loss 2
• Serology for lupus or syphilis: Only if systemic disease suspected 1, 2

Avoid ordering excessive laboratory panels when alopecia areata is clinically evident—this is a common pitfall. 2, 3

Treatment Algorithm

For Alopecia Areata (Patchy, Non-Inflammatory)

Limited patchy disease (<25% scalp involvement, <5 patches, <3 cm diameter):

1. Reassurance alone is legitimate as spontaneous remission occurs in 34-80% of patients within one year 1, 3
2. If patient desires intervention: Intralesional triamcinolone acetonide injections are first-line treatment (Strength of recommendation B) 1, 3, 8
   • Achieves 62% full regrowth rates in limited disease 3
   • Inject monthly until satisfactory response 3
   • Warn patients about pain during procedure and high relapse rates 8
3. Adjunctive therapy: Topical minoxidil 5% can be added but should not be used as monotherapy 3
4. Alternative if injections not tolerated: Clobetasol propionate 0.05% foam/cream twice daily (achieved ≥50% regrowth in 21% versus 3% placebo at 12 weeks) 3, 8

Extensive patchy disease or alopecia totalis/universalis:

• Contact immunotherapy is the best-documented treatment, though response rates are <50% in severe disease 1, 3
• Wig provision is appropriate (Strength of recommendation D) 1

For Inflammatory Scalp Conditions (Tender, Itchy, Scaling)

Tinea capitis:

• Requires oral antifungal therapy after fungal culture confirmation 2
• Topical treatments alone are insufficient 4, 6

Seborrheic dermatitis/Scalp psoriasis:

• Coal tar shampoos (2-10% coal tar solution) for pruritus control 5
• Salicylic acid 5-10% in ointment for keratolytic effect 5
• Topical corticosteroids (most frequently used): fast-acting with maximal efficacy in 3-4 weeks 5
• Imidazole antifungals if resistant to other treatments (addresses Pityrosporum overgrowth) 5

Scalp dysesthesia (neuropathic):

• Consider neuropathic pain medications if burning/itching without visible disease 7
• More common in geriatric patients, women, diabetics, and those with psychiatric history 7

Critical Pitfalls to Avoid

• Do not assume all itchy scalp with hair loss is alopecia areata—true alopecia areata has minimal inflammation and tenderness 1, 2
• Do not use intralesional steroids for androgenetic alopecia—the mechanism addresses autoimmune inflammation specific to alopecia areata 3
• Do not fail to perform fungal culture before treating suspected tinea capitis—incorrect diagnosis is the most common cause of treatment failure 2
• Do not overlook the psychological impact—alopecia areata causes considerable psychological and social disability warranting assessment for anxiety and depression 1, 2

Prognostic Counseling

• Disease severity at presentation is the strongest predictor: 68% of patients with <25% hair loss initially are disease-free at follow-up 3
• Childhood onset and ophiasis pattern (scalp margin involvement) carry poorer prognoses 1, 2
• Hair follicles remain preserved even in longstanding disease, maintaining potential for recovery 3