Evaluating Patients with Alopecia

Clinical Presentation and Pattern Recognition

The pattern of hair loss can be patchy, diffuse, or localized to specific areas, and determining the time course and completeness of hair loss is crucial for diagnosis 1, 2
Assessing for exclamation mark hairs and inquiring about scalp symptoms such as itching, pain, scaling, or irritation can help differentiate between conditions 1, 2
The British Journal of Dermatology recommends examining the scalp for signs of inflammation or infection, and determining if hair can be easily pulled out 1, 2

Approximately 20% of alopecia areata patients have affected family members, and screening for autoimmune diseases such as thyroid disease, vitiligo, or lupus is essential 2, 3
Inquiring about atopic disease history, such as eczema, asthma, or allergies, can indicate a poorer prognosis 2
The age of onset is an important factor, with childhood onset carrying a worse prognosis than adult onset 2, 4

Certain medications can cause anagen effluvium, mimicking diffuse alopecia areata, and reviewing all current medications is necessary 1, 2
Recent chemotherapy or systemic treatments can cause anagen effluvium, and questioning about topical scalp products is also important 1, 2
Screening for hair pulling behaviors, such as trichotillomania, is crucial, as it can coexist with or mimic alopecia areata 1, 2

Inquiring about recent infections or illnesses, such as fungal infections, and screening for syphilis risk factors can help identify underlying causes 1, 2, 3
Assessing for lupus symptoms, such as joint pain, rash, or photosensitivity, is essential, as systemic lupus erythematosus can present with patchy hair loss 1, 2
For women, asking about menstrual irregularities and questioning about signs of androgen excess can help identify hormonal imbalances contributing to hair loss 3

Directly asking how the hair loss affects the patient emotionally and screening for behavioral changes can help assess the psychological impact 1
Assessing coping strategies and inquiring about social impact can help identify patients who require additional support 1
Determining if the patient needs psychological support and assessing school impact for children can help provide comprehensive care 1

Quantifying the extent of hair loss and asking about nail changes can help determine disease severity and prognosis 2, 4
Determining if this is the first episode or recurrence and asking about previous treatment responses can help identify patients with a poorer prognosis 1, 2
The British Journal of Dermatology recommends considering fungal culture, skin biopsy, lupus serology, or syphilis serology when diagnosis is uncertain 1, 2, 3