Approach to the patient with hair loss

Kaelynn Workman, BS,a,b and Melissa Piliang, MDb

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Publication of this supplement was supported in part by educational grants from Pfizer Inc. and Lilly USA, LLC.

Hair loss is a common complaint among both men and women and is associated with significant
psychologic distress. Due to the varied causes, it is important to correctly diagnose the type of alopecia a
patient is experiencing to ensure tailoring of treatment. This continuing medical education article describes
the approach to diagnose alopecia based on current clinical practice and standards. ( J Am Acad Dermatol
2023;89:S3-8.)

Key words: alopecia; diagnosing alopecia; general dermatology; hair and scalp disorders; hair loss; work-
up of patient with alopecia.

INTRODUCTION could help either ameliorate or heighten concerns of

Hair loss, medically known as alopecia, is a nutritional deficiency, inciting psychologic stressors
complex concern wrought with negative emotions and acquired defects of the hair shaft that may be
and frustration for the patient.1 Due to the multitude contributing to alopecia.2 Further, it is important to
of causes and the great desire by the patient to assess the timeline of the hair loss, how the hair loss
remedy the issue, it is important to have an appro- began and the duration of time over which the hair
priate diagnostic work-up to ensure that the treat- loss occurred. Associated scalp symptoms such as
ment addresses the underlying cause of the alopecia. burning, itching, tenderness, erythema, and scaling
This article will review the recommended guidelines are important to identify along with systemic symp-
and approaches when working-up a patient with toms that may point to an underlying disease pro-
alopecia. cess.3 In frontal fibrosing alopecia and alopecia
areata, other hair-bearing areas such as the eyebrows,
HISTORY eyelashes, underarm, and groin hair may be affected.
Clinical history gathering remains the first step in Thus, it is important to inquire on these areas in
approaching any diagnosis. A comprehensive history addition to the scalp. A full medication reconciliation
should include detailed inquiry regarding nutritional, should also be performed to identify all prescription
family, psychosocial, and hair care habits (Fig 1). This and over the counter medications, as many

From the Case Western Reserve University School of Medicine Accepted for publication May 10, 2023.
Cleveland, Ohioa; and Dermatology and Plastic Surgery Insti- Correspondence and reprint requests to: Melissa Piliang, MD,
tute, Cleveland Clinic Foundation, Cleveland, Ohio.b Dermatology and Plastic Surgery Institute, Cleveland Clinic
Funding sources: None. Foundation, 9500 Euclid Ave e A61, Cleveland, OH 44123.
IRB approval status: Not applicable. E-mail: pilianm@ccf.org.
Disclosures: Author Workman has no conflicts to disclose. 0190-9622/$36.00
Dr Piliang has the following relationships with Eli Lilly and Ó 2023 Published by Elsevier Inc. on behalf of the American
Company and Pfizer, Inc: Eli Lilly and Company (Investigator/No Academy of Dermatology, Inc.
Compensation); Pfizer, Inc. (Advisory Board/Honoraria); Pfizer, https://doi.org/10.1016/j.jaad.2023.05.040
Inc. (Investigator/No Compensation.) Date of release: August 2023.
Patient consent: Not applicable. Expiration date: August 2026.

S3
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AUGUST 2023

medications are known to contribute to induction or gold standard for definitively diagnosing scarring
exacerbation of hair loss in the form of telogen alopecias.
effluvium (Table I). In addition to personal history,
family history proves useful, especially if a diagnosis LABORATORY EVALUATION
such as alopecia areata or androgenetic alopecia is While this CME article discusses pertinent labs
suspected.2,3 Gynecological and reproductive history to obtain when diagnosing alopecia, it is impor-
are important as hormonal abnormalities can precip- tant to note there is not a standard and widely
itate telogen effluvium or accepted laboratory panel
indicate androgenetic alope- among dermatologists, and
cia and metabolic syndrome/ CAPSULE SUMMARY
any labs obtained vary from
polycystic ovary syndrome.2 physician to physician and
d
Diagnosing alopecia requires a are often based in physician
comprehensive approach and should opinion and preference.
VISUAL PATTERN include a thorough history, scalp, and
RECOGNITION OF With that being said, the
hair examination, and when necessary, following labs listed are a
HAIR LOSS laboratory analysis and biopsy.
To evaluate hair loss clin- general suggestion and
ically, visual inspection re- d Dermatologists should be aware of how should be modified de-
mains a cornerstone of to categorize an alopecia, along with the pending on the patient and
evaluation. Hair loss be- characteristic clinical and physician involved.
comes most noticeable to histopathological signs and symptoms A complete blood cell
patients when scalp hair associated with the alopecia count and comprehensive
density is reduced by 50%. 2 classifications. metabolic panel is always
Visual inspection should good to gather as it is a
encompass noting where reflection of general health.
the hair loss is occurring and if the loss is diffuse In women with suspected androgenetic alopecia,
or patchy. It should also encompass taking note of dehydroepiandrosterone sulfate, and testosterone
the general hair density, the pattern of hair loss and should be obtained, especially if irregular menses,
3
the integrity of the hair fibers (Figs 3 to 5). Further, it acne, or hirsutism is present.3,9 A ferritin level aids in
is important to note the presence of scale, crust or assessment of excessive hair shedding secondary to
pustules on the scalp as these signs can indicate an iron deficiency anemia, although iron, total iron-
underlying infectious process that requires adequate binding capacity, and transferrin saturation may be
control in order to address the alopecia. In such more accurate to assess for iron deficiency anemia due
cases, scalp scrapings and culture are imperative. 4,5 to the elevation of ferritin in inflammatory processes as
Lastly, assessment for the absence or presence of an acute phase reactant.10 Due to the role of vitamin D
follicular ostia should be done, as loss of follicular in hair follicle cycling, adequate vitamin D levels
ostia is one of the cardinal signs of cicatricial should be assessed.2,9 Additional laboratory studies
alopecia. When examining the scalp visually, there should be directed by the history. In patients who have
are a number of clinical tools that aid in diagnosis. symptoms of thyroid disease, a thyroid-stimulating
Wood’s lamp uses electromagnetic wavelengths in hormone should be performed. In patients who eat a
the spectra of 320 to 450 nm to identify perifollicular restricted diet, other nutritional labs such as zinc or B12
scaling that may be present in cicatricial alopecias, could be obtained.9
along with fungal or bacterial infections via fluores-
cent color change.6 Trichoscopy remains another SCARRING AND NONSCARRING
important tool in diagnosing and following hair and ALOPECIAS
scalp disorders, as certain cutaneous microscopic To understand how to properly diagnose alope-
changes are associated and/or specific to certain cia, it is important to understand the different types
types of alopecia.5,7 Trichoscopy can also prove of alopecia. Alopecia can be characterized as cica-
useful for diagnosing structural hair shaft disorders tricial (scarring) or noncicatricial (nonscarring), with
and can assist in ruling out alopecia caused by hair nonscarring alopecia being clinically characterized
fragility or damaging hair care practices.8 Further, by preserved follicular ostia and the potential for hair
there are also other tools and techniques that assist regrowth and scarring alopecias being clinically
in diagnosis, such as the hair pull test, the tug characterized by follicular drop-out, loss of follicular
test, and trichograms.3 Lastly, biopsy remain the openings, and permanent absence of hair.11 Scarring
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VOLUME 89, NUMBER 2S

Fig 1. Past medical history for diagnosing alopecias. Flowchart of pertinent medical and social
history for diagnosing alopecia.

alopecias can be split into primary and secondary alopecia, central centrifugal cicatricial alopecia, and
alopecias and primary alopecias can further be split lichen planopilaris are examples of primary cicatri-
into a lymphocytic process, neutrophilic process and cial alopecias.5 Clinical symptoms such as burning,
mixed inflammatory process (Fig 2).11 While primary itching, and scalp tenderness are associated with the
cicatricial alopecias result from a direct inflammatory primary cicatricial alopecias but can also be present
insult to the hair follicle, secondary alopecias result in alopecia areata, a nonscarring alopecia.12
from chronic and progressive scarring and inflam- Therefore, it is important to determine if the patient
mation of the hair follicle secondary to an external is experiencing any of these symptoms, as this may
process.12 Traction alopecia and chemotherapy help hone in on the diagnosis.
induced alopecia are examples of secondary cicatri-
cial alopecias and result from continuous exposure BIOPSY
of the follicle to injurious factors, causing scarring To definitively diagnose scarring alopecic disor-
and inflammation in the follicle.5 Frontal fibrosing ders, a biopsy remains standard. At a minimum, a
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AUGUST 2023

Table I. Medication induced alopecia

Medications associated
with alopecia Class Medication
Telogen effluvium 1. ACE-inhibitors 1. Lisinopril, captopril
2. Beta-blockers 2. Metoprolol, propranolol, timolol
3. Antidepressants 3. Maprotiline, trazodone, fluoxetine, paroxetine,
4. Antiepileptics buspirone
5. Antipsychotics 4. Valproic acid, divalproex, carbamazepine, phenytoin
6. Mood stabilizers 5. Haloperidol, olanzapine, risperidone, clonazepam
7. Antifungals 6. Lithium therapy
8. Anticoagulants 7. Terbinafine
9. Retinol and retinoids 8. Heparin, acenocoumarol, warfarin, phenindione,
10. Antiretrovirals rivaroxaban, dabigatran, apixaban
11. Oral contraceptives 9. Acitretin, etretinate, isotretinoin
12. Dopamine agonists 10. Indinavir, lamivudine, cidofovir
13. Triazoles 11. OCPs containing androgenic progestin and or
14. Analgesics/anti-inflammatory high dose progesterone
15. H2 antagonist 12. Levodopa, bromocriptine
13. Fluconazole, clotrimazole
14. Mesalazine, piroxicam, Sulfasalazine
15. Cimetidine
Anagen effluvium 1. Antimicrotubule agents 1. Vincristine, vinblastine
2. Topoisomerase inhibitors 2. Etoposide, topotecan, irinotecan, epirubicin
3. Alkylators 3. Cyclophosphamide, ifosfamide, busulfan, thiotepa,
4. Antimetabolites lomustine
5. Tyrosine kinase inhibitor 4. Azathioprine, 5-fluorouracil, cytarabine, gemcitabine
6. Sonic hedgehog pathway inhibitor 5. Sorafenib
7. Heavy metals 6. Vismodegib
8. Taxanes 7. Thallium, gold, bismuth, arsenic
9. Antineoplastic antibiotic 8. Docetaxel, paclitaxel
10. Anthracycline 9. Bleomycin, dactinomycin
10. Doxorubicin, daunorubicin

Drugs and specific medications that cause or are associated with alopecia.
ACE, Angiotensin-converting enzyme; OCP, oral contraceptive pills.

Fig 2. Categorization of alopecia. Flowchart of cicatricial and noncicatricial alopecias.

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VOLUME 89, NUMBER 2S

Fig 3. Nonscarring alopecias. Visual and descriptive depiction of the location and pattern of
hair loss among the noncicatricial alopecias.

Fig 4. Scarring alopecias. Visual and descriptive depiction of the location and pattern of hair
loss among the cicatricial alopecias.

4 mm punch biopsy into the fat is required. For selection. For nonscarring alopecias, the biopsy
scarring alopecias, the biopsy should be taken from should be taken from an area of activity. For
the area of inflammation with residual hair, with specimen sectioning and preparation, it is generally
trichoscopic guidance proving helpful for site accepted that combining both vertical and
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AUGUST 2023

Fig 5. Trichodystrophy. Visual and descriptive depiction of the pattern of hair structure
disorders that lead to increased fiber fragility and alopecia.

horizontally sectioned scalp biopsies maximizes the 4. Al Aboud AM, Crane JS. Tinea capitis. StatPearls; 2022. https://
diagnostic yield. Transverse sections are preferred in www.ncbi.nlm.nih.gov/books/NBK536909/
5. Miteva M. Alopecia. Elsevier; 2019.
cases of nonscarring alopecias and either transverse 6. Al Aboud DM, Gossman W. Wood’s light. StatPearls; 2022.
or vertical sectioning can be used in cases of https://www.ncbi.nlm.nih.gov/books/NBK537193/
cicatricial alopecias.13 Due to the detection of 7. Miteva M, Tosti A. Hair and scalp dermatoscopy. J Am Acad
autoantibody types in cicatricial alopecias, direct Dermatol. 2012;67(5):1040-1048. https://doi.org/10.1016/J.JAAD.
immunofluorescence has been considered to be of 2012.02.013
8. Quaresma MV, Martinez Velasco MA, Tosti A, et al. Hair
use in diagnosing cicatricial alopecias, however, it is breakage in patients of African descent: role of dermoscopy.
now accepted that direct immunofluorescence is of Skin Appendage Disord. 2015;1(2):99-104. https://doi.org/10.
limited use except when discoid lupus erythemato- 1159/000436981
sus is considered.14 9. Jackson AJ, Price VH. How to diagnose hair loss. Dermatol Clin.
2013;31(1):21-28. https://doi.org/10.1016/J.DET.2012.08.007
10. Olsen EA, Reed KB, Cacchio PB, et al. Iron deficiency in female
CONCLUSION pattern hair loss, chronic telogen effluvium, and control
Ultimately, diagnosing alopecia is a multimodal groups. J Am Acad Dermatol. 2010;63(6):991-999. https://doi.
approach and there are many tools that can help org/10.1016/J.JAAD.2009.12.006
obtain an accurate diagnosis. These include a 11. Bern
ardez C, Molina-Ruiz AM, Requena L. Histologic features
of alopecias: part II: scarring alopecias. Actas Dermosifiliogr.
comprehensive history, visual inspection, labora-
2015;106(4):260-270. https://doi.org/10.1016/J.AD.2014.06.016
tories, trichoscopy, and biopsy. 12. Rongioletti F, Christana K. Cicatricial (scarring) alopecias: an
overview of pathogenesis, classification, diagnosis, and treat-
REFERENCES ment. Am J Clin Dermatol. 2012;13(4):247-260. https://doi.org/
1. Hunt N, McHale S. The psychological impact of alopecia. BMJ. 10.2165/11596960-000000000-00000
2005;331(7522):951-953. https://doi.org/10.1136/BMJ.331.7522.951 13. Yadav D, Mahajan S, Agarwal S, Khandpur S, Pandey A,
2. Mubki T, Rudnicka L, Olszewska M, et al. Evaluation and Singh MK. Vertical versus transverse sectioning in histopath-
diagnosis of the hair loss patient: part I. History and clinical ological diagnosis of alopecia: a comparative study. Indian J
examination. J Am Acad Dermatol. 2014;71(3):415.e1-415.e15. Dermatol Venereol Leprol. 2023;89(1):126-129. https://doi.org/
https://doi.org/10.1016/J.JAAD.2014.04.070 10.25259/IJDVL_1145_2021
3. Gordon K, Tosti A. Alopecia: evaluation and treatment. Clin 14. Trachsler S, Tr€
ueb RM. Value of direct immunofluorescence for
Cosmet Investig Dermatol. 2011;4:101-106. https://doi.org/10. differential diagnosis of cicatricial alopecia. Dermatology. 2005;
2147/CCID.S10182 211(2):98-102. https://doi.org/10.1159/000086436