Fig. 14.1
Upper panel reveals a middle-aged woman with severe diffuse alopecia secondary to telogen effluvium. Lower panel reveals an 18-year-old woman with severe early onset androgenetic alopecia
Case
A 55-year-old white woman presents with the complaint “I am losing my hair,” or “my hair is thinning,” or “my hairdresser told me that I’m losing my hair.”
These and other similar statements are commonly heard by dermatologists and often cause a slight state anxiety. Questions that often arise in the mind of the dermatologist include:
Will the physical findings be diagnostic?
Will I need to do a biopsy,
Will I have to do hormonal and systemic evaluation?
Will the patient have one disorder or more?
Will I be able to help the patient?
In this presentation, physical examination and histological findings may be only moderately helpful. History, especially, if provided accurately by the patient, is extremely helpful and is able to put the patient in one of two major categories of hair loss.
History
Increased hair shedding is characteristic of diffuse alopecia areata AA and telogen effluvium TE . Patients with TE and AA either volunteer or respond to questioning by admitting that they are “losing hair” or “shedding more hair than usual” for a definable period of time.
On the other hand, patients with hair loss secondary to androgenetic alopecia, systemic causes, or drugs report progressive hair thinning over a longer period of time of several months to a few years that may be brought to their attention by a hairdresser, friend, or relative.
Further questioning includes:
Hormonal status (menopause, hormone replacement, and history of surgical removal of the ovaries)
List of medications and their duration
History of recent febrile illness, surgery, and other traumatic experiences
Family history of scalp hair thinning in siblings and both parents
Detailed medical history
Hair styling techniques (more applicable in African–American women)
Physical Examination
Physical examination of the scalp is aimed at determining the following:
Presence of skin surface findings such as erythema and scaling (this chapter presupposes that the scalp appearance is normal)
Confirming that the hair loss is diffuse, rather than patchy (patchy hair loss is discussed in Chap. 13)
Assessing the degree of hair loss with the realization that if hair thinning can be appreciated by simple inspection, then hair loss is significant
Assessing the predominant sites of involvement, specifically, whether the hair loss is diffuse or favors the top or vertex of the scalp
Assessing the degree of telogen shift (characteristic of both active AA and active TE) by a gentle hair pull test
Looking for signs of hyperandrogenization such as hirsutism and acne
Looking for signs of alopecia areata involving other hairy areas such as the axilla and pubic area
Looking for skin signs of systemic disease, such as iron deficiency and hyper- or hypothyroidism , which are well known to dermatologists.
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