By Gary M. White, MD
Alopecia means the loss of hair. It is not a specific diagnosis, but instead a clinical sign seen in a wide variety of disorders.
The hair pull test (HPT) is widely used, but of uncertain clinical value. It is said to be best utilized to monitor the advancing edge of alopecia areata, and confirming the diagnosis of acute cases of telogen effluvium, anagen effluvium and loose anagen syndrome. It has a low sensitivity and high interobserver variability [JAAD 2017;76;472]. The HPT is performed as follows: The clinician selects 50-60 hairs and holds them close to the scalp between the thumb, index finger and long finger. The clinician then firmly pulls on the hairs using slow traction as the fingers slide down the hair shaft, avoiding a fast and forceful tug. Any broken hairs are discarded. Only those extracted from the root are counted. If fewer than 10% of hairs are removed, then the hair loss is considered normal. One study found that 97% of normal controls had 2 or fewer hairs on the HPT [JAAD 2017;76;472]. Multiple areas of the scalp may be tested. AA may only affect selected areas. Telogen or anagen effluvium may involve the scalp more diffusely. There is no need to restrict hair washing or brushing prior to testing.
Aplasia Cutis Congenita
LIPH Gene Mutation
Cutaneous Lupus Erythematosus
Dissecting Cellulitis of the Scalp
Alopecia Associated Pseudocyst of the Scalp
Androgenetic Alopecia in Men
Hair Treatment Alopecia
Keratosis Follicularis Spinulosa Decalvans
Posterior Alopecia in a Newborn
Temporal Triangular Alopecia
General questions: Any recent severe stress, e.g., labor and delivery, car accident, death of a loved one?
General blood workup: ferritin, TSH, ANA, DHEAS, testosterone.
See also general workup for hair loss in a woman.
Anagen Effluvium. See below.
Lupus Erythematosus, some forms.
Telogen Effluvium. Hair loss here usually occurs across the front.
Hormone-Related. This patient's DHEAS was 9 times normal.
Low Iron. Measure the ferritin. It should be above 40 in a woman with thinning hair.
Drug-Induced Alopecia, e.g., retinoids. May occur, for example, at the end of a course of isotretinoin for acne.
Discoid Lupus Erythematosus (Courtesy Michael O. Murphy, MD)
Systemic Lupus Erythematosus
Central Centrifugal Cicatricial Alopecia
Female Pattern Hair Loss
Atrichia with Papular Lesions
Sarcoidosis. This is a scarring type of alopecia. Granulomas are seen on biopsy. [Dermatology Online Journal]
Receding Hairline in a Woman
Chronic Telogen Effluvium
Male Pattern Androgenetic Alopecia in a Woman
Frontal Fibrosing Alopecia. This is most common in older women, causes a loss of hair anteriorly, and is paired with loss of eyebrow hair.
Male Pattern Hair Loss
Frontal Fibrosing Alopecia (see picture just above)
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