SCALP, ALOPECIA

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

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.

Congenital

Aplasia Cutis Congenita
Aplasia Cutis Congenita

LIPH Gene Mutation

Localized, Inflamed/Scarring

Tinea Capitis
Tinea Capitis

Bacterial Folliculitis

Cutaneous Lupus Erythematosus
Cutaneous Lupus Erythematosus

Dissecting Cellulitis of the Scalp
Dissecting Cellulitis of the Scalp

Lichen Planopilaris
Lichen Planopilaris

Tufted Folliculitis
Tufted Folliculitis

Alopecia Associated Pseudocyst of the Scalp
Alopecia Associated Pseudocyst of the Scalp

Localized, Uninflamed

Alopecia Areata
Alopecia Areata

Androgenetic Alopecia in Men

Tinea Capitis
Tinea Capitis

Hair Treatment Alopecia

Keratosis Follicularis Spinulosa Decalvans

Posterior Alopecia in a Newborn
Posterior Alopecia in a Newborn

Pressure Alopecia

Pseudopelade
Pseudopelade

Temporal Triangular Alopecia

Traction Alopecia
Traction Alopecia

Trichotillomania
Trichotillomania

Diffuse Thinning, Nonscarring (Usually in a Woman)

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.
Hormone-Related Alopecia

Hypothyroidism

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.

Diffuse, Extensive Hair Loss

Secondary Syphilis

Alopecia Totalis/Universalis
Alopecia Totalis/Universalis

Discoid Lupus Erythematosus (Courtesy Michael O. Murphy, MD)
Discoid Lupus Erythematosus of the Scalp

Systemic Lupus Erythematosus
Systemic Lupus Erythematosus

Dermatomyositis

Central Centrifugal Cicatricial Alopecia
Central Centrifugal Cicatricial Alopecia

Anagen Effluvium
Anagen Effluvium

Female Pattern Hair Loss
Female Pattern Hair Loss

Senescent Alopecia

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.
Frontal Fibrosing Alopecia

Receding Hairline

Male Pattern Hair Loss
Male Pattern Hair Loss

Frontal Fibrosing Alopecia (see picture just above)

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