Alopecia

Diagnosis/Definition

• Hair loss can be further classified as localized or diffuse and scarring or nonscarring.

Initial Diagnosis and Management

• History and physical examination, including determination of the pattern of hair loss
• Localized, Nonscarring Alopecia
• Tinea capitis presents with erythema, scaling and broken hair shafts on exam. Evaluation includes KOH or fungal culture of broken hair shaft and appropriate oral antifungal treatment.
• Alopecia areata presents as smooth round bald patches in the scalp, beard area, or eyebrows. Evaluation includes TSH, CBC, and RPR to evaluate for associated autoimmune disease or syphilis. The condition is self limited but referral for treatment is appropriate for multiple areas of involvement or large surface area involved.
• Traumatic alopecia includes trichotillomania and traction alopecia. Treatment involves pinpointing the underlying cause and emphasizing behavior modification.
• Diffuse, Nonscarring Alopecia
• Telogen effluvium is diffuse hair loss caused by any condition or situation that shifts the normal distribution of follicles in anagen (growing phase) to a telogen (hair no longer living phase)-predominant distribution. Usually begins two to four months after the causative event and lasts for several months. If telogen effluvium is suspected, a thorough history should be obtained to elucidate recent event (childbirth, crash or liquid protein diets, high fever, major surgery, severe psychological stress) Condition is self-limited and treatment is based on identifying and treating or correcting the underlying cause.
• Androgenetic alopecia (common balding). Male pattern alopecia is characterized by a receding hairline and/or hair loss on the top of the head. A similar type of hair loss in women, female pattern alopecia, results in thinning hair on the vertex (top) of the scalp or widening of the part but is generally less severe than occurs in males; no medical treatment required; patient may purchase minoxidil lotion (over the counter) for cosmesis and should use it for up to 4 months to see if it is effective.
• Other causes of diffuse nonscarring alopecia: systemic lupus, syphilis (moth-eaten alopecia), hypothyroidism, anemia, low iron states, poor nutrition, and medications.
• Scarring Alopecia
• Discoid lupus, folliculitis decalvans, dissecting cellulitus, lichen planus, central centrifugal scarring alopecia (follicular degeneration syndrome).

Ongoing Management and Objectives

• Primary care treatment should include documented assessment of hair loss pattern and whether scarring (loss of follicular orifices) is noted.
• Appropriate lab work-up may include: TSH, RPR, ANA, CBC, iron panel, ferritin.

Indications for Specialty Care Referral

The following may be referred to Dermatology:

Patients with any type of scarring alopecia for evaluation and possible scalp biopsy

Patients with alopecia areata who require treatment (see above)

Patients with diffuse nonscarring hair loss > 6mo for which no underlying cause is detected

Appropriate labs (as above) should be drawn before visit.

Criteria for Return to Primary Care

After completion of the surgical procedure or systemic therapy, patients may be managed at the primary care level.