Alopecia Initial Assessment

Clinical Presentation

Androgenic Alopecia in Males/Females

In male pattern hair loss (MPHL), the thinning of hair begins between 12-40 years, while there is chronic progressive hair loss in the 20’s and 30’s for those with female pattern hair loss (FPHL).

Alopecia_Initial Assesment 1

• Patch alopecia areata: Circumscribed areas of alopecia (patches), which may be oval, rounded, single, or multiple
• Total alopecia areata (alopecia totalis): 100% loss of scalp hair
• Universal alopecia areata (alopecia universalis): 100% loss of hair on the scalp and the body
• Diffuse alopecia areata: Hair loss resulting in overall decrease in density, distributed all over the scalp, without patches
• Acute diffuse and total alopecia: Acute onset of diffuse hair loss, usually progressing to total alopecia areata within 3 months

Most patients with alopecia areata are <40 years of age. 

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History

It is important that history should be reviewed for medications, severe diet restriction, vitamin A supplementation, thyroid symptoms, concomitant illness, and stress factor.

Androgenic Alopecia in Males/Females

Some patients may not have a family history; some have an androgen-dependent trait.

Alopecia Areata

In alopecia areata, there may be a family history of alopecia. Patients often give a history of emotional trauma/stress prior to its onset. There is usually rapid hair loss in a well-defined, typically round area. Patients complain of 1-4 cm² area of hair loss on the scalp; the patch is usually clean looking without scaling. Patients may be asymptomatic, but some patients experience paresthesias with pruritus, burning sensation, pain or tenderness prior to loss of hair.

Physical Examination

Some tests that can be done include a pull test and examination of facial and body hair and nails. In androgenic alopecia in males/females, the pull test must be performed in the right and left parietal areas, frontal and occipital areas, and in visibly affected areas. Hair pull test is positive in active early hair loss but negative in long standing hair loss. In alopecia areata, the hair pull test may be positive at the margins which is indicative of active disease.

Alopecia_Initial Assesment 3

Diagnosis or Diagnostic Criteria

Androgenic Alopecia in Males/Females

Patterned Hair Loss

Hamilton-Norwood Staging (MPHL)

In the Hamilton-Norwood staging, the higher the stage, the more severe the hair loss. This usually starts with the bitemporal recession of frontal hairline and continuing with the thinning over the vertex, eventually with complete hair loss on the vertex then bald hair. There is a bald patch that enlarges and joins the receding frontal hairline. Other patterns may develop, but it is the androgenic-independent hair (on the sides and back of the scalp) that does not thin.

Ludwig Staging (FPHL)

FPHL is marked by the presence of miniaturized, vellus-like hair follicles. In the Ludwig staging, the higher the stage, the more severe the hair loss. In FPHL, the thinning is usually diffused, but more marked on the frontal and parietal regions. In severe cases, it is characterized by a “monk’s haircut”. A Christmas tree pattern is another pattern of female hair loss characterized by centroparietal thinning and frontal accentuation.

Alopecia Areata

The diagnosis of alopecia areata is usually clinical.