Evaluation and diagnosis of hair loss
- Jerry Shapiro, MD
Jerry Shapiro, MD
- Professor - The Ronald O. Perelman Department of Dermatology
- New York University
- Nina Otberg, MD
Nina Otberg, MD
- Head of the Hair Clinic
- Skin and Laser Center, Potsdam, Berlin
- Maria Hordinsky, MD
Maria Hordinsky, MD
- Section Editor — Hair and Scalp Disease
- Chair and Professor - Department of Dermatology
- University of Minnesota Medical School
"Hair loss" is a common clinical complaint that is a manifestation of a wide variety of disorders. Although the cause of hair loss is easily diagnosed in some cases, such as in patients who present with classic male pattern hair loss or patchy hair loss due to alopecia areata, the diagnosis of hair loss also can be challenging.
An overview of the basic principles of hair biology, potential causes of hair loss, and the assessment of patients who present with a complaint of hair loss is provided here. Specific types of hair disorders are reviewed in greater detail separately.
●(See "Acne keloidalis nuchae".)
- Whiting DA. The structure of human hair follicle, Canfield Publishing, Fairfield, NJ 2004.
- Paus R, Cotsarelis G. The biology of hair follicles. N Engl J Med 1999; 341:491.
- Childs JM, Sperling LC. Histopathology of scarring and nonscarring hair loss. Dermatol Clin 2013; 31:43.
- Schweizer J, Langbein L, Rogers MA, Winter H. Hair follicle-specific keratins and their diseases. Exp Cell Res 2007; 313:2010.
- Myung P, Ito M. Dissecting the bulge in hair regeneration. J Clin Invest 2012; 122:448.
- Mobini N, Tam S, Kamino H. Possible role of the bulge region in the pathogenesis of inflammatory scarring alopecia: lichen planopilaris as the prototype. J Cutan Pathol 2005; 32:675.
- Ito M, Liu Y, Yang Z, et al. Stem cells in the hair follicle bulge contribute to wound repair but not to homeostasis of the epidermis. Nat Med 2005; 11:1351.
- Cotsarelis G, Botchkarev V. Biology of hair follicles. In: Fitzpatrick's Dermatology in General Medicine, 8th ed, Goldsmith LA, Katz SI, Gilchrest BA, et al (Eds), McGraw-Hill, New York 2012. Vol 1, p.960.
- Breitkopf T, Leung G, Yu M, et al. The basic science of hair biology: what are the causal mechanisms for the disordered hair follicle? Dermatol Clin 2013; 31:1.
- Miranda BH, Tobin DJ, Sharpe DT, Randall VA. Intermediate hair follicles: a new more clinically relevant model for hair growth investigations. Br J Dermatol 2010; 163:287.
- Price VH. Treatment of hair loss. N Engl J Med 1999; 341:964.
- Rebora A, Guarrera M. Kenogen. A new phase of the hair cycle? Dermatology 2002; 205:108.
- Olsen EA, Bergfeld WF, Cotsarelis G, et al. Summary of North American Hair Research Society (NAHRS)-sponsored Workshop on Cicatricial Alopecia, Duke University Medical Center, February 10 and 11, 2001. J Am Acad Dermatol 2003; 48:103.
- Ross EK, Tan E, Shapiro J. Update on primary cicatricial alopecias. J Am Acad Dermatol 2005; 53:1.
- Zvulunov A, Shkalim V, Ben-Amitai D, Feinmesser M. Clinical and histopathologic spectrum of alopecia mucinosa/follicular mucinosis and its natural history in children. J Am Acad Dermatol 2012; 67:1174.
- Otberg N. Primary cicatricial alopecias. Dermatol Clin 2013; 31:155.
- Aten E, Brasz LC, Bornholdt D, et al. Keratosis Follicularis Spinulosa Decalvans is caused by mutations in MBTPS2. Hum Mutat 2010; 31:1125.
- Castori M, Covaciu C, Paradisi M, Zambruno G. Clinical and genetic heterogeneity in keratosis follicularis spinulosa decalvans. Eur J Med Genet 2009; 52:53.
- Bellet JS, Kaplan AL, Selim MA, Olsen EA. Keratosis follicularis spinulosa decalvans in a family. J Am Acad Dermatol 2008; 58:499.
- Kang H, Alzolibani AA, Otberg N, Shapiro J. Lichen planopilaris. Dermatol Ther 2008; 21:249.
- MacDonald A, Clark C, Holmes S. Frontal fibrosing alopecia: a review of 60 cases. J Am Acad Dermatol 2012; 67:955.
- Donati A, Molina L, Doche I, et al. Facial papules in frontal fibrosing alopecia: evidence of vellus follicle involvement. Arch Dermatol 2011; 147:1424.
- RONCHESE F. Pseudopelade. Arch Dermatol 1960; 82:336.
- Scheinfeld NS. A case of dissecting cellulitis and a review of the literature. Dermatol Online J 2003; 9:8.
- Powell JJ, Dawber RP, Gatter K. Folliculitis decalvans including tufted folliculitis: clinical, histological and therapeutic findings. Br J Dermatol 1999; 140:328.
- Whiting DA. Cicatricial alopecia: clinico-pathological findings and treatment. Clin Dermatol 2001; 19:211.
- STRITZLER C, FRIEDMAN R, LOVEMAN AB. Acne necrotica; relation to acne necrotica miliaris and response to penicillin and other antibiotics. AMA Arch Derm Syphilol 1951; 64:464.
- Kossard S, Collins A, McCrossin I. Necrotizing lymphocytic folliculitis: the early lesion of acne necrotica (varioliformis). J Am Acad Dermatol 1987; 16:1007.
- Grattan CE, Peachey RD, Boon A. Evidence for a role of local trauma in the pathogenesis of erosive pustular dermatosis of the scalp. Clin Exp Dermatol 1988; 13:7.
- Starace M, Loi C, Bruni F, et al. Erosive pustular dermatosis of the scalp: Clinical, trichoscopic, and histopathologic features of 20 cases. J Am Acad Dermatol 2017; 76:1109.
- Rongioletti F, Chinazzo C, Javor S. Erosive pustular dermatosis of the scalp induced by ingenol mebutate. J Eur Acad Dermatol Venereol 2016; 30:e110.
- Wiles JC, Hansen RC. Postoperative (pressure) alopecia. J Am Acad Dermatol 1985; 12:195.
- Hanly AJ, Jorda M, Badiavas E, et al. Postoperative pressure-induced alopecia: report of a case and discussion of the role of apoptosis in non-scarring alopecia. J Cutan Pathol 1999; 26:357.
- Trakimas C, Sperling LC, Skelton HG 3rd, et al. Clinical and histologic findings in temporal triangular alopecia. J Am Acad Dermatol 1994; 31:205.
- Yamazaki M, Irisawa R, Tsuboi R. Temporal triangular alopecia and a review of 52 past cases. J Dermatol 2010; 37:360.
- Chung J, Sim JH, Gye J, et al. Successful hair transplantation for treatment of acquired temporal triangular alopecia. Dermatol Surg 2012; 38:1404.
- Wu WY, Otberg N, Kang H, et al. Successful treatment of temporal triangular alopecia by hair restoration surgery using follicular unit transplantation. Dermatol Surg 2009; 35:1307.
- Sehgal VN, Srivastava G. Trichotillomania +/- trichobezoar: revisited. J Eur Acad Dermatol Venereol 2006; 20:911.
- Cantatore-Francis JL, Orlow SJ. Practical guidelines for evaluation of loose anagen hair syndrome. Arch Dermatol 2009; 145:1123.
- Otberg N, Shapiro J. Hair growth disorders. In: Fitzpatrick's Dermatology in General Medicine, 8th ed, Goldsmith LA, Katz SI, Gilchrest BA, et al (Eds), McGraw-Hill, New York 2012. Vol 1, p.979.
- Michailidis E, Theos A, Zlotogorski A, et al. Atrichia with papular lesions resulting from novel compound heterozygous mutations in the human hairless gene. Pediatr Dermatol 2007; 24:E79.
- Pasternack SM, Refke M, Paknia E, et al. Mutations in SNRPE, which encodes a core protein of the spliceosome, cause autosomal-dominant hypotrichosis simplex. Am J Hum Genet 2013; 92:81.
- Moghadam-Kia S, Franks AG Jr. Autoimmune disease and hair loss. Dermatol Clin 2013; 31:75.
- Tümer Z, Møller LB. Menkes disease. Eur J Hum Genet 2010; 18:511.
- De Cruz R, Horev L, Green J, et al. A novel monilethrix mutation in coil 2A of KRT86 causing autosomal dominant monilethrix with incomplete penetrance. Br J Dermatol 2012; 166 Suppl 2:20.
- Hashimoto S, Egly JM. Trichothiodystrophy view from the molecular basis of DNA repair/transcription factor TFIIH. Hum Mol Genet 2009; 18:R224.
- Sun JD, Linden KG. Netherton syndrome: a case report and review of the literature. Int J Dermatol 2006; 45:693.
- Jackson AJ, Price VH. How to diagnose hair loss. Dermatol Clin 2013; 31:21.
- Mubki T, Rudnicka L, Olszewska M, Shapiro J. Evaluation and diagnosis of the hair loss patient: part II. Trichoscopic and laboratory evaluations. J Am Acad Dermatol 2014; 71:431.e1.
- Rakowska A, Slowinska M, Kowalska-Oledzka E, et al. Trichoscopy of cicatricial alopecia. J Drugs Dermatol 2012; 11:753.
- Karadağ Köse Ö, Güleç AT. Clinical evaluation of alopecias using a handheld dermatoscope. J Am Acad Dermatol 2012; 67:206.
- Haliasos EC, Kerner M, Jaimes-Lopez N, et al. Dermoscopy for the pediatric dermatologist part I: dermoscopy of pediatric infectious and inflammatory skin lesions and hair disorders. Pediatr Dermatol 2013; 30:163.
- Miteva M, Tosti A. Hair and scalp dermatoscopy. J Am Acad Dermatol 2012; 67:1040.
- Lencastre A, Tosti A. Role of trichoscopy in children's scalp and hair disorders. Pediatr Dermatol 2013; 30:674.
- Olsen EA. Current and novel methods for assessing efficacy of hair growth promoters in pattern hair loss. J Am Acad Dermatol 2003; 48:253.
- Blume-Peytavi U, Hillmann K, Guarrera M. Hair growth assessment techniques. In: Hair Growth and Disorders, Blume-Peytavi U, Tosti A, Whiting DA, et al. (Eds), Springer, 2008. p.125.
- Van Neste D, Trüeb RM. Critical study of hair growth analysis with computer-assisted methods. J Eur Acad Dermatol Venereol 2006; 20:578.
- HAIR BIOLOGY
- Hair types
- Hair cycle
- Cicatricial alopecia
- Nonscarring alopecia
- Inherited and acquired structural hair disorders
- PATIENT INTERVIEW
- Description of hair loss
- Medical and family history
- PHYSICAL EXAMINATION
- Scalp and hair examination
- - Visual inspection
- - Trichoscopy
- - Hair pull test
- Examination of other sites
- DIAGNOSTIC TECHNIQUES
- Microscopic examination
- Scalp biopsies
- - Cicatricial alopecia
- - Nonscarring alopecia
- Trichograms and phototrichograms
- Laboratory studies
- INDICATIONS FOR REFERRAL
- PATIENT SUPPORT
- SUMMARY AND RECOMMENDATIONS