Careful history and physical examination of all patients

Observation for Pattern of hair loss consistent with Norwood Hamilton (for men) or Ludwig or Olsen pattern (for women) is helpful. Be mindful that men can have female patterns of hair loss and women can have male patterns of hair loss.

Family history is helpful. Lack thereof should not rule out Androgenetic Alopecia as possible diagnosis

Medication history with a focus on the intake of pro-androgenic; anti-thyroid; anti-epileptic meds; beta blockers; chemotherapeutics and supplements

History regarding eating – enquire about crash dieting; strictly vegetarian; any recent weight loss of more than 5 kg to 10 kg

Key laboratory tests include checking Iron; Ferritin; Thyroid Stimulating Hormone; Blood Hemoglobin; RPR (Treponemal antibody) if indicated

Hormone levels in women – check only if clinically indicated by a presence of any signs of Hyperandrogenism or Hormonal Dysregulation. Patient’s menstrual history; Reproductive history; Use of Hormmone Replacement Therapy or Birth Control Pill. Any time there is a history of Acne; Seborrhoea; Hirsutism; Irregular menstruation and Infertility, consider Polycystic Ovarian Syndrome (PCOS).

Lab tests for women with signs of hormone irregularities include checking the Free Androgen Index (FAI), which is the Total Testosterone value x 100 / SHBG (Sex Hormone Binding Globulin). If this value is equal or greater than 5 then PCOS should be considered. Furthermore, Prolactin can also be used as a screening parameter. These hormones must be drawn while the patient is off all hormone therapy, between 08h00am and 09h00am in the morning and between the 2nd and 5th day of the menstrual cycle.

Lab workup of women with diffuse alopecia or alopecia of undetermined origin:
Complete Blood Count; Thyroid Functions; RPR; ANA (exclude collagen vascular disease); Iron levels; Ferritin levels (must be off iron supplements for 3 weeks prior to testing)

Adolescents with early onset AGA should be seen in consultation with a Paediatric Endocrinologist.

Consider Nutritional factors; Hypotrichosis Simplex; Ectodermal Dysplasia

The Hair Pull Test is usually negative in AGA but positive in Telogen Effluvium or active Alopecia Areata. Anagen hairs may also be positive in a Hair Pull Test in cases of Loose Anagen Syndrome; Anagen Effluvium; Cicatricial Alopecias and cases of heavy metal poisoning, eg Mercury; Thallium; Arsenic etc. A positive Pull Test: more than 5 Telogen Hairs and any Anagen hairs present. The Pull Test involves grasping 50 to 60 hairs and is positive if more than 10% of hair come out.

Microscopic examination of hair – Use 10x Power magnification.
Hair Shaft Anomalies:
– Monilethrix (Beaded hair)– Autosomal dominant (Congenital)
– Pili torti (Twisted hair) – Ectodermal defects; Abnormal copper metabolism; Can also be acquired in Cicatricial (Scarring) Alopecias.
– Trichorrhexis Invaginata (Bamboo hair) – also seen with Ectopic dermatitis and Ichthiosis – Netherton’s syndrome
– Pili annulati (Ringed hair) – Clinically healthy – see alternating light and dark bands on hair shafts
– Bubble hair – consequence of excessive “blow drying”
– Trichorrhexis Nodosa (Hair shaft damage/injuries)
– Trichonodosis (Spontaneous knotting of hair)
– Trichoptilosis (Split ends)
– Trichoschisis (Hair shaft fractures)

Dermoscopy can help identify the variation in hair diameter seen in AGA, as well as the perifollicular erythema (redness) or scales seen in Scarring Alopecias

Automated digital systems such as a Trichoscan are most useful for clinical studies , for carefull tracking of progress

Global photography is usefull when technique is standardized

Scalp Biopsy, 4mm Horizontal and Vertical sections (punch biopsy).
Indications: Suspected Scarring Alopecia; Questionable Alopecia Areata; Questionable Trichotillomania; Any unexplained Diffuse Hair Loss.

Sources:
– Forum Magazine International, 2011, May/June Volume 3, Dr. Nicole Rogers Article
– ISHRS Basics Course lectures 2014/2015 – Identification of Non-Androgenetic Pathological Hair Loss – Lecture by Dr. Bernard Nussbaum
– Hair Transplantation, 5th Edition, Unger; Shapiro

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