Do you have any suggestions for patients with hair loss deemed a 'mystery'?


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QUESTION: My hair loss seems a mystery to many doctors. Do you have any suggestions on making the right diagnosis?



There’s no doubt that diagnosing hair loss can be challenging. But hair loss is never labelled a mystery until we’ve properly used the tools we have available. These include asking good questions, examining the scalp, blood tests, scalp biopsies and hair collections. 


1.     Asking Questions

There are potentially 500 questions that are relevant to the patient with hair loss. It’s simply not possible to ask every question so one needs to choose the highest yield questions. There are certain questions that must always be asked and certain questions that should be asked if one finds that a certain line of question is uncovering helpful information. 

The proper diagnosis of hair loss must be approached like detective work. One needs to think of the most common scenario and then the least likely ones.  Patients don’t always volunteer information because they don’t know if it’s relevant or not. The clinician must ask. 

A detective would not label a particular case a ‘mystery’ without having asked some good questions. Hair loss should not be labelled a mystery until one has asked some line of questions. 


2.     Examining the Scalp. 

You simply can’t properly diagnose hair loss from sitting across from the patient. One needs to get up, and examine the hair and the scalp. One needs to look at where on the scalp the hair loss is occurring, and what’s happening to the hairs.

If the hair loss is occurring only in certain areas and other areas seem unaffected, the clinician has gained valuable information that he or she is dealing with one of a group of conditions that are part of the so called ‘localized hair loss conditions.’ If the hair loss is occurring all off the scalp in a diffuse manner, the clinician has gained valuable information that he or she is dealing with one of a group of conditions that are part of the so called ‘diffuse hair loss conditions.’ Narrowing it down is helpful. 

Similarly one needs to look at the hair and the scalp. One needs to look if there is redness in the scalp, scaling, pustules, crusting. One needs to determine if the hairs are all the same size of whether some are thinner. The presence of thinner and thinner hair can be an indication of androgenetic alopecia for some. Are there hairs breaking off?  Is their a lot of new regrowth. 

The scalp examination provides key information. Hair loss should not be labelled a mystery until one has carefully examined the scalp.



3.     Blood tests

I’m of the opinion that everyone with hair loss needs blood tests. Some require only a basic blood count, thyroid study and iron level (ferritin test). Others require more detailed testing. But certainly one can’t label any case a mystery without a basic thyroid and iron level. Iron deficiency and thyroid abnormalities are very common and can have a range of different hair loss presentations.

One can’t order all the 150 blood tests that are available. It’s not practical, and it’s not cost effective. Women with irregular periods needs more detailed hormonal testing and so do women with acne and excessive hair growth on the body. Males and females with fatigue, joint pains, chronic headaches and sun sensitive rashes may be worked up for autoimmune disease.  Sexual transmitted diseases need to always be considered in patients with unexplained hair loss.  Zinc levels may be appropriate in patients with poor diet or weight changes. 

Hair loss should not be labelled a mystery until one has at least ordered a blood count, thyroid and iron study and given thought to the relevancy of the other tests we have available.


4. Scalp Biopsy

Scalp biopsies are not needed for most patients with hair loss. In fact, for every 20 patients I see, I might perform a scalp biopsy on only 1 or 2.  But no patient’s hair loss can be considered a mystery if one has not done a biopsy. It’s a tool that can provide helpful information.

The problem with scalp biopsies is they are not the final step in diagnosis and so are frequently incorrectly used. If a biopsy is not taken from the right spot on the scalp and not processed correctly and not interpreted by a pathologist who understands hair loss, it’s better not to do the biopsy at all. There are certainly a good number of inaccurate biopsy results that I see on a weekly basis. 

But a properly conducted and properly interpreted biopsy can give immediate information about whether or not a patient has a scarring alopecia and whether or not there is any component of androgenetic alopecia in the area biopsied. Biopsies are not accurate method for determining telogen effluvium (this is a clinical diagnosis that comes from asking questions and looking at the scalp).

Not everyone needs a scalp biopsy. But certainly hair loss should not be labelled a mystery until one has had a scalp biopsy.


5.     Hair Collections

Hair collections are not used very often but also provide a tool to better understand how much hair a patient is shedding. A five day hair collections requires the patient not to wash the hair for five days and then the hair is collected in a specific way while shampooing. The number of hairs that come out in that wash as well as the length of the hairs give valuable information about shedding patterns and whether genetic hair loss is likely. 


The Role of Physician Experience

Before we leave the topics of history taking, scalp examination, and blood tests, and biopsies one must also respectfully consider that physicians all have different skills in these areas. If one has seen thousands of hair loss conditions, it is more likely that key questions will be asked, subtle or key findings will be picked up on examination of the scalp, key blood tests ordered or biopsies taken from the correct area of the scalp than if a physician has not seen or treated as many hair loss patients. For that reason, one must also consider referral to a physician who specializes in hair loss disorders for any hair loss condition truly deemed a 'mystery.'



Diagnosing hair loss is truly detective work. One needs to come prepared with the right tools. There certainly are a good share of hair loss mysteries in everyday practice but many so called hair loss mysteries are not really mysteries. They are simply patients with hair loss that have not been thoroughly evaluated. 

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