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Probability diagnosis

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Androgenetic alopecia (male pattern baldness)

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Alopecia areata (diffuse type)

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Telogen effluvian (incl. postpartum)

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Anagen effluvian (esp. cytotoxic therapy)

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Seborrhoeic dermatitis

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Serious disorders not to be missed

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Infection:

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  • tinea capitis

  • bacterial folliculitis

  • secondary syphilis

  • post-febrile state

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Cancer:

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  • treatment for cancer

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Other:

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  • systemic disease (e.g. lupus)

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Pitfalls (often missed)

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Rarities:

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Heavy metal poisoning

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Nutritional:

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  • severe dieting

  • malnutrition

  • zinc/iron deficiency

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Masquerades checklist

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Drugs (cytotoxics, anticoagulants, anti-epileptics, amphetamines, anti-thyroid agents, various hormones, cessation OCP)

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Thyroid/other endocrine (hypothyroidism)

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Is the patient trying to tell me something?

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Emotional stress → telogen effluvium. Trichotillomania.

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Key history

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  • Onset, duration, quantity and rate of loss

  • Localised or generalised loss

  • Characteristics of hair (e.g. scales, white bulbs)

  • Associated symptoms (e.g. pruritus, scaling, pustules)

  • Systems review including fever, acute illness, surgery, stressors

  • Endocrine features

  • Past history including skin disorders, cancer, thyroid disorders

  • Family history of hair loss

  • Drug history

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Key examination

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  • General review with emphasis on endocrine system and examination of scalp

  • Look for exclamation mark hair, ‘white bulb’ hair, state of bald patch (clean, scaly, scarred or inflamed) and the unusual pattern of trichotillomania

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Key investigations

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Consider:

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  • FBE/ESR

  • pituitary hormones (FSH/LH/prolactin/TSH)

  • hair pull test

  • trichogram

  • scalp biopsy

  • skin scrapings and hair sample for fungal microsurgery and culture.

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Diagnostic tips

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  • Androgenetic (male pattern and female pattern hair loss) is the most common type.

  • Microscopic examination (light or electron) may be required for definitive diagnosis.

  • For patchy loss consider alopecia areata and trichotillomania.

  • Generalised loss: consider telogen effluvium, systemic disease and drugs.

  • In telogen effluvium, the traumatic event has preceded the hair loss by about 2 months (peak loss at 4 months). ‘White bulbs’ are diagnostic.

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