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Proper Diagnosis of Hair Loss
Before one can decide if they might need medical treatment or a hair transplant, a proper diagnosis of their hair loss condition should be made by a dermatologist or hair loss specialist. Hair loss may be pattern hair loss (male or female) or non-pattern hair loss.

Most hair loss is male or female pattern hair loss, which is characterized by the gradual miniaturization of hairs – usually in a specific pattern – for a few to several years until finally falling out due to a sensitivity to dihydrotestosterone in the case of males.
Normal and miniaturized hair shaft comparison
Normal and miniaturized hair shaft comparison

Pattern Hair Loss
Miniaturized or missing hairs in a distinct male or female pattern occurs as illustrated below.

Norwood: Male Pattern Hair Loss

The great majority of all hair loss is male or female pattern alopecia. The treatment for these is chemical and/or surgical therapy.

Ludwig: Female Pattern Hair Loss

1  Christmas Tree Pattern       2  Ludwig Pattern I       3  Ludwig Pattern II       4  Ludwig Pattern III

Non-Pattern Hair Loss
Hair loss (or alopecia) that is not in a genetic male or female pattern is divided into:
1)    Hair shedding.
2)    Scarring alopecia.
3)    Focal non-scarring alopecia.
4)    Telogen effluvium.
5)    Hair breakage problems.
6)    Diffuse thinning, although recent evidence suggests that this is a genetic
condition also, which is related to deficiencies in one or more hormones as persons age.
A discussion of each follows.

Hair Shedding
Sometimes generalized hair thinning is caused by hair shedding. More than 100 hairs per day are significant –  this usually is a telogen effluvium (hairs which have entered the resting or telogen phase of the growth cycle – and are thus falling out). When hair follicles enter the telogen phase, the hairs held firmly in those follicles become loose and fall out.  Certain severe toxins, radiation or chemo can cause anagen effluvium – where hairs are shed during the anagen (growth) phase of the cycle – as the follicles are destroyed. A telogen effluvium usually occurs about three months after the precipitating event, whereas anagen effluvium occurs closer to the toxic event.

Causes of Hair Shedding (telogen or anagen effluvium)


Focal Non-Scarring Alopecia

  • Entity / Distinguishing features
  • Secondary syphilis: Serology for syphilis (contagious)
  • Tinea capitis (ringworm): Broken hairs, scaling, erythema, positive smear and culture (contagious)
  • Traction alopecia: Typical  pattern from traction
  • Triangular alopecia: Pattern, configuration and history on temple
  • Trichoterlomania: Shaved hairs
  • Trichotillomania: Broken hairs present from manipulation, hairs of various lengths
  • Alopecia areata: Irregular patches, frequently round, of missing hair, scattered throughout the scalp, usually characterized by fine, silvery hairs at the base. This is thought to be an autoimmune condition which lasts for several months to several years, may be characterized by hair regrowth in some of the areas, followed by development of patchy hair loss in other areas. This is diagnosed by biopsy, appearance, hair-pull test and history.

Cicatricial (Scarring) Alopecias
Hair transplant surgeons often find unusual cases where the normal patterns of male-pattern baldness or female-pattern baldness are not present. Usually these are unusual and irregular patterns of hair loss on the scalp, frequently accompanied by loss of pores and hair in the area in question, and often a smooth, glassy appearance on the scalp.
When these are present, it is necessary to do a biopsy to determine the process that is active.
Generally loss of pores and smooth shiny scalp indicate a scarring alopecia. The following are the types of scarring alopecia which require a biopsy:

  • Chronic cutaneous lupus erythematosus
  • Lichen planus pilaris
  • Frontal fibrosing alopecia
  • Graham-Little Syndrome
  • Pseudopelade of Brocq
  • Central centrifugal cicatricial alopecia
  • Alopecia mucinosa
  • Keratosis follicularis spinulosa decalvans
  • Folliculitis decalvans
  • Dissecting cellulitis/folliculitis

If there is any doubt about which condition one is dealing with, even in the rare cases where they tend to mimic a male or female pattern baldness, a biopsy should be done. Generally the biopsy will determine which condition is present.
Scarring alopecias cannot be transplanted until such time as the inflammatory component of the process has been burned out for a few years.


Hair Breakage, Causes:
1)    Chemical  or Physical Damage
2)    Trichotillomonia
3)    Anagen Effluvium
4)    Hair Shaft Anomalies:

  • Monilethrix (beaded hair)
  • Pili torti (twisted hair)
  • Trichorrhexis invaginata (bamboo hair)
  • Pili annulati (ringed hair)
  • Bubble hair (damage from heat of hair dryers, curling irons, etc.)
  • Trichorrhexis nodosa (nodes on hair)
  • Trichonodosis (knotted hair)
  • Trichoptilosis (split ends)
  • Trichoschisis (broken or split hairs)

Pattern Baldness Versus Generalized Diffuse Hair Loss
Note that male and female pattern baldness are just that, hair loss in a pattern, generally on the top, sides, and back of the head, but sparing a thick donor area. Other types of systemic problems such as low thyroid, iron deficiency, collagen disorder, growth or sex hormone deficiency, secondary syphilis all may cause diffuse hair thinning. If you have generalized hair thinning, you need a complete medical workup for the various causes. Also note that some people have both a pattern hair loss as well as a diffuse or generalized decrease in density. These people may well have both conditions simultaneously, but still require a complete medical workup, normally with lab tests and biopsy.


Comprehensive Medical Workup for Diffuse Thinning and Hair Loss
A)    LAB:  CBC, Free T3 and T4 (thyroid), Ferritin, Total and Free Testosterone, SHBG,  and Estradiol, DHEAS, Prolactin, RPR, TSH, IGF-1, DHT, Progesterone, ANA
B)    SCALP BIOPSIES: Vertical and horizontal sections
C)    OFFICE TESTS:  Hair-pull test, hair window, KOH prep, bacterial and fungal culture and sensitivity