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.

  • Actual hair loss verses hair breakage
  • Focal hair loss verses diffuse hair loss
  • Hair thinning verses hair shedding
  • Scarring hair loss verses non-scaring hair loss
  • Hair shaft miniaturization verses reduced density


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.


Male Pattern Hair Loss

Norwood: Male Pattern Hair Loss Scale

Female Pattern Hair Loss

Ludwig: Female Pattern Hair Loss Scale

Pattern Hair Loss

The great majority of all hair loss is male or female pattern alopecia.

Non-Pattern Hair Loss

Hair loss (or alopecia) that is not in a genetic male or female pattern is divided into:

  • – Hair shedding
  • – Scarring alopecia
  • – Focal non-scarring alopecia
  • – Telogen effluvium
  • – Hair breakage problems
  • – Diffuse thinning
Scarring Alopecia

Hair Shedding

Sometimes generalized hair thinning is caused by hair shedding. More than 100 hairs per day is 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.

Telogen Effluvium
(Common Precipitating Events)

– Childbirth
– General Anesthesia
– High Fever
– Hormonal Changes
– Protein-Deficient Diet
– Starting or Stopping OCAs
– Stress
– Sudden Weight Loss
– Systemic Diseases

Common Drugs that can
cause Telogen Effluvium

– ACE Inhibitors
– Androgens
– Anti-Cholesterol Agents
– Beta Blockers
– Cimetidine
– Coumadin, Heparin
– Lithium
– Oral Contraceptives (OCAs)
– Vitamin A

Anagen Effluvium
(Common Precipitating Events)

– Childbirth
– General Anesthesia
– High Fever
– Hormonal Changes
– Protein-Deficient Diet
– Starting or Stopping OCAs
– Stress
– Sudden Weight Loss
– Systemic Disease

Cicatricial (Scarring) Alopecia

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

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.


Hair Breakage

– Chemical or Physical Damage
– Trichotillomonia
– Anagen Effluvium
– 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)

Diffuse Hair Loss

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.


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