Confirming diagnosis In fair-skinned patients, Wood’s light examination in a darkened room detects vitiliginous patches; depigmented skin reflects the light, and pigmented skin absorbs it. Biopsy will show normal skin except for the absence of melanocytes. If autoimmune or endocrine disturbances are suspected, laboratory studies (such as thyroid studies) are appropriate.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Alopecia [Hair loss]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient isn’t receiving a chemotherapeutic drug or radiation therapy, begin by asking when he first noticed the hair loss or thinning. Does it affect the scalp alone, or does it occur elsewhere on the body? Is it accompanied by itching or rashes? Then carefully explore other signs and symptoms to help distinguish between normal and pathologic hair loss. Ask about recent weight change, anorexia, nausea, vomiting, excessive stress, and altered bowel habits. Also ask about urinary tract changes, such as hematuria or oliguria. Has the patient been especially tired or irritable? Does he have a cough or difficulty breathing? Ask about joint pain or stiffness and about heat or cold intolerance. Inquire about exposure to insecticides. If the patient is female, ask if she has had menstrual irregularities and note her pregnancy history. If the patient is male, ask about sexual dysfunction, such as decreased libido or impotence.
Next, ask about hair care. Does the patient frequently use a hot blow dryer or electric curlers? Does he periodically dye, bleach, or perm his hair? If the patient is black, ask if he uses a hot comb to straighten his hair or a long-toothed comb to achieve an Afro look. Does he ever braid the hair in cornrows? Check for a family history of alopecia, and ask what age relatives were when they started experiencing hair loss. Also ask about nervous habits, such as pulling the hair or twirling it around a finger.
Begin the physical examination by taking vital signs and then assessing the extent and pattern of scalp hair loss. Is it patchy or symmetrical? Is the hair surrounding a bald area brittle or lusterless? Is it a different color than other scalp hair? Does it fall out easily? Inspect the underlying skin for follicular openings, erythema, loss of pigment, scaling, induration, broken hair shafts, and hair regrowth.
Then examine the rest of the skin. Note the size, color, texture, and location of any lesions. Check for jaundice, edema, hyperpigmentation, pallor, or duskiness. Examine nails for vertical or horizontal pitting, thickening, brittleness, or whitening. As you do so, watch for fine tremors in the hands. Observe the patient for muscle weakness and ptosis. Palpate for lymphadenopathy, enlarged thyroid or salivary glands, and masses in the abdomen or chest.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Alopecia:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
Important questions to ask: What are the patient’s normal grooming habits? When was hair loss initially noted? Was hair loss gradual or abrupt in onset? Is the pattern of hair loss localized or generalized ? Are there other family members with a similar pattern of hair loss? Has there been recent psychological or physical stress? Was there exposure to radiation therapy, cytotoxic chemotherapy, or chemicals, including heavy metals?
A. Androgenic alopecia and chronic telogen effluvium are insidious in onset. Alopecia caused by radiation therapy, cytotoxic chemicals, heavy metals, or severe stress occurs almost immediately.
B. Androgenic alopecia can be localized (male pattern) or diffuse (female pattern). Diffuse hair loss is common in postpartum, radiation therapy- or chemotherapy-induced alopecia and in telogen anagen effluvium and loose anagen syndrome.
Patchy hair loss occurs with bacterial and fungal infections, discoid lupus, alopecia areata, trichotillomania, HIV, and traction alopecia.
C. Androgenic alopecia and alopecia areata have a familial predisposition.
D. Hair loss can be related to stressors such as childbirth or severe illness.
E. Chemotherapy and radiation therapy induce the rapid development of alopecia.
F. Excessive brushing or shampooing can cause hair loss. Damage to both the hair and scalp can result from the use of chemicals, tight braids, thermal heat, or rubber bands (2,3).
Physical examination
Carefully assess the scalp, hair on all body parts, and other body areas for rashes or signs of virilization. Signs of virilization include acne, hypertrichosis, clitoromegaly, frontotemporal balding, and deepening of the voice. Discoid lupus presents as scarred, patchy alopecia of the scalp and can cause loss of facial hair. Trichotillomania can involve the eyebrows and eyelashes. Frontotemporal balding is common in male pattern androgenic alopecia, whereas diffuse hair loss occurs in the female variety; both are associated with normal skin on the scalp. Tinea capitis and psoriatic alopecia should be considered with scalp flaking. “Moth eaten” areas on the scalp suggest sarcoidosis, syphilis, or discoid lupus.
The texture, length, or thickness of individual hairs may suggest the cause of alopecia. Shorter, fine hairs may be found in areas of thinning in androgenic alopecia. Trichotillomania and tinea capitis result in short broken hairs. “Black dots” occur in the lesions of tinea capitis, whereas “exclamation point” hairs occur with alopecia areata (4). Long eyelashes and straightening of scalp hair suggest infection with HIV.
Hair in loose anagen syndrome is easily removed with gentle pulling. The hair in traction alopecia and trichotillomania is firmly rooted in the scalp.
Both lichen planopilaris and discoid lupus may have associated lesions on other parts of the body, a finding that may be useful in diagnosis.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Alopecia/Hirsutism:
Differential Overview
(Field Guide to Bedside Diagnosis)
Alopecia
❑ Androgenetic
❑ Telogen effluvium
❑ Drugs/hair loss
❑ Anagen effluvium
❑ Alopecia areata
❑ Tinea capitis
❑ Traction
❑ Hypothyroidism
❑ Seborrheic dermatitis
❑ Discoid lupus
❑ Systemic lupus erythematosus
❑ Lichen planus
❑ Scleroderma
❑ Dietary deficiency
❑ Trichotillomania
❑ Syphilis
Hirsutism
❑ Idiopathic hirsutism
❑ Drugs/hair growth
❑ Hypertrichosis
❑ Hyperprolactinemia
❑ Polycystic ovary syndrome
❑ Cushing syndrome
❑ Adrenal tumor
❑ Ovarian tumor
❑ Ovarian hyperthecosis
Diagnostic Approach
Nonscarring alopecia includes androgenetic, telogen effluvium, trichotillomania, traction, aerata, and syphilis. Scarring alopecia is characterized by fibrosis, inflammation and loss of follicles, occurring with inflammatory dermatoses, deep infections, neoplasms, burns, and genodermatoses. Broken hair shafts are seen in fungal infections, traction, and trichotillomania.
Most hirsutism is familial. If a woman with hirsutism has normal menses, a family history of hirsutism, no virilization, and gradual onset, no further evaluation is needed.
Signs of androgen excess include defeminization with amenorrhea, decrease in breast size, or loss of female body contours more often than virilization. Other signs include acne, increased libido, clitoromegaly, temporal hair loss, deepened voice, and increased muscle mass. Acute onset of hirsutism and virilization suggests an androgen-producing adrenal or ovarian tumor, or exogenous androgen ingestion.
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Source: Field Guide to Bedside Diagnosis, 2007
Alopecia:
Diagnosis
(Handbook of Diseases)
Physical examination is usually sufficient to confirm alopecia. In trichotillomania, an occlusive dressing can help establish a diagnosis by allowing new hair to grow, revealing that the hair is being pulled out. The diagnosis must also identify any underlying disorder.
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Source: Handbook of Diseases, 2003
Alopecia:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient isn’t receiving a chemotherapeutic drug or radiation therapy, begin by asking when he first noticed the hair loss or thinning. Does it affect the scalp alone, or does it occur elsewhere on the body? Is it accompanied by itching or rashes? Then carefully explore other signs and symptoms to help distinguish between normal and pathologic hair loss. Ask about recent weight change, anorexia, nausea, vomiting, excessive stress, and altered bowel habits. Also ask about urinary tract changes, such as hematuria or oliguria. Has the patient been especially tired or irritable? Does he have a cough or difficulty breathing? Ask about joint pain or stiffness and about heat or cold intolerance. Inquire about exposure to insecticides. If the patient is female, find out if she has had menstrual irregularities and note her pregnancy history. If the patient is male, ask about sexual dysfunction, such as decreased libido or impotence.
Next, ask about hair care. Does the patient frequently use a hot blow-dryer or electric curlers? Does he periodically dye, bleach, or perm his hair? If the patient is black, ask if he uses a hot comb to straighten his hair or a long-toothed comb to achieve an Afro look. Does he ever braid the hair in cornrows? Check for a family history of alopecia, and ask what age relatives were when they started experiencing hair loss. Also ask about nervous habits, such as pulling the hair or twirling it around a finger.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
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