Diagnostic Tests for Alopecia Areata
Alopecia Areata Tests: Book Excerpts
Alopecia Areata Diagnosis: Book Excerpts
Diagnostic Tests for Alopecia Areata: Online Medical Books
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ALOPECIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
If you are looking for pyoderma or a fungal infection, then a smear and culture of the scrapings for bacteria and fungi should be done. If these are negative, a skin biopsy should be performed. The skin biopsy will help identify lupus erythematosus, psoriasis, and alopecia areata. Systemic disorders may need to be ruled out with thyroid function tests, antinuclear antibody (ANA) assay, VDRL test, CBC, and serum iron and ferritin. A dermatologist should be consulted in difficult cases.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
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:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Testing
A. Laboratory tests should be based on clinical findings. Androgenic alopecia, with normal skin on the scalp of male patients, requires no further evaluation.
1. Female patients with diffuse hair loss should be evaluated with complete blood count, serum ferritin, and thyroid stimulating hormone to rule out infection, iron deficiency anemia, and thyroid abnormality. Screening tests for ovarian, adrenal, and pituitary or hypothalamic disorders include dehydroepiandrosterone sulfate, total testosterone, testosterone-estradiol binding globulin, and prolactin.
2. Tests ordered in patients with virilization are 17-hydroxyprogesterone, luteinizing hormone, follicle-stimulating hormone, and ovarian ultrasound.
3. Repeat testosterone, corticotropin stimulation tests, computed tomography of the adrenals, urinary free cortisol, dexamethasone suppression tests, adrenal or ovarian vein catheterization, and surgical exploration may be indicated if screening tests are abnormal.
4. Patient with scarred, “moth eaten” scalp lesions should have antinuclear antibodies and syphilis serology checked to rule out systemic lupus and syphilis.
5. Patients with flaking of the scalp should have potassium hydroxide examination of scalp scrapings and hair for fungal elements. Scalp scrapings or scalp hairs can be cultured for fungus or bacteria.
6. Bacterial cultures of any drainage should be obtained.
7. The gentle hair pull test is done to assess pluckability. Fewer than four hairs should be obtained per pull. Large numbers of hairs are easily plucked in loose anagen syndrome.
8. The forcible hair pluck test and trichogram assess the stages (anagen, catagen or telogen) of hairs obtained by forceful pulling of hairs with rubber-tipped forceps. These tests are best performed by the dermatologist. If a biopsy is to be done, these tests are not necessary.
B. Scalp biopsy taken with a 4-mm punch of the active area of a lesion is useful in establishing a diagnosis when the findings are equivocal; in diagnosing scarring alopecias (discoid lupus, sarcoid, lichen planopilaris, pseudopelade) or infiltrating alopecias (scleroderma, metastatic adenocarcinoma); and in distinguishing alopecias that can be similar in appearance (lichen planopilaris, pseudopelade, discoid lupus, or scleroderma). Hair samples are studied to assess follicular structure and number, the stages of the sampled hair and its structure and number. The tissue can be studied using direct immunofluorescence for evidence of an autoimmune or infectious cause (2,3).
Diagnostic assessment
Most cases of alopecia are caused by androgenic alopecia and chronic telogen effluvium. Early diagnosis and intervention can be critical in the remaining cases, if caused by metastatic adenocarcinoma, squamous cell carcinoma, melanoma, HIV, syphilis, systemic lupus, adrenal carcinoma, or a thyroid disorder. Permanent hair loss may be prevented by early institution of therapy when alopecia is caused by fungal infection or an infiltrative, scarring processes. If the offending agent is a drug (e.g., oral contraceptives, beta-blockers, antidepressants, or neuroleptics), hair loss can be reversible if the drug is stopped early in the process.
References
1. Van Neste DJ, Rushton DH. Hair problems in women. Clin Dermatol 1997;15:113–125.
2. Habif TP. Clinical dermatology: a color guide to diagnosis and therapy, 3rd ed. St. Louis: Mosby-Yearbook, 1996.
3. Sullivan JR, Kossard S. Acquired scalp alopecia. Part I: A review. Aust J Dermatol 1998;38:2207–2221.
4. Nielsen TA, Reichel M. Alopecia: diagnosis and management. Am Fam Physician 1995;51(6):1513–1522.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Alopecia/Hirsutism:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the physical assessment by taking the patient’s 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 from 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.
CULTURAL CUE:Be aware that hair distribution may vary depending on the patient’s ethnic background. For example, Chinese males tend to lack facial hair and Koreans tend to have less body hair.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
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