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  • Diagnosis of the etiology of hair loss can be made with the combination of clinical history, clinical exam, and the appropriate diagnostic tests.

  • Diagnostic tests should be performed as indicated from the history and clinical exam.


  • The clinical history should evaluate for the onset, duration, and evolution of hair loss as well as related symptoms, personal history of relevant diseases and medications, and family history of hair loss.

  • Hair loss distributions may be classified as patchy, patterned, marginal, or diffuse alopecias

  • Noninvasive diagnostic tests include the hair shedding visual scale, hair pull test, wash test, and scalp dermoscopy/trichoscopy,

  • Semi-invasive tests, such as the trichogram, should only be used in select cases.

  • Scalp biopsy should be guided by dermoscopy.


  • Evaluate eyebrows, eyelashes, facial and body hair.

  • Ask about hairstyle and hair treatments.

  • Perform a pull test or a tug test to assess shedding/breakage and use dermoscopy to evaluate the roots/tips.

  • Evaluate frontal and temporal hairline of all women with patterned or diffuse alopecia.

  • Use dry or polarized trichoscopy to evaluate patients complaining of scalp symptoms.


  • Be aware that hair dyes and camouflage/styling products can simulate pathological findings.


  • Quickly examine the patient first, as the type of alopecia will direct clinical history.

  • Always examine and compare androgen dependent to non-androgen dependent scalps.

  • Utilize the hair shedding visual scale to roughly assess severity of shedding.

  • Trichoscopy is a fast help to distinguish scarring from non-scarring alopecia, chronic telogen effluvium from androgenetic alopecia and detect hair breakage from anagen effluvium including alopecia areata.


  • Ask the patient to shampoo the day before or the same day of the visit.

  • Don’t use camouflage products before the visit.

  • Bring all relevant medical records to the visit.


Hair loss is a frequently occurring condition that, although not considered a life-threatening disease, may pose significant distress and negatively impact one’s health and well-being.

This chapter will provide a guide on clinical evaluation of hair loss discussed in the following sections: clinical history, clinical exam, hair shedding visual scale, pull test, wash test, dermoscopy/trichoscopy, and trichogram.


Clinical history is crucial for arriving at a correct diagnosis of hair loss. A physician should evaluate for the onset, duration, and evolution of hair loss and related symptoms, personal history of relevant diseases and medications, and family history of hair loss.1 Some hair loss conditions are associated with certain hair practices; for example, the majority of patients with traction alopecia carry specific hairstyles known to cause traction. Patients who have undergone keratin treatments may suffer from scalp irritant or allergic dermatitis, whereas hair bleaching commonly leads to hair breakage and fragility. Thus, it is important to ask for hairstyling and chemical hair ...

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