Diffuse Non – Scarring Physiological:
- Normal ageing process.
- Female pattern hair loss (FPHL)- thinning over crown
- Telogen effluvium/ excessive shedding occurs three–four months after pregnancy/ other major event
- May be component of polycystic ovarian disease in young women
- Consider any new medications
Localised Non-Scarring Alopecia areata Patchy hair loss with exclamation mark hair
Diffuse inflamed non-scarring.
Consider seborrhoeic dermatitis or psoriasis (may also rarely cause scarring)
Localised inflamed non-scarring.
- Consider tinea infection (may also cause scarring)
- Consider psoriasis or seborrhoeic dermatitis
Scarring : no visible hair growth or follicles. Skin is atrophic or inflamed Loss of hair follicles with or without inflammation and accompanied by scarring local or diffuse causes include:
Lichen planuopilaris, folliculitis decalvans and frontal fibrosing alopec
R.C 18-05-23
Dermatology Referral Criteria
- Inflammatory scarring alopecia
- Diagnostic uncertainty
- Persistent or extensive alopecia (scarring or non-scarring)
- Hairpiece or wig prescription for alopecia caused by trauma or disease resulting in psychological distress (if available)
Investigations
In diffuse alopecia check FBC, ferritin and TFTs. Consider iron supplementation if ferritin at lower end of normal range or below. The need for any additional tests depends on the history / examination eg ANA / ENA for suspected lupus, VDRL for suspected syphilis
Non-Scarring:
Diffuse
- Inform patients with mild FPHL that condition is physiological. Topical Minoxidil 2% may prevent further hair loss and encourage hair growth but only during use. This is NOT available on the NHS.
- Reassure patients that Telogen effluvium will recover spontaneously and there is no specific treatment.
- Patients with severe widespread alopecia caused by disease can be considered for NHS wig prescription.
Localised
- Reassure patients with alopecia areata that spontaneous regrowth is likely, though less so if widespread and involving areas out with the scalp.
- Generally good outcome in patients with short history and limited extent.
- Consider trial of potent topical steroid lotion for three months when there is diagnostic certainty.
Diffuse inflamed
Treatment:
- Coal tar + salicylic acid ointment ( eg Cocois/Sebco)
- Anti-fungal shampoo ( eg ketoconazole)
- Topical steroid lotion/mousse/foam.
Localised inflamed
- Send plucked hairs to mycology lab.
- If dermatophyte infection confirmed, treat with oral terbinafine.
- Treat as for diffuse inflamed non-scarring if psoriasis or seborrhoeic dermatitis
Scarring
- Refer to Dermatology
