Chapter 3 — Hair History & Examination

GP-Level Analogy

"A trichology consultation is like diagnosing a leaking pipe. You need to know when the leak started, where the water is going, how fast it's leaking, and what changed in the house beforehand. The history is your plumber's questionnaire; the examination is your hands on the pipes."

Hair loss is one of the most emotionally charged presentations in general practice. A structured, systematic approach distinguishes the confident trichologist from the overwhelmed GP. This chapter equips you with a reproducible consultation framework.

The key insight is this: most diagnoses in trichology are made by history alone, with examination confirming and refining. Investigations are the third step — not the first refuge of a confused clinician.

The Trichology Consultation Structure

Chief Complaint

Is it shedding (hair coming out) or thinning (reduced density/calibre)? This single distinction shapes everything that follows.

Detailed History (9 Domains)

Onset, pattern, rate, triggers, systemic symptoms, medications, family history, diet, and scalp symptoms — each domain is a diagnostic filter.

Systematic Examination (DICS)

Scalp inspection (scarring/non-scarring), density and distribution, shaft calibre, pull test, and trichoscopy.

Targeted Investigations

Blood tests, trichoscopy, biopsy — ordered based on clinical hypothesis, not as a fishing expedition.

Founding Principle

Shedding ≠ Thinning. Shedding = hair falling out (telogen effluvium, alopecia areata). Thinning = reduced shaft calibre/density (AGA, nutritional deficiency). Many patients conflate these — your first job is to separate them.

Taking the Hair History — Nine Domains

A complete hair history covers nine domains. Think of each as a diagnostic filter — positive answers narrow the differential, negative answers are equally informative. The mnemonic OPTICS-MFS covers all nine.

Fig 3.1 — The nine domains of hair history (OPTICS-MFS)

Fig 3.1: The nine domains of trichology history — OPTICS-MFS. Each domain acts as a diagnostic filter. A combination of positive and negative responses narrows the differential to one or two conditions before examination begins.

Domain 1 — Onset & Duration

Establish whether loss is acute (<6 months) or chronic (≥6 months). Acute onset suggests a precipitant event; chronic onset favours AGA, nutritional deficiency, or subacute systemic disease.

Domain 2 — Pattern of Loss

Pattern A

Diffuse (generalised)

Uniform thinning across whole scalp. Think: telogen effluvium, thyroid disease, iron deficiency, diffuse AGA in women.

Pattern B

Patterned / zonal

Frontotemporal recession, vertex thinning, discrete patches. Think: AGA, alopecia areata, traction, tinea capitis.

Domain 3 — Rate of Loss

More than 100 hairs per day constitutes pathological shedding. Ask the patient to count hairs on the pillow each morning for 3 days, or to collect combing/washing fallout in a bag for quantification.

Domain 4 — Shedding vs Thinning

Feature	Shedding predominant	Thinning predominant
Chief complaint	"Hair is falling out"	"Hair looks thin / limp / fine"
Hairs on pillow/brush	Increased, often alarming	Normal or mildly increased
Shaft calibre	Normal calibre in shed hairs	Fine, miniaturised shafts
Typical diagnosis	Telogen effluvium, alopecia areata	AGA, nutritional deficiency
Bulb on shed hair	White/pigmented club bulb (telogen)	Miniaturised terminal or vellus-like

Domain 5 — Triggers (the 3-month lookback)

Physical stress

Surgery, trauma, severe illness, high fever, COVID-19, crash dieting, rapid weight loss (>15% body weight).

Hormonal

Postpartum (peaks 3–6 months after delivery), stopping OCP, menopause, PCOS, thyroid disturbance.

Psychological

Bereavement, relationship breakdown, job loss. HPA axis activation via CRH receptors on the follicle.

Nutritional

Iron deficiency (most common in women), zinc, vitamin D, B12 in vegans, protein malnutrition.

Domain 6 — Medications (ask about the preceding 3–6 months)

Drug class	Mechanism	Examples
Cytotoxic agents	Anagen effluvium — mitotic arrest in matrix	Cyclophosphamide, taxanes, methotrexate
Anticoagulants	Telogen effluvium	Warfarin, heparin, DOACs
Retinoids	Telogen effluvium (dose-dependent)	Isotretinoin, acitretin
Antithyroid drugs	Telogen effluvium	Carbimazole, propylthiouracil
Beta-blockers	Telogen effluvium	Propranolol, atenolol
Lithium	Telogen effluvium	Lithium carbonate
Oral contraceptives	TE on cessation; androgenic OCPs worsen AGA	Especially levonorgestrel-containing

Domain 7 — Family History

AGA has polygenic inheritance — ask about maternal AND paternal sides. Alopecia areata: 25% first-degree family history; association with HLA-DQ3 and autoimmune disease in family members.

Domain 8 — Systemic Co-morbidities

Thyroid disease

Both hypo- and hyperthyroidism cause diffuse TE. Ask: weight change, cold intolerance, palpitations, fatigue, bowel change, menstrual irregularity.

Iron deficiency

Fatigue, dyspnoea, pica, restless legs. Ferritin <30 mcg/L is relevant even without anaemia — check ferritin, not just Hb.

Hormonal/PCOS

Irregular cycles, acne, hirsutism, weight gain, acanthosis nigricans. Androgenic hair loss warrants androgen screen if features present.

Autoimmune

Joint pain, rash, photosensitivity, oral ulcers, Raynaud's. SLE, LPP, discoid lupus all cause distinct patterns.

Domain 9 — Scalp Symptoms

Symptom	Significance	Think
Pruritus (itch)	Active inflammation	Seborrhoeic dermatitis, psoriasis, LPP
Pain/tenderness	Inflammation or nerve involvement	Active scarring alopecia (LPP, FFA), dissecting cellulitis
Scaling	Inflammatory condition	Psoriasis, seborrhoeic dermatitis, tinea capitis
Burning	Neuropathic or inflammatory	LPP (trichodynia), FFA — burning precedes patches
No symptoms	May indicate non-inflammatory process	AGA, telogen effluvium, nutritional

Red Flag Symptoms in History

Rapid total loss over days–weeks · Scalp pain + loss of follicular ostia (scarring — urgent referral) · Systemic features (fever, arthralgia, rash) — consider SLE · Children with patchy loss + scalp scale — exclude tinea capitis before treating · Virilisation + rapid female hair loss — exclude androgen-secreting tumour

Systematic Scalp Examination — DICS

Examination follows the DICS framework: Distribution → Inflammation → Calibre → Scarring. Good lighting is essential; a dermatoscope (trichoscopy) is strongly recommended.

Fig 3.2 — Examination sequence and scalp zones (top view)

Fig 3.2: The DICS examination sequence (right) and the five scalp zones (left). Always examine all five zones even when the patient only reports loss in one area.

Step 1 — Distribution

Examine in good lighting with hair parted systematically in multiple directions. Compare frontal density to occipital density — in AGA the occipital zone is preserved. In diffuse TE, all zones are equally affected.

Step 2 — Inflammation

Perifollicular erythema

Active LPP, FFA, or early alopecia areata. A sign of active scarring — urgent.

Perifollicular scale

White/grey scale on shaft — "matchstick sign." Hallmark of lichen planopilaris.

Yellow scale/crust

Diffuse yellow greasy scale: seborrhoeic dermatitis. Focal yellow pustules: folliculitis decalvans.

Silver/brown scale

Silver plaques with hair parting: psoriasis. Thick amiantum scale: pityriasis amiantacea.

Pale, smooth scalp

No follicular openings. End-stage scarring — irreversible. Follicles replaced by fibrous tissue.

Normal-appearing scalp

No inflammation, ostia visible. Typical of AGA, TE, nutritional — non-scarring.

Step 3 — Hair Density & Shaft Calibre

Normal density: 200–300 hairs/cm². Visible thinning only apparent after >50% density loss. Miniaturisation (terminal → vellus-like) is the hallmark of AGA. A miniaturisation ratio >20% in the frontal or vertex zone is diagnostic in the right clinical context.

Step 4 — Scarring vs Non-Scarring

Critical Distinction

The most important examination finding in trichology. Follicular ostia present = non-scarring = potentially reversible. Follicular ostia absent = scarring = irreversible. This one finding determines urgency of referral.

Feature	Non-scarring	Scarring
Follicular ostia	Present (visible pores)	Absent — smooth, pale, atrophic skin
Reversibility	Potentially reversible	Irreversible (stem cell destruction)
Examples	AGA, TE, alopecia areata	LPP, FFA, discoid lupus
Action	Investigate, treat, monitor	Urgent referral — prevent further loss

Step 5 — The Pull Test

Grasp 40–60 hairs near the scalp and apply firm traction. >6 hairs extracted = positive (active effluvium). Perform in three regions: frontal, vertex, occipital. Positive in all zones = diffuse TE. Positive only frontal/vertex, negative occiput = AGA. Examine bulb: white club = telogen; fleshy anagen bulb = anagen effluvium.

Step 6 — Shaft Examination

Shaft finding	Description	Diagnosis
Exclamation-mark hairs	Narrow depigmented base, dark tip	Alopecia areata (pathognomonic)
Trichorrhexis nodosa	White nodes — cortex fracture	Chemical/thermal damage
Broken hairs at different lengths	Irregular stubble	Tinea capitis, trichotillomania
Hair casts (pseudo-nits)	White cylinders around shaft, movable	Psoriasis, seborrhoeic dermatitis

Diagnostic Tools

Gold standard

Dermoscopy (Trichoscopy)

10–20× magnification. Identifies: yellow/black dots (AA), peripilar casts (LPP), honeycomb pattern (AGA), comma hairs (tinea). Strongly recommended in all trichology consultations.

Quantification

60-Second Hair Count (Wash Test)

Patient counts hairs shed after standardised wash and 24-hour collection. Normal: <100/day. TE: often 200–400/day. Useful for monitoring treatment response.

Monitoring

Global Photography

Standardised photographs at baseline and follow-up using defined scalp zones and fixed camera distance. Essential for documenting treatment response.

Gold standard scarring Dx

Scalp Biopsy

4 mm punch biopsy in 2 planes (vertical + horizontal). Gold standard for scarring alopecia. Should be taken from active edge — not burnt-out centre.

Blood Test Reference Guide

Test	Threshold	Associated condition
Ferritin	<30 mcg/L (relevant); <70 mcg/L (optimal for hair)	Iron deficiency TE, diffuse hair loss in women
TSH	>4.5 or <0.4 mIU/L	Hypo/hyperthyroid TE
25-OH Vitamin D	<50 nmol/L	Diffuse loss; possible AA association
Zinc	<10 µmol/L	Diffuse loss, brittle hair
Free androgen index	>5 in women	Female AGA, PCOS-related hair loss
ANA	Titre >1:80 with clinical features	Discoid lupus, SLE, mixed CTD
FBC	Hb <120 g/L (F), <130 g/L (M)	Anaemia, nutritional deficiency

Key Principle

Always check ferritin (not just Hb) in women with diffuse hair loss. Ferritin <70 mcg/L can cause or perpetuate hair loss even when haemoglobin is normal. Treat to >70 mcg/L, not just above the laboratory reference range.

Pattern Recognition: History + Exam Combinations

The following classic vignettes show how history and examination combine to point to a specific diagnosis.

Fig 3.3 — Differential diagnosis by clinical pattern

Fig 3.3: Six common presentation patterns mapped to diagnosis. AGA = androgenetic alopecia, TE = telogen effluvium, AA = alopecia areata, FFA = frontal fibrosing alopecia, TC = tinea capitis, TTM = trichotillomania.

Quick Recall

History: OPTICS-MFS

OPTICS-MFS

Onset — when? acute or chronic?
Pattern — diffuse, focal, frontal?
Trigger — 3–6 months prior?
Intensity — shedding vs thinning?
Co-morbidities — thyroid/iron/hormones?
Scalp Sx — itch/pain/scale?
Medications — last 3–6 months?
Family history — parents/siblings?
Shed hair — collect for 3 days

Examination: DICS

DICS

Distribution — which zones? Diffuse?
Inflammation — colour, scale, crust?
Calibre — miniaturisation ratio?
Scarring — ostia present or absent?
Then: Pull test, shaft exam, trichoscopy

Red Flags: SAFE

SAFE

Scarring — no ostia, fibrosis
Accelerated total loss
Fever + alopecia (systemic)
Exclamation hairs + rapid extension

Shedding vs Thinning

KEY SPLIT

Shedding = hair coming OUT (TE, AA)
Thinning = finer shafts (AGA, nutrition)
Both = mixed (chronic TE on AGA)
Ask: "Falling out OR getting finer?"

GP Quick-Reference Action Card

Presentation	First question	Key exam	First investigation	Action
Diffuse shedding, female	Pregnant/postpartum? Illness 3 mo ago?	Pull test; thyroid signs	Ferritin, TFTs, FBC, Vit D	Treat deficiency; reassure TE
Frontotemporal recession, male	FHx? Gradual?	Miniaturisation, pull test (–)	Clinical only (classic)	Counsel AGA; offer minoxidil/finasteride
Patches, smooth scalp, child	School/pet contact? Scalp scale?	Broken hairs, posterior LN	Mycology swab; Wood's lamp	Systemic antifungal if tinea
Hairline recession + burning, F >50	Eyebrow loss? Menopause?	Perifollicular cast/erythema	Dermoscopy; biopsy	Urgent referral — FFA
Irregular patch, child, denies pulling	Hairs of different lengths? Stress?	Flame/tulip hairs on derm.	Dermoscopy; coiled hairs	Trichotillomania — psychology

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References

APA 7th edition format.

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