eMedicine Specialties > Dermatology > Diseases of the Adnexa

Alopecia Areata: Differential Diagnoses & Workup

Author: Chantal Bolduc, MD, FRCP(C), Assistant Professor, Department of Dermatology, University of Montreal
Coauthor(s): Harvey Lui, MD, FRCPC, Professor and Head, Department of Dermatology and Skin Science, Vancouver General Hospital, University of British Columbia; Medical Director, The Skin Centre, Lions Laser Skin Centre and Psoriasis and Phototherapy Clinic, Vancouver General Hospital; Jerry Shapiro, MD, FRCP(C), Clinical Associate Professor, Department of Medicine, Division of Dermatology, University of British Columbia, Canada
Contributor Information and Disclosures

Updated: Apr 13, 2009

Differential Diagnoses

Androgenetic Alopecia
Pseudopelade, Brocq
Syphilis
Telogen Effluvium
Tinea Capitis
Trichotillomania

Other Problems to Be Considered

  • Trichotillomania: Alopecic patches have unusual shapes and sizes and show broken hairs; no inflammation or epidermal change occurs. A scalp biopsy can be helpful if the diagnosis is difficult clinically.
  • Tinea capitis: The diagnosis is suggested by erythema, scaling, and crusting locally on the scalp.
  • Scarring alopecia and posttraumatic alopecia: These can be differentiated by the absence of follicular ostia or some degree of atrophy.
  • Syphilis: Syphilis rarely is seen but should be suspected in patients at high risk or with other signs or symptoms.
  • Telogen effluvium and androgenetic alopecia: Exclude these when hair loss is diffuse. In androgenetic alopecia, hair loss is patterned and usually is slowly progressive rather than acute. Differentiating telogen effluvium from diffuse alopecia areata is difficult in the absence of an obvious precipitating factor that can result in telogen effluvium. Noting hair loss on other hair-bearing areas can be helpful and favors a diagnosis of alopecia areata.

Workup

Procedures

Diagnosis usually can be made on clinical grounds; a scalp biopsy seldom is needed, but it can be helpful when the clinical diagnosis is less certain.

Histologic Findings

A histologic diagnosis of alopecia areata can be made when characteristic features are present. Horizontal sections usually are preferred to vertical sections because they allow examination of multiple hair follicles at different levels.

The most characteristic feature is a peribulbar lymphocytic infiltrate, which is described as appearing similar to a swarm of bees. The infiltrate often is sparse and usually involves only a few of the affected hairs in a biopsy specimen. Occasionally, no inflammation is found, which can result in diagnostic difficulties. A significant decrease in terminal hairs is associated with an increase in vellus hairs, with a ratio of 1.1:1 (normal is 7:1). Other helpful findings include pigment incontinence in the hair bulb and follicular stellae.

A shift occurs in the anagen-to-telogen ratio, which is not specific. The normal ratio is approximately 90% anagen phase to 10% telogen phase hair follicles; in alopecia areata, 73% of hairs are found to be in the anagen phase and 27% in the telogen phase. In longstanding cases of alopecia areata, the percentage of telogen-phase hairs can approach 100%. Degenerative changes of the hair matrix can be found but are uncommon. Eosinophils may be present in fibrous tracts and near hair bulbs.

More on Alopecia Areata

Overview: Alopecia Areata
Differential Diagnoses & Workup: Alopecia Areata
Treatment & Medication: Alopecia Areata
Follow-up: Alopecia Areata
Multimedia: Alopecia Areata
References
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References

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Further Reading

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Keywords

alopecia areata, hair loss, autoimmune alopecia, baldness

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Contributor Information and Disclosures

Author

Chantal Bolduc, MD, FRCP(C), Assistant Professor, Department of Dermatology, University of Montreal
Disclosure: Nothing to disclose.

Coauthor(s)

Harvey Lui, MD, FRCPC, Professor and Head, Department of Dermatology and Skin Science, Vancouver General Hospital, University of British Columbia; Medical Director, The Skin Centre, Lions Laser Skin Centre and Psoriasis and Phototherapy Clinic, Vancouver General Hospital
Harvey Lui, MD, FRCPC is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Society for Laser Medicine and Surgery, American Society for Photobiology, Canadian Dermatology Association, Canadian Dermatology Foundation, Canadian Medical Association, College of Physicians and Surgeons of British Columbia, Dermatology Foundation, European Academy of Dermatology and Venereology, National Psoriasis Foundation, North American Hair Research Society, and Photomedicine Society
Disclosure: Astellas Consulting fee Review panel membership; Amgen/Wyeth Consulting fee Speaking and teaching; LEO Pharma Honoraria Speaking and teaching; LEO Pharma Grant/research funds Investigator; Serono Grant/research funds Investigator; Galderma Grant/research funds Other

Jerry Shapiro, MD, FRCP(C), Clinical Associate Professor, Department of Medicine, Division of Dermatology, University of British Columbia, Canada
Disclosure: Nothing to disclose.

Medical Editor

Leonard Sperling, MD, Chair, Professor, Department of Dermatology, Uniformed Services University of the Health Sciences
Leonard Sperling, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory
Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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