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Diagnosing Hair Loss Subtypes


Veronica Richardson, MSN, ANP-BC, DCNP, discussed how she diagnoses hair loss subtypes in her session at the 3rd Annual Society of Dermatology Nurse Practitioners Symposium.

Hair loss continues to be a hot topic in dermatology, especially considering best practices in the diagnosis of subtypes and treatment. In a session on hair loss at the 3rd Annual Society of Dermatology Nurse Practitioners Symposium, held April 22-23, 2022, in Nashville, Tennessee, Veronica Richardson, MSN, ANP-BC, DCNP, reviewed the key clinical features and historical clues for subtype diagnosis.1

Central Centrifugal Cicatricial Alopecia

Richardson, who is nurse practitioner (NP), medical dermatology, at the Ruth & Raymond Perelman Center for Advanced Medicine at the University of Pennsylvania in Philadelphia, outlined the key features of central centrifugal cicatricial alopecia (CCCA). She noted it is almost exclusively seen in Black women and has a prevalence rate that varies from 2.7% to 16%.2

Premature loss of inner root sheath, follicular rupture, and follicular degeneration are some of the proposed causes of this hair loss. Other causes include fibroproliferative disorder and persistent low-grade inflammation that results in end stage fibrosis of the follicular unit. Hair care practices also can contribute to the pathogenesis of the disease, according to Richardson.

CCCA manifests as scarring patches or loss of follicular openings beginning on the crown of the head and spreading outward. Additionally, it is characterized by early stage hair breakage, follicular papules, pustules, erythema, scaling, and possibly an absence of overt inflammation, Richardson said.

To help in diagnosis, she recommended a 4mm punch biopsy from an area of active inflammation, and testing for any vitamin D, ferritin, erythrocyte sedimentation rate (ESR), and zinc deficiencies. Also, she recommended doing a complete blood count (CBC) if anemia is suspected.

Female Pattern Hair Loss

Discussing female pattern hair loss (FPHL), Richardson emphasized looking for gradual, increased scalp visibility, widening midline part, decreased ponytail size, and preservation of frontal hairline. Other symptom to watch include increased miniaturized follicles (T:V ratio < 4:1), a shorter anagen phase, and a longer telogen phase.

She recommended a patient work-up checking:

  • CBC
  • Micronutrients: Vitamin D, ferritin, ESR, zinc
  • Hormones or hormonal levels/: Thyroid-stimulating hormone (TSH), testosterone free/total, dehydroepiandrosterone sulfate (DHEAS)
  • Richardson suggested a biopsy only if there are concerns for concomitant scarring alopecia.

Frontal Fibrosing Alopecia

For frontal fibrosing alopecia (FFA), look for a band-like recession of the frontal hairline, loss of eyebrows, lonely hairs, forehead vein prominence, and perifollicular papules and pustules. Additionally, facial papules and occipital scalp may be involved. Itching may be absent in FFA, according to Richardson.

Histological features of FFA include lymphocyte predominant inflammatory infiltrate, and scarring. She recommended biopsy of the affected area, along with testing TSH to determinewhether the patient is prothrombin time (PT) dependent.

Alopecia Areata

Finally, Richardson described the characteristics of alopecia areata (AA). These characteristics are single or multiple round/oval hairless patches with visible follicular ostia, hairpull, exclamation point hairs, and possible nail dystrophy.

For acute AA, histological features of disease include peribulbar inflammation, melanin incontinence, increased catagen and telogen, miniaturization, and residual inflammatory cells in follicular stalae. Chronic disease features include having most follicles in the telogen phase and miniaturization.

For diagnosing AA, Richardson recommended checking:

  • TSH
  • Vitamin D, Ferritin, ESR, zinc
  • If anemia is suspected, check CBC. If there is a celiac/gluten sensitivity, check TTG Ab (transglutaminase IgA).
  • Baseline labs if systemic therapy is planned.


Richardson serves on the advisory boards for Boehringer Ingelheim, Bristol Myers Squibb, and Eli Lilly and Company.


  1. Richardson V. Getting to the Roots of Hair Loss. Presented at: The Society of Dermatology Nurse Practitioners Annual Symposium; April 22-23, 2022; Nashville, Tennessee.
  2. Lawson CN, Bakayoko A, Callender VD. Central Centrifugal Cicatricial Alopecia: Challenges and Treatments. Dermatol Clin. 2021;39(3):389-405. doi:10.1016/j.det.2021.03.004
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