S1 Guideline for Diagnostic Evaluation in Androgenetic Alopecia in Men, Women and Adolescents

U. Blume-Peytavi; A. Blumeyer; A. Tosti; A. Finner; V. Marmol; M. Trakatelli; P. Reygagne; A. Messenger

The British Journal of Dermatology. 2011;164(1):5-15.

Clinical Picture

Men

In most men, AGA involves the fronto temporal area and the vertex, following a pattern corresponding to the Hamilton–Norwood scale (Fig. 1).^[17,18] In some instances, however, men develop diffuse thinning of the crown with retention of the frontal hairline with a pattern that resembles the Ludwig type observed in women.

(Enlarge Image)

Figure 1.

Hamilton–Norwood classification of male balding.¹⁸

Women

Female pattern hair loss may have three different patterns:

Diffuse thinning of the crown region with preservation of the frontal hairline. There are two scales that describe this pattern: the commonly used 3-point Ludwig scale (Fig. 2)^[19,20] and the 5-point Sinclair scale (Fig. 3).^[21–23]
Thinning and widening of the central part of the scalp with breach of frontal hairline (Olsen scale: Christmas tree pattern, Fig. 4).^[20,24]
Thinning associated with bitemporal recession (Hamilton–Norwood type, Fig. 1).^[17,18,24]

However, involvement of the parietal and occipital scalp with diffuse alopecia is clinically observed (Fig. 5).^[24,25]

(Enlarge Image)

Figure 5.

Regions of the scalp potentially involved in pattern hair loss.^20,24 F, frontal; M, mid; T, temporal; V, vertex.

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Table 1. Diagnostic evaluation form for androgenetic alopecia
1. History
Age	___ years
Sex	□ Male
Sex	□ Female
First manifestation of hair loss	Age: ___
Course of hair loss	□ Acute
	□ Chronic – Intermittent
	□ Chronic – Persistent
Complaining of increased shedding of hair	□ Moderate
	□ Severe
	□ No
Complaining of increased thinning of hair	□ Diffuse
	□ Localized
	□ No
Itching	□ Yes □ No
Dandruff	□ Yes □ No
Trichodynia	□ Yes □ No
Family history of androgenetic alopecia	□ Yes
	□ Mother/maternal side □ Father/paternal side
	□ No
Concomitant diseases (chronic, autoimmune, recently diagnosed, with possibly chronologic relation to hair loss)	___________
Previous surgery	___________
Eating behaviour
Strictly vegetarian diet	□ Yes □ No
Crash diet or eating behaviour disorders	□ Yes □ No
Important weight loss > 5–10 kg	□ Yes □ No
Weight	___________
Height	___________
Drug history (e.g. pro-androgenic, antithyroid, anti-epiletics, β-blocker, chemotherapeutics, supplements)	Please provide details: ___________
Smoking	□ Yes □ No
Only in women
Menstrual cycle	□ Regular □ Irregular
Menopause	___________
Oligomenorrhoea	□ Yes □ No
Amenorrhoea	□ Yes □ No
Since when	___________
Hormonal contraception	□ Yes □ No
Hormonal replacement therapy	□ Yes □ No
Fertility treatment	□ Yes □ No
Specify drug and duration	___________
Succesful and unsuccessful pregnancies	___________
Excessive facial and/or body hair growth	□ Yes □ No
Skin changes (acne)	□ Yes □ No
Seborrhoea of scalp/skin	□ Yes □ No
In children and adolescents
Hair loss	□ Congenital □ Acquired
Signs of pubertal development	□ Yes □ No
If yes, at which age	___________
If yes, at which age	□ Mature □ Premature
2. Clinical examination
Hair density	□ Normal
	□ Decreased
	□ Pattern distribution
	□ Alopecic patches
Scalp skin	□ Normal
	□ Erythema
	□ Scaling
	□ Seborrhoea
	□ Pustules
	□ Signs of scarring
	□ Others (e.g. psoriasis, pigmentation)
Eyebrows/eyelashes	□ Normal
Eyebrows/eyelashes	□ Abnormal
Facial and body hair	□ Normal
	□ Excessive hair growth/hirsutism
	□ Decreased axillary hair
	□ Decreased pubic hair
Signs of acne	□ Yes □ No
3. Laboratory
Iron, ferritin	□
TSH	□
Blood haemoglobin	□
TPHA/RPR if indicated by clinical DD	□
In women only, if hormonal dysregulation is suspected
FAI [total testosterone (nmol L⁻¹) × 100 SHBG (nmol L⁻¹)]	□
DHEAS	□
Prolactin	□
4. Hair examination tests
Pull test	□
(Video-) Dermoscopy/loupe	□
Hair shaft examination	□
Trichogram	□
Biopsy	□

DD, differential diagnosis; DHEAS, dehydroepiandrosterone sulphate; FAI, free androgen index test; RPR, rapid plasma regain; SHBG, sex hormone-binding globulin; TPHA, treponemal haemagglutinin assay; TSH, thyroid-stimulating hormone.

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