Hair loss assessment and scalp examination

What it is

It combines the history, examination of the scalp and the part, a pull test and trichoscopy, and blood tests where the picture calls for them — iron and ferritin, thyroid, vitamin D, and after weight-loss surgery also protein, zinc and B12. Pattern loss, telogen shedding, traction from tight styling and scarring alopecia look alike to the patient and are treated very differently.

What this page covers

• History, pattern recognition, part-width measurement and hair pull test
• Trichoscopy of the scalp and the hairline
• Separating androgenetic, telogen, traction and scarring causes
• Telogen effluvium, including post-partum shedding
• Post-bariatric and post-GLP-1 hair shedding, with nutritional screening
• Iron, ferritin, thyroid and vitamin D work-up where indicated
• Traction alopecia from tight ponytails, extensions and head-covering fastening
• Recognition of frontal fibrosing alopecia before any hairline procedure
• Hair shaft breakage from chemical straightening, keratin and heat, which is not shedding at all
• Hair restoration candidacy and donor area assessment
• Referral for a diagnostic scalp biopsy where the diagnosis changes the plan

Who it suits

• Someone whose hair has changed and who wants to know why before anything is bought or booked — shedding that is new, or heavier than it was, or a part that looks wider, and nobody has yet said what it is.
• Someone whose shedding followed something: a delivery, a fever or an operation, a strict diet, weight-loss surgery or a weight-loss injection. That history often decides the visit more than the scalp does, which is why it is asked about in detail.
• Someone who has spent months on serums, supplements and sessions with no diagnosis behind them. Bring the bottles themselves — including what was bought abroad and what a relative recommended — rather than a list from memory.
• Someone considering something on the hairline — laser, forehead reduction, a transplant — who wants the scalp read before it rather than after; and someone who had a transplant elsewhere and is not happy with it.
• Not you if what you want is to leave with a prescription or a session booked today whatever the examination finds. This is a visit for a diagnosis first. Its honest end may be a blood test and a review rather than a treatment, and it may be a name you did not want to hear.

When we advise delaying or not treating

• Blood tests taken while you are on a hair and nail supplement. Almost all of them contain biotin in a high dose, and high-dose biotin interferes with laboratory immunoassays — it can make a thyroid result look abnormal when the thyroid is fine, and it can hide a result that is genuinely abnormal. Tell us what you take before the sample is drawn and ask when to stop it; a wrong thyroid result does not only waste a test, it sends the whole plan the wrong way.
• A request for a full panel of blood tests to check everything. Investigations are chosen from the clinical picture rather than ordered as a set list, and they are read alongside the examination rather than on their own; a result read on its own is a common route to being treated for something you do not have.
• A diagnosis from a photograph on WhatsApp. We decline it: the part is measured, the scalp is read under magnification — trichoscopy — and the hair is pulled gently at several sites. Your photographs are useful inside the visit and do not replace it.
• Hairline laser hair removal, cosmetic hairline shaping or forehead reduction, and a hair transplant — over a hairline that is receding. These are postponed until the scalp has been examined and a scarring alopecia excluded, because in frontal fibrosing alopecia they speed up the very loss you came about.
• A transplant while the loss is still moving, or where the donor area is not adequate, or where a scarring alopecia is active. Transplanting into a scalp that is still shedding gives a result that recedes around the grafts, and transplanting into an active scarring alopecia spends donor hair that cannot be replaced.
• Supplements with no deficiency documented on a test. There is no established benefit then, and high doses of vitamin A, biotin and selenium can do harm. After weight-loss surgery, replacement is coordinated with the team already looking after you rather than layered on top of what they prescribe.
• Scalp micropigmentation or a laser cap over a scalp nobody has diagnosed. Camouflage over an unnamed cause is months passing with the cause still underneath it.
• Pregnancy and breastfeeding do not postpone this visit; the examination and the blood work go ahead. What changes is what may be prescribed afterward: every medicine and supplement is checked for safety in pregnancy and breastfeeding before it is given, so tell us if you are pregnant, breastfeeding or planning a pregnancy.

Possible effects

The examination itself carries little in the way of physical risk, and saying that plainly is not the same as saying there is nothing to weigh. These are stated in full, because a decision to be examined and investigated — and then a decision to act on what is found — is not sound without them.

• The pull test. The hair is pulled gently at several sites and some hairs come away. That is what the test measures; it is not adding to your shedding.
• Trichoscopy. A magnifying lens held against the scalp. It does not break the skin and needs no anesthetic.
• The blood draw. A bruise, soreness, and lightheadedness in some people. And results that sit at the edge of the normal range: those are read with the examination and are often repeated rather than treated on the spot.
• An answer you did not come for. The examination can name a scarring alopecia, and hair lost from an area that has scarred does not come back; the aim of early treatment is to stop it spreading rather than to bring back what has gone — an aim, not something to be promised. It can also point away from the scalp altogether — to the thyroid, to iron, to the ovaries, or to an illness affecting the whole body — and then the next appointment is with another specialty.
• A visit that ends without a name. Some pictures cannot be read yet, and the honest answer then is review over time, photographs, or a biopsy — not a label chosen to end the conversation.
• If a scalp biopsy is needed. Local anesthetic, a small mark that stays, and in Fitzpatrick types IV to VI a risk of pigmentation or a keloid at the site; the site is chosen inside the hair and that is discussed beforehand rather than afterward. Healing is slower where diabetes is uncontrolled or immunity is suppressed.
• Photographs. Photographs taken at the same angle and light make change measurable. They are kept in your record, and nothing is published anywhere without your written consent — which you may refuse without any change in the care you receive.
• The visit asks something of you. The scalp has to be uncovered and the hair let down from its tie and pins, and some of the questions are personal. A chaperone is offered, and you may decline any part of the examination or any photograph at any point without it changing your care.

What deserves the most caution on this page is nothing that happens at the visit: it is what gets decided without one. Months spent on cosmetic sessions with a scarring alopecia widening underneath them, or a treatment built on a laboratory result that nobody read next to an examination. Where the examination says pattern hair loss, or alopecia areata, each has its own page and its own plan.

A note on darker skin

Most of the scalps examined here belong to Fitzpatrick types III to VI, and that changes what the examination has to look for rather than what can be treated. Redness around the follicle — one of the clearest signs of inflammation in fair skin — is barely visible in brown and darker skin, so the reading rests instead on whether the follicular openings are present or gone, on scale wrapped around the hair shaft, and on differences in hair caliber; which is why the scalp is read under magnification rather than by eye. What decides some of the questions here is hair texture rather than skin tone: chemical relaxing, heat, tight braids, extensions, and how a head covering is fastened and where its pins sit — asked directly and without blame, because central centrifugal cicatricial alopecia, which begins at the crown and widens outward, is common in coarse, tightly curled hair and is repeatedly managed for years as ordinary thinning. A pale, smooth patch in deeper skin is a sign to show us, not something to cover. If a biopsy is needed, its site is chosen inside the hair, and the possibility of pigmentation or a keloid there is discussed beforehand in types IV to VI, as is the darkening of entry points if scalp injections or needling later become part of the plan. Deeper skin does not make hair loss harder to treat; it makes it easier to miss, and magnification and direct questions are what make up for that.

Afterwards

• If blood tests were ordered, stop the hair and nail supplement before the sample is drawn, for as long as we tell you; the biotin in it can make a thyroid result look like something it is not. If the sample was already taken while you were on it, say so — it may need repeating.
• Bring the bottles themselves to the review rather than a list from memory: supplements, medicines, oils, and anything bought abroad.
• If the diagnosis is traction, change how the hair is secured from today: loosen the pull, move the pin points, lighten the extensions. That change is the treatment, and no medicine substitutes for it.
• If a deficiency was found and corrected, come back for the repeat test when you are told to; correcting a deficiency without measuring it again leaves the whole thing a guess.
• If you were referred — to endocrinology, to a dietitian, or back to the team that looked after your weight-loss surgery — go, and bring the result with you to the review.
• Photograph the same part in the same light every few months and keep the photographs. Hair changes more slowly than memory can hold, and memory is what makes people abandon a plan that was working.
• Report, without waiting for the next appointment: a new patch, pain or burning or scale on the scalp, a hairline moving back, an eyebrow thinning, a scalp sore that bleeds or will not heal, or shedding that continues past the point we agreed to review it.
• And before you start anything a relative, a pharmacy or a video has recommended — a medicine, a supplement or an oil — tell us about it first.

Honestly

What this visit produces is a diagnosis, not a product. A scarring alopecia has to be named early, because hair lost in scarred areas does not grow back and months spent on cosmetic sessions are months that cannot be recovered; and where the cause is nutritional or thyroid, correcting that matters more than any scalp session, since no injection compensates for a deficiency that has not been treated.

Common questions

See also

Trichoscopy, Pattern hair loss, Alopecia areata, Scalp injections (PRP)