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Now we're going to move on to do the hair exam or scalp exam, and this is an important part
of the dermatologic exam that you don't want to miss. And I'm just going to focus on
3 specific conditions, and we'll start with alopecia androgenetica. This is simply the hair loss
that accompanies aging in both men and women. There's a particular pattern in men where
typically men lose hair on the vertices of the scalp in a very predictable way over time.
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There's no evidence of inflammation, you shouldn't see erythema or scale or any other
concerns that should be symmetric as well. That will be typical of "male pattern baldness".
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Women also lose hair progressively over time as they get older. It's a different pattern,
however, it tends to be more diffusely across the entire top of the scalp, less so in the ears
but it's more diffusely scattered than a specific pattern with a receding hairline. So that's
alopecia androgenetica and it's not something we get to worked up about. The next condition
is alopecia areata. This is an autoimmune mediated disease and instead of it being symmetric
and in specific predictable locations, alopecia areata is more focal and it can really be
anywhere on the entirety of the scalp. So the patient may report that "I'm just losing hair in
one specific patch over here" and when you move the hair away you'll take a look and you'll
see a complete bald spot in one little discrete area. There is a specific test that we can do
to really discern whether or not alopecia areata is happening. I will just add that there should
not be any signs of inflammation, this is a disease happening at the microscopic level so you
shouldn't see scarring, erythema, redness, tenderness. Any of those things would not be
consistent with this autoimmune disease. However, if you were to look in that patch, you may
see what's called exclamation point sign, which is these broken hair follicles that have a
somewhat tapered ending on them, so you could see that on the scalp. And that would be
one of the most prominent features. The next condition I wanted to talk about is telogen
effluvium. Telogen effluvium is also relatively common and it is similar to female pattern
alopecia androgenetica, it's diffuse nonspecific hair loss but it's occurring under specific
typically transient situations. So pregnancy. Oftentimes a few months after pregnancy a
patient may report that I'm losing all my hair. Or in the setting of having bariatric surgery
or some other major surgery this may happen. Occasionally, you can see with malnutrition
or hypoalbuminemia, other sort of systemic stressors to the body. And one great way to
confirm that the patient really is losing hair because sometimes people say all their hair is
falling out and you could see a full head of hair and something called the hair pull test. And
what you'll simply do is grab an area of hair, you want to make sure you've got maybe 60 or
so not that you're going to count specifically, but just imagine about 60 or so hairs and then
simply pull back between your finger and your thumb and see how many hairs come out with
that simple test. If you get more than 3-5 hairs; in this case I got one, two; two total hairs. If you
get more than 3, 4, or 5 or more then that would be abnormal and would suggest that the
hair follicles are releasing their hair a lot easier than they should and that would at least
support the patient's report that they are in fact losing all of their hair. At that point, you'd
have to figure out exactly what the cause is in this circumstance. At this juncture, I'll just
make one final point as we wrap up the skin exam. It's really important to acknowledge that
not all skin tones and hair types are the same when you're assessing the skin and assessing
the hair. And in fact people who have darker skin are more prone to certain types of skin
diseases. Those who are more fair-skinned are in particular more prone to sun cancers. And
folks who have different types of hair are also more likely to develop certain conditions like
traction alopecia in African Americans or acne keloidalis nuchae on the back of the head also
in African Americans. Keloids maybe more common or definitely more common in folks who are
darker skinned as well. So, it's important to make sure that you're educated about the
different kinds of conditions that can occur in different skin types.