Differential diagnoses: Alopecia

Dr Nigel Stollery compares similar presentations and offers clues for their diagnosis, including alopecia areata, pseudopelad, male pattern baldness and lichen planopilaris

Alopecia areata


  • Most common in teenagers
  • Males and females equally affected, but develops later in life in females
  • Typically, one or more patches develop, usually on scalp
  • Usually regular or round areas of loss with normal-looking skin
  • Occasionally, skin may be red, with fine scale and mild itch


  • Diagnosis usually clinical
  • Managed in primary care
  • If in doubt, a biopsy can be taken
  • If less than half scalp affected, 80% recover without treatment
  • Treatment includes topical steroids, steroid injections, minoxidil and topical immunotherapy



  • Cicatricial alopecia
  • Scarring alopecia with abnormal-looking skin in affected areas
  • Irregular areas of hair loss
  • Discrete areas of hair loss, most commonly on parietal scalp
  • Typically, worsens then improves in cycles
  • Can affect non-scalp hair, but very rarely


  • Diagnosis of exclusion
  • Biopsy usually undertaken to look for other causes
  • Urgent referral may be needed
  • Treatment includes topical and intralesional steroids, with or without topical tacrolimus
  • Hydroxychloroquine with or without oral prednisolone can be helpful in severe cases

Male pattern baldness


  • Most common cause of hair loss in men
  • Affects >50% of men by the age of 50 years
  • Typically, temples and crown affected first
  • Progressive condition
  • Genetic component, usually with familial history
  • Hair follicles present, but much smaller than normal
  • Underlying skin looks normal


  • Minoxidil and finasteride may help, but improvement lost after stopping treatment
  • Surgical treatment not available on the NHS

Lichen planopilaris


  • Scarring alopecia mainly affecting scalp
  • Rare inflammatory disorder
  • Cause unknown
  • Usually affects young women
  • Commonly associated with lichen planus in other areas
  • Smooth white skin with no visible follicles


  • Refer to secondary care
  • Treatment includes topical and intralesional steroids, topical tacrolimus
  • Oral treatment includes hydroxychloroquine, tetracycline, acitretin, griseofulvin and mycophenolate
  • Response very variable
  • Dr Stollery is a GP in Kibworth, Leicestershire

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