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

Click here to take a test on this article and claim a certificate on MIMS Learning

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins


Already registered?

Sign in

Before commenting please read our rules for commenting on articles.

If you see a comment you find offensive, you can flag it as inappropriate. In the top right-hand corner of an individual comment, you will see 'flag as inappropriate'. Clicking this prompts us to review the comment. For further information see our rules for commenting on articles.

comments powered by Disqus