Hair Loss Diagnosis

Before recommending or performing a hair restoration procedure, a hair restoration doctor will conduct a scalp examination to perform a hair loss diagnosis. If the examination indicates that hair loss may be due to a condition other than male or female pattern baldness, the physician will seek the cause with other diagnostic measures. In some cases an underlying condition may have to be treated before hair restoration is undertaken.

Hair Pull

A hair pull is a diagnostic procedure used in virtually every patient with a complaint of unexplained hair loss, to assess the presence or absence of any abnormalities in the hair growth cycle. About 25 to 50 hairs are removed from the scalp by a series of gentle hair pulls. Normally only a few hairs are dislodged with each pull.

When more are removed the possibility of an abnormality of hair growth cycling is indicated; the ends of the pulled-out hairs may be examined under a microscope to evaluate the condition of the hair shaft and the bulb (the end of the hair shaft extracted from the hair follicle).

Variations of the hair pull are the phototrichogram and hair window:


Hairs are clipped or shaved in an area of the scalp and consecutive photographs taken over a period of 3 to 5 days to determine the pattern of hair growth.

Hair window

Hairs are clipped or shaved in an area of the scalp and hair growth is evaluated over the next 3 to 30 days. Abnormalities of hair growth cycling is a relatively uncommon cause of hair loss but may occur at any age. Underlying causes of these abnormalities include thyroid hormone imbalance, nutritional deficiencies, side effects of certain drugs, anemia and other systemic illness, and psychological stress.

Scalp Biopsy

A biopsy of the scalp is usually performed only if additional information is needed to evaluate the mechanism of hair loss inside the hair follicle. Biopsy is not necessary in the great majority of patients evaluated for hair loss and hair restoration.

Hair Shaft Evaluation

If a hair shaft abnormality or infection is suspected, the hair shafts removed from the scalp by hair pull are examined under a microscope. Hair shaft abnormalities and fungal, bacterial or viral infection can be responsible for hair loss associated with hair breakage, hair shedding and hair that is unruly.

Hair Analysis

Hair analysis is a laboratory test performed if a hair shaft abnormality needs to be assessed for (1) altered hair-protein profile due to an inherited abnormality, or (2) drug ingestion or heavy metal contamination. Hair analysis is ordered by a hair specialist physician only to determine the cause and mechanism of a hair shaft abnormality. The test has no value for the diagnosis of systemic disease or nutritional status, contrary to claims by non-physician “hair analysis specialists”.

Fortunately, most persons seeking hair restoration in the U.S. are among the 80 million men and women who have male and female pattern hair loss, a condition simple to diagnose and easy to treat. Extensive diagnostic work-ups for these easily recognized conditions are usually not necessary. There are other causes of hair loss, however, and it is essential that the cause of hair loss be evaluated before hair restoration is undertaken.

The Psychology of Hair Loss

Hair loss is not just a physical issue. It can also have a significant psychological impact. This impact may be more obvious for women but the effects on men should not be underestimated. Hair loss can result in anxiety, withdrawal and depression. Considerable research has been undertaken to more clearly understand the psychology of hair loss.

This research can help sufferers recognize the emotions they may experience. It is important that you take time to think about how the loss of your hair makes you feel as this will help you make the right treatment choice for you. The research has shown that there are several common reactions to hair loss.

These include:


Hair loss in men commonly triggers masculinity issues. Hair has historically, in most cultures, been associated with strength and manliness. As hair loss can cause a drastic change in one’s appearance, it is not surprising that worrying questions arise. Will I still be attractive to others? Will I look older than I am? Will this affect my job prospects? Will my friends laugh at me? These valid concerns can result in feelings of fear and panic at the prospect of hair loss.


Some men may find it difficult to admit they are losing their hair, even to themselves. One manifestation of this is men going to great lengths to hide hair loss. A classic example of this reluctance to admit there is a problem is the comb over. It is not unheard of for a husband to keep his hair loss a secret, even from his wife. This unwillingness to come to terms with hair loss can lead to poor treatment choices.


Taunting or teasing from friends and colleagues about hair loss can lead to feelings of humiliation. How to deal with such comments can be a real problem. You may feel that if you react at all, it will show that you care about your hair and this may be perceived as vanity and result in further and more severe teasing.


The aforementioned reactions to hair loss may lead to a feeling of desperation. A desperate person may make impulsive and unwise choices.


This feeling can go hand in hand with that feeling of desperation. For example, men suffering from hair loss in several areas of their head may focus only on one area (i.e. the monk’s spot). This fixation on that one area may result in their failing to look at their hair loss holistically.


Unsurprisingly, men experiencing hair loss may be jealous of their friends who have full heads of hair.


Even though hair loss in men is very common, men report that they feel isolated and alone in the experience. Traditional models of male behaviour still deem the sharing of feelings and worries as “unmanly”. That is, being open about your feelings is perceived as a sign of weakness.

We do understand the aforementioned issues and we listen!

Personalized support with appropriate counseling referral to practitioners specializing in issues in this field will be a consideration, as you deem it necessary.

Other Hair Loss Causes

Alopecia Areata

Alopecia areata (AA) is a recurrent disease, which can cause hairloss in any hair-bearing area. The most common type of alopecia areata presents as round or oval patches of hair loss most noticeably on the scalp or in the eyebrows. The hair usually grows back within 6 months to one year. Most patients will suffer episodes of hair loss in the same area in the future. Those who develop round or oval areas of hair loss can progress to loss of all scalp hair (alopecia totalis).

The cause of alopecia areata is unknown but commonly thought to be an autoimmune disorder (the body does not recognize the hair follicles and attacks them). Stress and anxiety are frequently blamed by patients as the cause of their hair loss. The most common treatment is with steroids (cortisone is one form) either topically or by injection. The outcome of treatment is good when the alopecia areata process is present less than one year and poor, especially in adults, if the disease has been present for longer periods of time. Minoxidil (Rogaine®) can help to regrow hair. Surgical treatment of this disorder is not recommended. If you have questions concerning Alopecia areata, please let us know.

Traction Alopecia

Traction alopecia is caused by chronic traction (pulling) on the hair follicle and is seen most commonly in African-American females associated with tight braiding or cornrow hair styles. It is generally present along the hairline. Men who attach hairpieces to their existing hair can experience this type of permanent hairloss if the hairpiece is attached in the same location over a long period of time.

Trichotillomania is a traction alopecia related to a compulsive disorder caused when patients pull on and pluck hairs, often creating bizarre patterns of hairloss. In long term case of trichotillomania, permanent hairloss can occur.

Scarring Alopecia

Hair loss due to scarring of the scalp is called scarring alopecia. Scarring can be due to a variety of causes. Traction alopecia over a period of time may lead to scarring and permanent hair loss. Trichotillomania (compulsive hair-plucking) can cause permanent scalp scarring over time.

Injury to the scalp caused by physical trauma or burns may leave permanent scars and permanent hair loss. Diseases that may cause permanent hair loss due to scalp scarring include (1) the autoimmune conditions lupus erythematosus and scleroderma, and (2) bacterial infections such as folliculitis, fungal infections, and viral infections such as shingles (herpes zoster).


Trichotillomania is the name given to habitual, compulsive plucking of hair from the scalp or other hair-bearing areas of the body. Over time, continual plucking of scalp hair will result in a hairless area-a bald spot. Long-term trichotillomania can result in permanent damage to scalp skin and to scarring alopecia.

It is not known whether trichotillomania should be classified as a habit or as obsessive-compulsive behavior. In its mildest form, trichotillomania is a habitual plucking of hair while a person reads or watches television. In its more severe forms, trichotillomania has a ritualistic pattern and the hair-plucking may be conducted in front of a mirror. The person with trichotillomania often has guilt feelings about his or her “odd” behavior and will attempt to conceal it.

Triangular Alopecia

The cause of triangular alopecia is not known, but the condition can often be treated medically or surgically. The characteristic pattern of hair loss in triangular alopecia is thinning or complete loss of hair in the scalp area around the temples. If hair loss is not complete, the remaining hairs are often “miniaturized”-fine-textured hairs of thin diameter. Triangular alopecia sometimes begins in childhood with unexplained hair loss in the temporal areas of the scalp.

Telogen Effluvium

Telogen effluvium is the name given to hair loss that is caused when a large percentage of scalp hair follicles are shifted into the telogen or “shedding phase” of hair growth. The cause of this abnormally timed telogen phase may be hormonal, nutritional, drug-related or associated with stress.

Loose-Anagen Syndrome

Loose-anagen syndrome occurs most frequently in fair-haired persons. During the anagen (growth) cycle of hair, scalp hairs sit so loosely in the follicles from which they grow that they can be easily extracted by combing or brushing. The condition may appear in childhood and gradually improve or disappear over time.

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