Alopecia may be scarring or non-scarring, localised or diffuse, inflamed or non-inflamed 

Diffuse non-scarring 

• Physiological: normal ageing process 
• Female pattern hair loss (FPHL)- thinning over crown 
• Telogen effluvium/ excessive shedding occurs three–four months after pregnancy/ other major event 
• May be component of polycystic ovarian disease in young women 
• Consider any new medications 

Localised non-scarring 

• Alopecia areata 
• Patchy hair loss with exclamation mark hair 

Diffuse inflamed non-scarring 

• Consider seborrhoeic dermatitis or psoriasis (may also rarely cause scarring) 

Localised inflamed non-scarring 

• Consider tinea infection (may also cause scarring) 
• Consider psoriasis or seborrhoeic dermatitis 

Scarring 

• Loss of hair follicles with or without inflammation and accompanied by scarring 
• Local or diffuse 
• Causes include: Lichen planus

• Dermatology Referral Criteria 
• Inflammatory scarring alopecia 
• Diagnostic uncertainty 
• Persistent or extensive alopecia (scarring or non-scarring) 
• Hairpiece or wig prescription for alopecia caused by trauma or disease resulting in psychological distress (if available) 

Diffuse non-scarring 

• Reassure patients with mild FPHL that condition is physiological 
• Reassure patients that Telogen effluvium will recover spontaneously 
• Diffuse alopecia: check full blood count, ferritin and thyroid function 
• Patients with severe degree of alopecia caused by disease can be considered for NHS wig prescription 

Localised non-scarring 

• Reassure patients with alopecia areata that spontaneous regrowth is likely 
• Generally good outcome in patients with short history and limited extent 
• Trial of potent topical steroid lotion for three months 

Diffuse inflamed non-scarring 

Treatment: 

• Coal tar + salicylic acid ointment ( eg Cocois/Sebco) 
• Anti-fungal shampoo ( eg ketoconazole) 
• Topical steroid lotion/mousse/foam 

Localised inflamed non-scarring 

• Send hair pluckings to mycology lab 
• If dermatophyte infection confirmed, treat with oral terbinafine 
• Treat as for diffuse inflamed non-scarring if psoriasis or seborrhoeic dermatitis 

Scarring 

• Requires secondary care referral 

1. NHS Inform: www.nhsinform.scot 
2. Alopecia help and advice Scotland: https://www.alopecia.org.uk/ 
3. British Association of Dermatologists: http://www.bad.org.uk/for-the-public/patient-information-leaflets 
4. Dermnet NZ: www.dermnetnz.org