Diagnosis of androgenic alopecia in men

Diagnosis is usually on clinical grounds.

A detailed history of the patient should be taken which should include:

• first manifestation and course of hair loss (chronic or intermittent)
• the intake of anabolic steroids or supplemental androgens
• change in hair style - special hairstyles (traction)
• smoking status - a dose dependent association has been described in male patients who develop moderate to severe AGA
• UVR exposure - important in Mediterranean countries
• family history of androgenic alopecia
• eating habits e.g. - strict vegetarians, crash diet
• drug history e.g. - pro-androgenic, antithyroid, anti-epiletics, chemotherapeutic agents
• past medical history - systemic or newly diagnosed diseases within 1 year prior to first signs of hair loss might indicate that the other causes or aggrevating factors is responsible for the hair loss e.g.- diffuse effluvium as a result of severe infection, iron deficiency or thyroid dysfunction (1)

Clinical examination:

• in scalp - there can be concomitant signs of inflammation, seborrhoea and signs of scarring (1)
• hair thinning -
  • typical male pattern distribution with thinning of the hair of the crown and frontal/parietal areas and sometimes anterior recession (1)
  • finer shorter hairs (miniaturization) associated with reduced hair density may lead to baldness which is usually a more common occurrence in men than in women (2)

Assessment of hair loss can be done using the "pull test" (it has high inter-observer variation and is influenced by shampooing), more advanced tools for assessment include Dermoscopy or loupe, photographic techniques, trichogram (microscopic examination of hair roots) (1)

Laboratory testing is usually not necessary unless there in a suspicion of another underlying disorder or associated disease (1)

• men above 45 years who are starting on finasteride therapy should have the prostate-specific antigen (PSA) value measured before starting therapy (1)
• syphilis is a rare cause of atypical alopecia (1,3) - TPHA/RPR if indicated by clinical differential diagnosis

Reference:

• 1. Blume-Peytavi U et al. S1 guideline for diagnostic evaluation in androgenetic alopecia in men, women and adolescents. Br J Dermatol. 2011;164(1):5-15.
• 2. Olsen EA et al. Evaluation and treatment of male and female pattern hair loss. J Am Acad Dermatol. 2005;52(2):301-11.
• 3. Kennedy C. Syphilis presenting as hair loss. BMJ 1976;2: 854.