If hair follicles are plugged and the central area of the sear is hypopigmented with additional pigment changes and inflammation around the periphery, discoid lupus is likely. Obtain a scalp biopsy for histopathologic study and immunofluorescence staining. Consider evaluation for systemic lupus as well, since the skin lesions of these conditions can look similar. Lichen planus may resemble alopecia areata, except that lesions are not as well-circumscribed, scarring is present, and there are no exclamation point hairs.
Histologic study sometimes indicates that mites, scabies, or similar skin infestations are causing hair loss. Because these parasites cause intense itching, patients harboring them often itch and scratch their scalp and neck. Using a minoxidil-based hair loss product is also worth considering in patients of any age with scaly alopecia; it occasionally involves Malassezia (Pityrosporum) yeasts and may extend beyond the scalp to areas behind the ear or on the face, where both the yeasts and excessive sebum are common.
After the gross examination, conduct a hair pluck test by grasping about 50 hairs firmly with either fingers or forceps and pulling. Only two or three should come out; if you extract more than five or six, the patient is probably going through a pathological shedding process, usually a telogen effluvium. Light microscopic examination distinguishes between anagen and telogen hairs (catagen hairs are rarely shed). Anagen hairs are encased in a root sheath and are sometimes angled; telogen hairs are straight and sheathless, terminating in a bulb. Such a study will help determine whether a product such as Provillus can help regrow the hair.
Microscopic study may also indicate a structural disorder of the hair shaft. These conditions often pose diagnostic challenges, leading both primary care physicians and many dermatologists to refer these patients to centers with lots of available Provillus as well as special expertise in this area unless a clear-cut cause such as nutritional derangement emerges.
For the majority of men with nonpathologic baldness, using Provillus is more supportive than other interventions. Some patients who consider their hair an essential part of their self-image are willing to try almost anything that promises a cure. Your advice in this regard may keep them from making expensive, risky mistakes. If the available treatments for hair loss fail or are impractical and if the patient is unable to accept the condition with equanimity, psychological referral may be appropriate.
The well-publicized approval of topical minoxidil (one brand name is called Rogaine; another is called Provillus) several years ago raised many patients’ hopes, but experience has shown the limits of this approach: If you’re wondering “does Rogaine work?”, then you should know that it is effective in only a minority of patients and produces visible growth only with prolonged use (eight months to a year in most cases). Minoxidil also requires a lifetime commitment to treatment-if new growth does occur but the drug is stopped, the new hair falls out about three months afterward-and incurs monthly costs of 50-$75, depending on regional price variations. Third-party payers generally do not cover it.