The scalp is often overlooked during dermatologic evaluations. A thoughtful scalp exam requires more than a quick glance. It demands attention to detail, the right tools, and cultural awareness.
Accurately diagnosing hair and scalp disorders starts with a thorough history. Sometimes this can’t be accomplished in a standard visit, so consider scheduling a dedicated “hair loss visit” to ensure there is enough time for a careful evaluation. Questions should include:
Always begin by asking permission. Patients should feel comfortable and respected throughout the evaluation. When possible, wigs, extensions, or braids should be removed to allow full visualization. The hair should be gently parted, and the scalp examined section by section. A methodical approach ensures that no findings are overlooked, improving both diagnostic accuracy and patient trust.
Assess the pattern of hair loss (localized or diffuse), and which regions are affected (frontal, temporal, crown). Examine hair density for (uniform vs variable), and inspect the scalp for findings such as scaling, redness, pigmentation changes, scarring, or loss of follicular ostia. Evaluate the hair shaft for evidence of damage, and perform a hair pull test to assess active shedding. When necessary, a 4mm punch biopsy can provide definitive information to guide diagnosis and treatment.
Hair and scalp evaluation should also include areas outside the scalp, which can provide important diagnostic clues. Examine in and behind the ears for signs of seborrheic dermatitis, psoriasis, or discoid lupus. Assess facial hair, as loss may indicate alopecia areata (AA) or frontal fibrosing alopecia. Inspect the nails, which can reveal changes associated with psoriasis, AA, or iron-deficiency anemia. Finally, check for lymphadenopathy, which may be present in tinea capitis or secondary bacterial infections such as Staphylococcus.
Simple but essential tools (cotton-tipped applicators (for parting hair), gloves, proper lighting, magnifiers, and a dermatoscope) can greatly enhance a scalp evaluation. Using a dermatoscope to perform trichoscopy allows clinicians to distinguish scarring from non-scarring alopecia, identify perifollicular changes, and monitor response to therapy.
Many clinicians are accustomed to making a quick diagnosis based on history alone or a distant visual exam. This approach should be avoided during a hair and scalp evaluation, as important clinical clues may be missed. When examining the hair of Black patients, it is particularly important to avoid the “Lean In” - leaning toward the patient to inspect the scalp without proper touch. Instead, always touch and examine the scalp thoroughly and respectfully to ensure an accurate evaluation and build patient trust.
Hair care practices vary widely across cultures, and these differences can impact both scalp health and treatment adherence. For example, many Black patients wash their hair weekly or biweekly, so recommending a medicated shampoo “once daily” is unrealistic and may even damage the hair or strain the patient-provider relationship. High-tension hairstyles, chemical relaxers, and heat styling can also contribute to hair and scalp conditions and should be discussed respectfully. Asking open-ended questions such as, “Tell me about your hair care routine,” demonstrates cultural humility and helps clinicians tailor treatment plans to the patient’s needs.
Buchi Neita, MCMSc, PA-C, CAQ-Derm, DipACLM, is a physician assistant with Epiphany Dermatology in Peachtree City, GA. She enjoys fitness, nutrition, and lifestyle medicine as well as spending time with her two sons. She joined the Elevate-Derm Alliance as an Advisory Board Member in 2024 and is the co-host of the SkinSync Podcast.