How do doctors track progression of alopecia?

Tracking the progression of alopecia is a key part of alopecia evaluation. By combining clinical exams, standardized tools and patient feedback, doctors can monitor how hair loss changes over time and adjust treatment plans accordingly.

Why tracking matters
Accurate alopecia evaluation helps to:

• Measure response to treatments
• Identify sudden changes that may need urgent care
• Guide decisions about starting, stopping or switching therapies
• Provide patients with realistic expectations

Key components of alopecia evaluation

1. Medical history and symptom diary
   • Onset and pattern of hair loss (patchy, diffuse, frontal, etc.)
   • Family history of hair disorders
   • Triggering events (illness, stress, medications)
   • Associated symptoms (itching, scaling, pain)
   • Patient’s own observations, photos or notes

2. Physical examination
   • Scalp inspection for bald patches, thinning or scarring
   • Assessment of eyebrows, eyelashes and body hair
   • Scalp skin condition (redness, scaling, inflammation)
   • Nail changes (pitting, ridging) often seen in alopecia areata

3. Severity of Alopecia Tool (SALT) score
   Developed by Olsen et al. (2004) for alopecia areata, the SALT score quantifies scalp hair loss:

   • Divide the scalp into four regions (vertex 40%, right + left profiles 18% each, posterior 24%)
   • Estimate percentage hair loss in each region
   • SALT = sum of (region % × hair loss %)
     Example: 50% loss in vertex = 0.4 × 50 = 20 points
     SALT ranges from 0 (no loss) to 100 (complete scalp baldness)

4. Global photographic assessment
   • Standardized, high-resolution photographs are taken from multiple angles
   • Consistent lighting, camera settings and patient positioning
   • Provides objective visual records for comparing baseline and follow-up visits

5. Trichoscopy (dermoscopy of the scalp)
   • Non-invasive magnified view (×10–×70)
   • Identifies characteristic features: – Yellow dots (follicular keratin) in alopecia areata
   – Exclamation-mark hairs (narrowing at the base)
   – Broken hairs, black dots
   • Helps distinguish subtypes and guides prognosis

6. Hair pull test
   • Gentle pull of ~50–60 hairs at the root
   • More than 10% that come away may indicate active shedding
   • Repeat over time to gauge progression or improvement

7. Hair count and hair weight measurement
   • Patients mark a small 1 cm² area on the scalp
   • Daily collection of shed hairs from that area or comb collection
   • Counting hairs over a fixed period (e.g., 24 hours)
   • Weighing clipped hairs to assess density changes

8. Scalp biopsy (select cases)
   • Reserved for unclear diagnoses (e.g., scarring alopecias)
   • 4 mm punch biopsy provides miniaturization, inflammation or fibrosis data
   • Guides specific treatment when non-invasive methods are inconclusive

9. Patient-reported outcome measures
   • Quality-of-Life Index (e.g., Dermatology Life Quality Index, DLQI)
   • Itch, pain or distress scales (0–10 visual analog scales)
   • Impact on daily activities, work, social life
   • Improves understanding of emotional burden

10. Digital and mobile tools
    • Apps for patients to upload weekly photos
    • Automated hair-count algorithms under development
    • Enables remote alopecia evaluation and monitoring

Lessons from other fields
In liver disease, non-invasive indices like transient elastography or FIB-4 score (Wai et al. 2003; Castera et al. 2008) help track fibrosis without biopsy. Similarly, alopecia evaluation focuses on non-invasive, repeatable measures—photography, trichoscopy and scoring systems—to minimize discomfort and cost while maximizing reliability.

When to reassess
• Every 3–6 months during active treatment
• More frequently (monthly) if rapid hair loss or new symptoms occur
• After treatment changes (e.g., starting JAK inhibitors, immunotherapy)
• Before considering surgical options like hair transplantation

Free online tool
If you’re noticing patchy or diffuse hair loss, you might consider doing a free, online symptom check for Alopecia Areata.

Final thoughts
Tracking alopecia progression combines objective scoring, imaging and patient feedback. This comprehensive approach ensures you and your doctor have clear, measurable data to guide treatment decisions. If you notice any sudden or severe changes—such as rapid, widespread hair loss, scalp pain or signs of infection—speak to a doctor right away. For any persistent or worrying symptoms, professional evaluation is essential.