How can patients differentiate normal shedding from alopecia recurrence?

How can you tell if you’re just shedding normally…or if alopecia is coming back? Understanding the difference between everyday hair loss and the early signs of alopecia recurrence can help you take the right next steps without unnecessary worry.

Introduction
Every day, it’s normal to lose 50–100 hairs. New strands grow in their place, so your overall hair volume stays pretty constant. But when hair loss suddenly accelerates or appears in patches, that could mean alopecia (especially alopecia areata) is flaring up again. Here’s how to spot the difference.

1. What Is Normal Hair Shedding?
   Hair goes through a cycle of growth (anagen), transition (catagen), rest (telogen), and shedding (exogen). At any time:

• About 85–90% of hairs are in anagen (growth).
• Around 5–10% are in telogen (rest/shedding).

Every morning or shower you may notice loose hairs in your brush, on the floor, or in the drain. That’s perfectly normal if:

• You lose up to 100 hairs per day.
• Hair comes out evenly from all over your scalp.
• You don’t see new bald patches forming.
• The hair you do shed looks like full shafts (no broken stubs).

Common triggers of increased—but temporary—shedding:
• Stressful event (illness, surgery, job change)
• New medications
• Hormonal shifts (postpartum, stopping birth control)
• Diet changes or sudden weight loss

Such spikes in telogen effluvium usually start 2–3 months after the trigger and settle down on their own within 6–12 months. (Castera L et al. 2005, in transient vs. persistent shedding studies.)

2. What Is Alopecia Recurrence?
   Alopecia areata is an autoimmune condition where your immune system attacks hair follicles. After treatment or spontaneous regrowth, it can come back at any time. Key features of recurrence:

• New, round or oval bald patches anywhere on the scalp (or beard, eyebrows, body).
• Exclamation-mark hairs—shorter stubble that’s narrow at the base.
• Black dots or yellow dots under dermoscopy (tiny signs of destroyed hairs).
• Nail changes (pitting, ridging) in about 10–20% of patients.
• May expand or merge into larger areas over weeks to months.

Gilhar A et al. (2017) explain that alopecia areata can recur in the same spot or elsewhere, often unpredictably. Unlike telogen effluvium, it’s not just an uptick in normal shedding—it’s a targeted attack on follicles.

3. Comparing Normal Shedding vs. Alopecia Recurrence

Feature	Normal Shedding	Alopecia Recurrence
Daily hair count	≤ 100 hairs/day	Variable—often less but in clumps
Distribution	Evenly over the whole scalp	Localized patches
Hair shaft appearance	Full, unbroken strands	Broken hairs, exclamation-mark hairs
Onset	Gradual, linked to a trigger	Abrupt, patchy
Duration	Resolves in 6–12 months	May persist or worsen without treatment
Scalp symptoms	Usually none	Sometimes mild itching or tingling
Nail involvement	No	Possible (pitting, ridges)
Dermoscopy	Uniform follicle pattern	Black/yellow dots, empty follicles

4. Practical Tips to Tell the Difference

• Track Your Shedding
– Keep a simple hair diary. Note how many hairs you shed each day (brush count, shower drain).
– Take monthly selfies of your part line and crown. Compare for any new thin spots or patches.

• Perform a Gentle Hair Pull Test
– On dry hair, grasp ~20 strands close to the scalp and gently tug.
– Normal: 1–2 hairs come out.
– Concerning: > 5 hairs consistently—especially if they’re from the same spot.

• Look for Patchy Loss
– Stand under a bright light. Scan your scalp with your fingers parting the hair.
– A circular or oval bald spot, even if small, isn’t normal shedding.

• Check Hair Shaft Ends
– Shedding hair from telogen effluvium has a tiny white bulb at the root end.
– Broken or tapered ends (exclamation-mark hairs) suggest alopecia areata.

• Monitor Related Signs
– Notice any nail changes (pitting or ridging).
– Feel for tingling, itching, or unusual sensitivity on the scalp.

5. When to Seek Professional Help
   If you observe any of the following, book an appointment with a dermatologist:
   – New bald patches or rapidly widening spots
   – Signs of exclamation-mark hairs or “black dots” under a magnifier
   – Persistent shedding that doesn’t ease after 6 months
   – Nail changes alongside hair loss

Your dermatologist may use:
• Dermoscopy – to spot yellow or black dots and assess follicle health.
• Pull test – to quantify active shedding.
• Scalp biopsy (rarely) – to distinguish between scarring and non-scarring alopecia.

6. Self-Assessment & Next Steps
   If you’re worried about alopecia areata returning, you don’t have to wait for a clinic visit to get a read on your symptoms. Consider taking a free, online symptom check for Alopecia Areata to see if your pattern of hair loss and other signs fit this condition. This can guide your conversation with a doctor.

7. Managing Anxiety Around Hair Loss
   It’s natural to feel concerned if you notice more hairs coming out. But remember:
   • Up to 100 hairs/day is normal.
   • Temporary telogen effluvium is common and self-limiting.
   • Early patchy loss can be treated more effectively than widespread disease.

Understanding what’s happening in your scalp lets you respond calmly—tracking changes, reducing stress triggers, and seeking help if needed.

8. Treatment & Prevention of Recurrences
   If alopecia areata does recur, early treatment gives better chances of regrowth. Options include:
   • Topical corticosteroids or contact sensitizers (e.g., diphenylcyclopropenone).
   • Intralesional steroid injections into patches.
   • Oral therapies in extensive cases (e.g., methotrexate, JAK inhibitors).

Lifestyle approaches to support hair health:
• Eat a balanced diet rich in proteins, iron, zinc, biotin.
• Manage stress with mindfulness, yoga, or counseling.
• Avoid harsh hairstyling, tight braids, heat or chemical damage.

Conclusion
Distinguishing normal shedding from alopecia recurrence comes down to pattern, quantity, and associated signs. Track your hair loss, watch for patchy spots, and note special hairs (exclamation-marks or broken fibers). If you detect any red flags—or just want peace of mind—use an online symptom check for Alopecia Areata and schedule a visit with a dermatologist. Early evaluation and treatment can help you keep your hair on track.

Speak to a doctor about any sudden, severe, or worrying symptoms—especially if hair loss is just one part of more general health issues. If you experience scalp pain, fever, significant weight loss, or other systemic signs, don’t wait to get urgent medical advice.