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ukmla 2026

Alopecia

Hair loss: non-scarring (alopecia areata, androgenetic, telogen effluvium) or scarring (lichen planopilaris, discoid lupus). Alopecia areata shows exclamation mark hairs

Review date
reviewed 2026-04-05
Reading time
5 min read
Author
Dr Kola Tytler MBBS CertHE MBA MSt MRCGP
Dermatologycommonchronic
On this page
Condition details
Dermatology
common
5 min read
reviewed 2026-04-05
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About This Page

This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.

Key points

  • Non-scarring (follicles preserved): alopecia areata, androgenetic, telogen effluvium, traction
  • Scarring (follicles destroyed, irreversible): lichen planopilaris, discoid lupus, frontal fibrosing
  • Alopecia areata: smooth round patches + "exclamation mark" hairs. Autoimmune
  • Androgenetic: commonest overall. Male (bitemporal + vertex) or female (diffuse thinning)
  • Telogen effluvium: diffuse shedding 2-4 months after trigger (post-partum, illness, stress)

Overview

Key distinction: non-scarring (follicles preserved, potentially reversible) vs scarring (follicles destroyed, irreversible). Non-scarring: alopecia areata (autoimmune), androgenetic (hormonal/genetic), telogen effluvium (reactive shedding), traction, tinea capitis. Scarring: lichen planopilaris, discoid lupus, frontal fibrosing alopecia.

Epidemiology

Androgenetic: ~50% of men >50, ~50% of women >65. Alopecia areata: ~2% lifetime risk. Telogen effluvium very common, especially post-partum. Alopecia areata associated with vitiligo, thyroid disease, T1DM.

Clinical Features

Symptoms
Alopecia areata: well-demarcated smooth round patches with exclamation mark hairs
Androgenetic male: bitemporal recession + vertex thinning
Androgenetic female: diffuse thinning with preserved frontal hairline
Telogen effluvium: diffuse shedding 2-4 months after trigger
Scarring: permanent loss with visible scarring, absent follicular ostia
Rapidly progressive total hair loss (alopecia totalis/universalis)
Signs
Exclamation mark hairs: short tapered hairs at patch periphery (AA)
Scarring: loss of follicular ostia, skin atrophy within patch
Tinea capitis: scaling, broken hairs in children — always consider

Investigations

First-line
Clinical diagnosis + trichoscopyExclamation mark hairs, black dots (AA). Loss of follicle openings (scarring)
Second-line
BloodsTFTs, ferritin, FBC, vitamin D — screen for treatable causes
Scalp biopsyIf uncertain — essential to distinguish scarring from non-scarring
Fungal scrapingIf tinea capitis suspected in children

Management

BAD Guidelines + NICE CKS
1
Alopecia areata
  • Mild: watchful waiting — 80% regrows within 1 year
  • Potent topical corticosteroid or intralesional triamcinolone
  • Extensive: specialist — topical immunotherapy (DPCP), JAK inhibitors (baricitinib, NICE TA958)
  • NHS wig provision
2
Androgenetic
  • Male: topical minoxidil 5% BD or oral finasteride 1 mg OD
  • Female: topical minoxidil 2-5%. Spironolactone off-label via dermatology
  • Hair transplantation for stable disease
3
Telogen effluvium
  • Identify and address trigger
  • Reassurance: resolves 3-6 months once trigger removed
  • Correct iron deficiency (aim ferritin >70), check TFTs
4
Scarring alopecia
  • Urgent dermatology referral — early treatment halts progression
  • Potent topical/intralesional steroids, hydroxychloroquine
  • Hair lost to scarring does NOT regrow

Complications

  • Psychological impact: Significant distress, anxiety, depression
  • Alopecia totalis/universalis: ~5% of AA
  • Permanent loss: Scarring alopecia is irreversible
UKMLA Exam Tips
  • 1Exclamation mark hairs = alopecia areata — pathognomonic
  • 2Non-scarring: follicles visible, reversible. Scarring: follicles absent, irreversible
  • 3Telogen effluvium: diffuse shedding 2-4 months AFTER trigger
  • 4Finasteride: contraindicated in women of childbearing potential (teratogenic)
  • 5Children with hair loss + scaling = consider tinea capitis — take scraping
  • 6Nail pitting in AA and psoriasis — but smooth bald patches = AA

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Verified Sources & References

BAD — Alopecia Areata Guidelines
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