A scalp examination looks at more than how much hair is left. I explain what clinicians look for in the pattern, skin and individual hairs, and how those observations guide the next step.
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A useful examination should help explain why the hair is changing. It also establishes what the scalp looks like now, so that later decisions are based on a comparison rather than memory alone.
The clinician may already have a likely diagnosis from your history, but the examination tests whether the physical findings fit. A familiar pattern can be reassuring; an unexpected inflamed area or a patch with different features may change the plan.
I would want you to understand what has been seen and why it matters. You should not need to interpret a collection of medical terms without an explanation.
The front, temples, central scalp, crown and sides can tell different parts of the story. A clinician compares them rather than judging the whole scalp from the area that first caught your attention.
Temple recession and crown thinning are common in male pattern hair loss. Central thinning and a widening parting are common in female pattern hair loss. These are recognisable patterns, not rigid rules that every person must follow.
A diffuse change or an isolated patch raises different possibilities. The clinician may use a grading scale, such as Hamilton–Norwood or Sinclair, to describe the appearance. The grade helps with communication and follow-up; it does not measure the impact on your confidence.
The scalp itself can show clues that an ordinary hair photograph misses. Redness, scale, crusting, pustules and tenderness may suggest inflammation or infection.
Follicular openings are particularly useful. They are generally preserved in non-scarring conditions, even if few visible hairs are emerging. Loss of openings or a shiny scarred area raises concern about permanent follicular damage.
These findings can be subtle and may look different across skin tones. Symptoms such as burning or pain are worth mentioning even if the change is not obvious to you. Equally, the absence of discomfort does not exclude a scarring process.
A clinician may use trichoscopy to look more closely or recommend a biopsy if the diagnosis remains uncertain.
Miniaturisation produces a mixture of thicker and finer hairs in an affected region. That variation can help distinguish pattern thinning from a change in shedding alone.
Broken hairs need a different explanation from hairs released through the normal cycle. Chemical damage, repeated heat, traction and hair pulling can affect the shaft. Certain inherited shaft disorders also have recognisable features under magnification.
A pale club at the end of a shed hair does not mean the whole follicle has been pulled out. The follicle is a structure within the skin. Looking at the shaft and root can provide information, but a loose hair cannot reveal everything happening in the scalp.
In a hair pull test, the clinician gently applies traction to a small bundle and observes how many hairs release. The result may support evidence of active shedding. Its interpretation depends on the technique, the area tested and the wider clinical picture.
A negative result does not exclude gradual pattern hair loss. A positive one does not identify the cause by itself. Repeating the test frequently at home is unlikely to improve the assessment.
A tug test looks more at whether the shafts break under gentle tension. It can help when fragility or breakage is suspected. These simple tests answer different questions and are used when relevant, rather than as mandatory rituals at every appointment.
Changes in eyebrows, eyelashes, beard or body hair can help narrow the possibilities. Nail changes may be relevant in alopecia areata, while findings elsewhere on the skin can support an inflammatory diagnosis.
In children, a scaly patch with broken hairs may suggest a scalp infection such as tinea capitis, which needs medical assessment. A painful swollen area or signs of significant infection should be reviewed promptly.
Any examination beyond the scalp should be explained and performed with consent. You can ask why an area needs to be checked, request privacy and discuss a chaperone where appropriate.
Clinical notes and photographs provide a baseline. Comparable lighting, angle, hair length and styling make later images easier to interpret. Magnified photographs may be useful when monitoring a specific area.
The next step should follow the findings. It may be a treatment discussion, a targeted blood test, further imaging or a biopsy. Sometimes it is planned observation with clear instructions about when to return.
If the explanation is unclear, ask what features support the diagnosis and what would make the clinician reconsider it. That is a reasonable part of understanding your care.
