Patchy Hair Loss — Free SCA Practice Case
Woman with patchy hair loss
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Elena Rossi
Age
34 years
Consultation Type
VideoAge
34
Situation
Video Consultation.
Reason for Encounter
"Hairdresser noticed a bald patch at the back of my head. I'm really worried."
Medical Records
- ●PMH: Hypothyroidism (on Levothyroxine 100mcg - stable). Mild Eczema as a child.
- ●Medications: Levothyroxine 100mcg OD. Combined Pill (Microgynon).
- ●Allergies: NKDA.
Recent Notes
- ●6 Months Ago: Thyroid function tests normal (TSH 1.4).
Examination (Visuals provided during consult)
- ●Photograph: Single, well-defined, round area of hair loss (approx. 3cm diameter) on the occiput. The skin looks smooth and pale. There is no redness, scaling, or crusting.
Patient Script
For the friend playing the patient role
Character Overview: You are Elena. You are visibly distressed and self-conscious. You take great pride in your appearance. You are terrified that this is the start of you "going completely bald." You are looking for an immediate cure.
Opening Sentence: "Hi Doctor. I'm freaking out a bit. I went to get my roots done on Saturday and my hairdresser found this bald patch on the back of my head. She said I needed to see a doctor straight away in case it's an infection. Is it going to spread?"
History if Asked (Data Gathering Phase)
- ●The Lesion:
- ●"I didn't even feel it. It doesn't itch or hurt. It's just... smooth. Like a baby's bottom."
- ●"It's about the size of a £2 coin."
- ●"My hairdresser said she didn't see any broken hairs or rash, just smooth skin."
- ●Precipitants/Stress:
- ●"I have been really stressed at work lately — I'm a project manager and we've got a big deadline. Do you think stress caused this?"
- ●Associated Symptoms:
- ●"No, my eyebrows and eyelashes are fine."
- ●"No nail changes (pitting) that I've noticed."
- ●"I feel fine in myself. No tiredness or weight changes (thyroid symptoms controlled)."
- ●Family History:
- ●"My mum has an underactive thyroid too, and my cousin has that condition where white patches appear on the skin (Vitiligo)."
ICE — Ideas, Concerns, Expectations
Actor guidance: Elena does not volunteer this information unprompted. These responses surface only if the candidate directly explores her perspective.
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Ideas: "Honestly, my hairdresser thought it might be some kind of fungal infection — she said she'd seen something like it before. But then I went down a rabbit hole on Google and saw the word 'alopecia' and completely panicked. I don't really know what's causing it. Could it be stress? I've been under a lot of pressure at work."
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Concerns: "I'm terrified it's going to spread. I keep checking every morning in two mirrors to see if it's getting bigger. My hair is a big part of who I am — I spend a fortune on it. The thought of losing more... I don't think I could cope with that. And I'm worried people will notice. What if someone sees it and thinks I'm ill?"
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Expectations: "I just want something that's going to make it grow back. A cream, injections, whatever it takes. I need to know this is fixable. I can't just sit around and hope for the best — I need a plan."
If Asked — Medical History and Medications
Actor guidance: Elena confirms these details only if the candidate asks directly. She is focused on the hair loss and will not raise her medical history spontaneously.
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Levothyroxine 100mcg: "Yeah, I take that every morning for my thyroid — I've been on it for about five years now. I take it first thing before breakfast, like I was told. I had a blood test about six months ago and the doctor said my levels were all fine."
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Microgynon (Combined Pill): "I've been on the pill for years — maybe since I was about 20. No problems with it. I haven't changed it recently or anything like that."
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Childhood Eczema: "I had eczema as a kid, mostly in the creases of my elbows and behind my knees. It cleared up by the time I was a teenager. I haven't had any skin problems since — well, until now."
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Allergies: "No, no allergies to anything that I know of."
Social History and Lifestyle Impact
Actor guidance: Elena shares this naturally in conversation — it reflects how distressed she is about the situation. She does not deliver it as a monologue.
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Occupation and daily life: Elena is a project manager at a marketing agency. She works long hours and is currently leading a high-pressure campaign with a tight deadline. She describes the last few months as "relentless."
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Lifestyle impact of the condition: "I haven't been able to stop thinking about it since Saturday. I've cancelled plans with friends because I don't want anyone to see it. I've been wearing my hair down and clipped over it but I'm paranoid it's obvious. I even called in sick on Monday because I couldn't face going into the office — I had a presentation and all I could think about was 'what if someone notices?' I know it sounds so silly."
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Smoking / Alcohol / Recreational drugs (if asked): "I don't smoke. I'll have a glass of wine at the weekend, nothing much. No drugs."
If Asked — Associated Symptoms
Actor guidance: Elena answers these only if directly asked by the candidate. She responds naturally and briefly.
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If asked about other bald patches elsewhere on the scalp: "No, just the one patch at the back as far as I can tell. I've been checking obsessively."
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If asked about body hair loss (legs, arms, pubic): "No, everything else seems normal."
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If asked about any scalp itching, burning, or pain: "No, nothing like that at all. It doesn't feel any different to the rest of my scalp."
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If asked about any rash or redness on the scalp: "No, my hairdresser said the skin just looked smooth and pale — no redness or flaking."
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If asked about joint pain or swelling: "No, nothing like that."
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If asked about any mouth ulcers: "No."
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If asked about any skin rashes elsewhere or new skin patches: "No, I haven't noticed anything else on my skin."
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If asked about any recent illness or fevers: "No, I've been well — just stressed."
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If asked about changes in periods or menstrual cycle: "No, my periods are regular — no changes."
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If asked about diet or weight loss: "My diet's not great at the moment — lots of skipping meals and grabbing food on the go because of work. But I haven't lost weight or anything."
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If asked about hair pulling or traction (tight hairstyles): "No, I don't wear it up tightly or anything. And I definitely don't pull it out — I wouldn't do that to my hair."
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If asked about recent hair treatments or chemicals: "I get my colour done every six weeks — just a root touch-up, nothing dramatic. I've been going to the same hairdresser for years with no problems."
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If asked about feeling cold, constipated, or other thyroid symptoms: "No, I feel fine — no cold intolerance, no constipation, nothing like that. The thyroid seems under control."
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If asked about dry eyes or dry mouth: "No, nothing like that."
Responses to Management (The Negotiation Phase)
- ●If the Doctor diagnoses Alopecia Areata:
- ●Reaction: "Alopecia? That sounds serious. Will I lose all my hair?"
- ●If the Doctor suggests 'Doing Nothing' (Wait and See):
- ●Reaction: Unhappy. "I can't just wait! What if it gets bigger? Isn't there a cream or a steroid or something? My hairdresser mentioned injections?"
- ●If the Doctor prescribes Topical Steroids:
- ●Reaction: "Okay, I'll try it. How long will it take to work? Weeks? Months?"
- ●If the Doctor asks about a wig:
- ●Reaction: Offended/Upset. "Is it that bad? It's only one patch! Do you think I need a wig?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Distinguishing Alopecia Areata from Other Causes of Patchy Hair Loss
- ●Alopecia areata presents as a well-defined, round or oval patch of hair loss with smooth, non-scarred skin — no scaling, redness, or broken hairs at the surface. This is the key clinical picture to recognise.
- ●Tinea capitis is the most important differential to exclude: it causes scaling, itching, inflammation, and broken or fragile hairs. The absence of all these features effectively rules it out — antifungal treatment is not indicated when the skin is smooth and pale.
- ●Trichotillomania produces irregular patch borders, hairs of varying lengths, and broken stubble. It is associated with hair-pulling behaviour (which the patient will typically deny). The distribution is often on the dominant hand side.
- ●Traction alopecia follows the line of tight hairstyles; the history of hair styling habits and a consistent anatomical pattern are diagnostic clues.
- ●Telogen effluvium causes diffuse shedding — generalised thinning rather than discrete patches — typically 2–3 months after a physiological stressor (illness, surgery, significant weight loss, childbirth). It does not cause a single well-defined bald patch.
- ●On close inspection or dermatoscopy, look for exclamation mark hairs at the patch periphery — short hairs that are narrower at the base than the tip — which are pathognomonic of alopecia areata.
Autoimmune Associations and Investigations
- ●Alopecia areata is a T-cell mediated autoimmune condition causing reversible inflammation around the hair follicle. The follicle itself is not destroyed, which is why regrowth is possible.
- ●It is associated with a cluster of other autoimmune conditions: thyroid disease (Hashimoto's and Graves'), vitiligo, atopic eczema, and type 1 diabetes. A personal or family history of any of these should raise clinical suspicion and inform the working diagnosis.
- ●In this patient — known hypothyroidism, childhood eczema, and a first-degree relative with vitiligo — the autoimmune context strongly supports alopecia areata as the diagnosis.
- ●Check thyroid function (TSH ± free T4) even if the last result was normal: alopecia areata can be an indicator of suboptimal thyroid control or a harbinger of evolving autoimmune thyroid disease. Arrange repeat TFTs at this appointment.
- ●Check FBC and ferritin: iron deficiency is common in women of reproductive age and, while not a direct cause of alopecia areata, contributes to hair shedding and may impair treatment response. A poor diet (as in this case) makes nutritional deficiency worth excluding.
- ●Vitamin D is reasonable to check given the autoimmune context and its association with several autoimmune conditions, though evidence for its specific role in alopecia areata is limited.
- ●Routine immunological workup (ANA, anti-TPO antibodies) is not indicated for a single patch in primary care unless there are other clinical concerns.
First-Line Treatment: Topical Corticosteroids
- ●Spontaneous regrowth occurs in 50–80% of patients with limited alopecia areata (a single small patch, <50% scalp involvement) within 12 months. This is the basis for offering a watch-and-wait approach as a valid, evidence-based option.
- ●Where the patient requests active treatment, potent or super-potent topical corticosteroids are the recommended first-line option in primary care (NICE CKS):
- ●Clobetasol propionate 0.05% (Dermovate) — super-potent
- ●Betamethasone valerate 0.1% (Betnovate) — potent
- ●Apply a thin layer to the affected patch only, once or twice daily. Use a scalp formulation (foam, lotion, or scalp application) — creams are impractical on hair-bearing skin and are harder to apply precisely.
- ●Trial duration: at least 3 months before assessing response. If there is no regrowth after 3 months, reassess rather than continuing indefinitely.
- ●Key safety points: potent topical steroids can cause skin thinning (atrophy) with prolonged or excessive use. Apply only to the patch — not to surrounding normal scalp. Review use at 3 months and do not leave the patient on an unsupervised long-term course.
- ●Topical minoxidil (2% or 5%) is sometimes used as an adjunct to topical steroids, though evidence in alopecia areata is weaker than in androgenetic alopecia. It may be considered where topical steroids alone have not produced regrowth.
- ●Intralesional corticosteroid injections (triamcinolone acetonide, administered by a dermatologist or trained GP) are more effective than topical treatment for resistant patches but are not routine primary care first-line management — they require referral or specific training.
- ●Oral corticosteroids are not appropriate for a single small patch. The benefit does not outweigh the systemic risk, and any regrowth achieved tends to be lost once the course is completed.
Referral Criteria
- ●A single small patch managed in primary care does not require immediate dermatology referral.
- ●Refer to dermatology if:
- ●The patch enlarges significantly or multiple new patches develop
- ●Eyebrows, eyelashes, or body hair are lost (indicating more extensive disease)
- ●There is no response to potent topical corticosteroids after 3 months
- ●There is diagnostic uncertainty (e.g. scarring alopecia is suspected — these require early specialist assessment as scarring is irreversible)
- ●The patient's psychological distress is severe and not improving with primary care support
- ●Alopecia totalis (total scalp hair loss) and alopecia universalis (total body hair loss) should be referred promptly — these have a poorer prognosis for spontaneous regrowth.
Safety Netting and Follow-Up
- ●Arrange a review at 6–8 weeks to assess the patient's wellbeing, check blood results, and confirm the treatment plan is being followed correctly.
- ●A 3-month review is the appropriate interval to formally assess treatment response.
- ●Advise the patient to return sooner if:
- ●New patches appear on the scalp or elsewhere
- ●Eyebrow or eyelash hair is lost
- ●Nail changes develop (pitting, ridging)
- ●Mood or anxiety is worsening significantly
- ●Regrowing hair may initially appear fine, white, or depigmented before regaining its normal texture and colour — this is expected and not a sign of treatment failure.
- ●Inform the patient that alopecia areata can be a relapsing-remitting condition: even after full regrowth, future episodes are possible. This is not a cause for alarm but is worth communicating at diagnosis.
Psychological Impact and Holistic Management
- ●Do not underestimate the psychological burden of alopecia areata — even a single small patch can cause significant distress, avoidance behaviour, and functional impairment. This is not a disproportionate reaction; it reflects the close relationship between hair and identity, and should be addressed explicitly.
- ●Stress is commonly cited as a trigger by patients, and while psychosocial stress can modulate immune function, it is not the sole or certain cause. Acknowledge the patient's perception without attributing the condition entirely to stress — this risks unhelpful self-blame.
- ●Alopecia UK (alopeciauk.org) is the recommended patient support charity: it provides reliable condition information, peer support networks, and practical guidance including camouflage options. Signpost all patients at diagnosis.
- ●For patients with significant and persistent psychological distress, consider referral to IAPT or psychology input via the PCN mental health team.
Common Mistakes to Avoid
- ●Prescribing a mild topical steroid (e.g. hydrocortisone 1%) is a frequent error — it is ineffective for alopecia areata. A potent or super-potent preparation is required.
- ●Being swayed by the hairdresser's suggestion of fungal infection: the smooth, non-scaly skin makes tinea capitis clinically implausible. Do not prescribe antifungals without clinical evidence of infection.
- ●Failing to check thyroid function: in a patient with known autoimmune hypothyroidism presenting with another autoimmune condition, a repeat TFT is mandatory.
- ●Omitting ferritin: nutritional deficiency is common and modifiable — it is a simple check that is frequently missed.
- ●Imposing watch-and-wait without explanation: patients seeking active management need the rationale for observation explained clearly. Saying "let's see what happens" without context is likely to damage the therapeutic relationship.
- ●No follow-up plan: leaving a patient without a specific review date after prescribing a potent topical steroid is a prescribing safety failure. Always arrange a defined review.
Mapped to the RCGP curriculum topic: Dermatology.
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