ED70 - Alopecia or Hair Loss: Complete ICD-11 Coding Guide

1. Introduction

Alopecia or hair loss represents a diverse group of conditions characterized by abnormal hair loss, whether temporary or permanent, affecting mainly the scalp and beard region. This condition transcends the simple aesthetic issue, configuring itself as a significant medical problem that profoundly impacts quality of life, self-esteem, and psychological well-being of affected individuals.

Hair loss can manifest in multiple forms, from diffuse thinning to completely bald areas, and its causes are equally varied, including genetic, autoimmune, hormonal, nutritional, medication-related, and stress-related factors. The prevalence of alopecia is considerable in global populations, affecting men and women of all ages, although with distinct patterns and frequencies according to the specific type.

From a public health perspective, alopecia represents an important diagnostic and therapeutic challenge. Beyond the documented psychosocial impact, including anxiety, depression, and social isolation, hair loss can be a clinical sign of underlying systemic conditions that require appropriate investigation and treatment.

Correct coding using ICD-11 is critical for multiple purposes: it enables accurate epidemiological recording, facilitates prevalence and incidence studies, aids in health resource planning, ensures adequate reimbursement of diagnostic and therapeutic procedures, and assures continuity of care through clear and standardized documentation. Appropriate use of code ED70 is fundamental to distinguish alopecia from other hair conditions and ensure adequate clinical management.

2. Correct ICD-11 Code

Code: ED70

Description: Alopecia or hair loss

Parent category: Hair conditions (higher category in the classification of dermatological diseases)

Official definition: Conditions characterized by abnormal temporary or permanent loss of hair, particularly of the scalp and beard.

This code belongs to the chapter of skin diseases in ICD-11 and serves as the main category to group various types of hair loss. ED70 functions as a parent code, under which there are six more specific subcategories that detail different types of alopecia. The hierarchical structure of ICD-11 allows the coder to use ED70 when the specific type of alopecia is not clearly defined or when it is desired to make reference to hair loss in a general manner.

It is important to understand that ED70 encompasses both scarring (permanent) and non-scarring (potentially reversible) hair losses, both localized and diffuse, and both of congenital and acquired origin. This breadth makes the code versatile, but also requires attention to ensure that more specific subcategories are not more appropriate for the clinical case in question.

3. When to Use This Code

The code ED70 should be used in specific clinical scenarios where abnormal hair loss is the predominant feature. Here are detailed practical situations:

Scenario 1: Initial evaluation of unspecified hair loss Patient presents with complaint of increased hair loss for three months, with strands found on the pillow and in the shower drain. Physical examination reveals diffuse thinning without areas of complete baldness. Initial investigations are underway and the specific type of alopecia has not yet been determined. At this point, ED70 is appropriate until the diagnosis is refined.

Scenario 2: Acute telogen effluvium Patient reports intense hair loss beginning two months after a significant stressful event (major surgery, prolonged high fever, or childbirth). Pull test is positive with multiple hairs in telogen phase. There are no localized areas of baldness, but rather diffuse thinning. ED70 is appropriate and may be specified with a subcategory if available in the system.

Scenario 3: Confirmed alopecia areata Patient presents with one or multiple circular or oval areas of complete hair loss on the scalp, without signs of inflammation or scarring. Dermoscopic examination shows exclamation mark hairs at the edges of lesions. This is a classic use of ED70 or its specific subcategory for alopecia areata.

Scenario 4: Documented androgenetic alopecia Male with baldness pattern characterized by bitemporal recession and vertex rarefaction, or female with widening of the central hair parting line (Christmas tree sign). Positive family history and gradual progression over years. ED70 is applicable, preferably with specification of the androgenetic subtype.

Scenario 5: Scarring alopecia Patient presents with areas of permanent hair loss with smooth, shiny skin, without visible hair follicle openings. There may be history of lichen planopilaris, discoid lupus, or decalvans folliculitis. ED70 is used as the primary code, with possible additional code for the underlying condition.

Scenario 6: Documented trichotillomania Patient with irregular areas of hair loss with strands of varying lengths, resulting from compulsive pulling or manipulation of hair. Behavioral history confirms the diagnosis. ED70 may be used in conjunction with an impulse control disorder code.

4. When NOT to Use This Code

It is essential to recognize situations where ED70 is not appropriate, avoiding diagnostic confusion and ensuring accurate coding:

Excessive hair growth (Hypertrichosis - ED71): When the problem is increased or excessive hair growth in areas where fine hair normally exists, and not hair loss. Hypertrichosis represents the opposite of alopecia and requires a distinct code.

Male pattern hair growth in women (Hirsutism - ED72): When women present with terminal hair growth in a male pattern (face, chest, abdomen) due to hormonal causes. Although it may coexist with androgenetic alopecia, hirsutism itself requires the code ED72.

Structural alterations of the hair shaft (ED73): When the primary problem is not hair loss, but rather alterations in the structure of the hair shaft, such as tangled, brittle, twisted hair or hair with nodules. These acquired conditions of the hair shaft have their own code.

Hair loss secondary to specific dermatological conditions: When hair loss is a direct consequence of another skin disease that should be coded primarily, such as extensive scalp psoriasis, severe seborrheic dermatitis, or fungal infections (tinea capitis). In these cases, the primary condition is coded.

Temporary hair loss from normal cosmetic procedures: When there is hair breakage or loss related to expected cosmetic hair treatments (coloring, straightening) without characterizing disease. This does not constitute a codifiable medical condition, except if there is significant damage that constitutes chemical injury.

Congenital absence of hair as part of a syndrome: When the lack of hair is part of a complex genetic syndrome, the code of the specific syndrome should be prioritized.

5. Step-by-Step Coding Process

Step 1: Assess diagnostic criteria

The first essential step is to confirm that there is indeed abnormal hair loss. This requires:

Detailed history: Question about duration of hair loss, amount of hair strands lost daily (normal up to 100 strands), pattern of loss (diffuse or localized), family history, medications in use, recent stressful events, hormonal changes, hair care practices, and associated symptoms such as pruritus or pain.

Thorough physical examination: Assess overall hair density, presence of areas of rarefaction or complete baldness, characteristics of scalp skin (erythema, scaling, scars), perform pull test (gently pull 50-60 strands in different areas), examine strands for characteristics of the root (anagen or telogen) and shaft.

Diagnostic instruments: Consider dermoscopy (trichoscopy) to evaluate follicular patterns, wash test to quantify daily loss, trichogram for analysis of hair cycle phases, and scalp biopsy when necessary for definitive diagnosis of scarring types.

Complementary investigations: Request laboratory tests as clinically indicated, including complete blood count, ferritin, thyroid function, serum zinc, hormonal profile (in women with signs of hyperandrogenism), and specific tests based on diagnostic suspicion.

Step 2: Verify specifiers

After confirming the presence of alopecia, it is necessary to characterize:

Type of alopecia: Scarring (permanent, with follicular destruction) versus non-scarring (potentially reversible). This distinction is fundamental for prognosis and treatment.

Distribution pattern: Diffuse (affecting the entire scalp uniformly), localized (specific areas such as alopecia areata), or in characteristic pattern (androgenetic with typical distribution).

Duration: Acute (sudden onset, usually telogen effluvium) or chronic (gradual progression over months or years).

Severity: Mild (discrete rarefaction), moderate (evident areas of thinning) or severe (extensive areas of baldness or near-total loss).

Activity: Active (ongoing hair loss, positive pull test) versus stable or inactive.

These specifiers help determine whether a more specific subcategory of ED70 should be used.

Step 3: Differentiate from other codes

ED71 - Hypertrichosis: The fundamental difference is that hypertrichosis involves excessive hair growth, not loss. In hypertrichosis, there is an increase in quantity, length, or thickness of hair in areas that normally have fine (vellus) hair. It can be generalized or localized, congenital or acquired, but never involves hair loss as the primary characteristic.

ED72 - Hirsutism and syndromes with hirsutism: Hirsutism refers specifically to the growth of terminal hair in women following a male pattern of distribution (face, chest, linea alba, periareolar region). It is generally caused by androgen excess or increased follicular sensitivity to these hormones. Although women with hyperandrogenism may simultaneously present androgenetic alopecia (which would be coded with ED70), hirsutism itself requires the ED72 code.

ED73 - Acquired disorders of the hair shaft: This code is used when the primary problem is not the quantity of hair, but rather structural alterations of existing strands. It includes conditions such as nodose trichorrhexis (brittle strands with nodules), pili torti (twisted strands), trichothiodystrophy (fragile strands with low sulfur content), and other shaft alterations. Although these conditions may result in breakage and apparent "loss" of hair length, the follicle remains intact and producing strands, unlike true alopecia.

Step 4: Necessary documentation

Checklist of mandatory information:

• Date of symptom onset and duration
• Description of loss pattern (diffuse, localized, specific)
• Result of detailed physical examination of the scalp
• Result of pull test and characteristics of removed strands
• Presence or absence of inflammatory or scarring signs
• Identified triggering factors
• Relevant family history
• Medications and previous treatments
• Results of complementary tests performed
• Specific diagnosis of alopecia type when possible
• Severity and extent of involvement

How to document appropriately: The medical record should clearly describe the objective findings that justify the diagnosis of alopecia, including location, extent, and characteristics of skin and strands. It should document the diagnostic reasoning that led to the specific classification and justify the choice of ED70 code or its subcategories. Clinical photographs are valuable for documentation and follow-up evaluation.

6. Complete Practical Example

Clinical Case

A 32-year-old female patient presents to dermatology consultation with a complaint of intense hair loss for approximately three months. She reports noticing an excessive amount of hair on her pillow upon waking, in the shower drain after washing her hair, and on the comb while combing. She estimates losing about three times the usual amount of hair. She denies localized areas of baldness but notices that her hair is visibly thinner and finer.

On directed history, the patient reports that four months ago she had dengue fever with high fever sustained for five days, requiring hospitalization for two days for intravenous hydration. She completely recovered from the infectious condition. She does not use continuous medications, denies menstrual alterations, is not pregnant and has not had recent delivery. She denies aggressive hair practices or use of chemical products. Diet is varied and balanced. She denies family history of early baldness in women.

On dermatological physical examination, the scalp is observed without signs of erythema, scaling, or scars. Hair density is diffusely reduced, without areas of complete baldness. There are no signs of significant follicular miniaturization. The pull test is positive in multiple scalp areas, with removal of six to eight hairs per gentle pull in each tested area. The removed hairs present depigmented bulbs characteristic of telogen phase. There are no signs of exclamation mark hairs. Dermoscopy reveals reduced follicular density without structural alterations of the hairs or scalp.

Complementary tests were requested: complete blood count, serum ferritin, thyroid function (TSH and free T4), serum zinc, and C-reactive protein. Results show normal blood count, ferritin of 45 ng/mL (borderline low), normal thyroid function, normal zinc, and normal CRP.

Coding Step by Step

Analysis of criteria:

1. Confirmation of abnormal hair loss: The patient presents quantitatively increased hair loss (pull test positive with more than 5-6 hairs per area) and qualitatively abnormal (acute onset, excessive amount reported).

2. Temporal characterization: Onset three months ago, preceded by triggering event (high fever from infection) four months ago. This interval of 2-3 months is characteristic of telogen effluvium, the time necessary for follicles in anagen phase to prematurely enter telogen phase and hairs to be shed.

3. Pattern of distribution: Diffuse loss without specific localization, affecting the entire scalp uniformly.

4. Hair characteristics: Telogen bulbs confirm that follicles entered resting phase prematurely, characteristic of telogen effluvium.

5. Exclusion of other causes: Absence of signs of androgenetic alopecia (without significant miniaturization), alopecia areata (without circumscribed areas, without exclamation mark hairs), scarring alopecia (normal scalp without scars), or hair shaft disorders (structurally normal hairs).

Code selected: ED70 - Alopecia or hair loss (with specification of telogen effluvium if the subcategory is available in the coding system used)

Complete justification:

Code ED70 is appropriate because the patient presents objectively confirmed abnormal hair loss, characterized as acute telogen effluvium secondary to febrile event. Telogen effluvium is a common and generally reversible form of non-scarring alopecia, where significant physiological stress (high fever, severe infection, surgery, childbirth, rapid weight loss) causes premature entry of a large number of follicles into the telogen phase.

Coding with ED70 is justified by the following elements:

• Documented abnormal hair loss (positive pull test)
• Characteristic diffuse pattern
• Clear temporal relationship with triggering factor
• Absence of criteria for other differential diagnoses
• Hairs in telogen phase confirming the pathophysiological mechanism

Applicable complementary codes:

Although not mandatory, one may consider additional code to document the triggering factor (dengue code or fever of infectious origin) if the system allows multiple coding, establishing the causal relationship. Additionally, if documented iron deficiency (low ferritin), code for nutritional deficiency may be added, as this condition may contribute to prolongation of telogen effluvium.

The prognosis in this case is favorable, with expectation of spontaneous recovery in 6-12 months after resolution of the triggering factor, although iron supplementation may be beneficial given the borderline ferritin level.

7. Related Codes and Differentiation

Within the Same Category

ED71: Hypertrichosis

When to use ED71 vs. ED70: The code ED71 should be used when the patient presents with excessive hair growth, not hair loss. Hypertrichosis is characterized by an increase in the quantity, length, or thickness of hair in areas that normally present fine (vellus) hair. It can be generalized (affecting the entire body) or localized (specific areas).

Main difference: The fundamental distinction is directional - ED71 involves excess (more hair than normal), while ED70 involves deficiency (less hair than normal). Hypertrichosis can be congenital (present since birth) or acquired (secondary to medications such as minoxidil, cyclosporine, systemic corticosteroids, or associated with conditions such as porphyria). There is no overlap between these codes, as they represent opposite situations.

ED72: Hirsutism and syndromes with hirsutism

When to use ED72 vs. ED70: The code ED72 is specific for women who present with terminal hair growth (thick and pigmented) in a male distribution pattern, including face (mustache, beard), chest, abdomen, back, and inner thighs. It is generally the result of androgen excess or increased follicular sensitivity to these hormones.

Main difference: ED72 is gender-specific (women) and related to androgenic hormones, while ED70 affects both sexes and has varied causes. A patient may simultaneously present with hirsutism (excessive hair growth in a male pattern) and androgenetic alopecia (hair loss on the scalp), both related to hyperandrogenism. In this case, both codes can be used to completely document the clinical presentation, as they represent distinct manifestations of the same hormonal alteration.

ED73: Acquired disorders of the hair shaft

When to use ED73 vs. ED70: The code ED73 is appropriate when the primary problem is not the quantity of hair on the scalp, but rather alterations in the structure of existing hair shafts. It includes conditions such as trichorrhexis nodosa (hair shafts with nodules and easy breakage), pili torti (hair shafts twisted on their own axis), monilethrix (hair shafts with a beaded appearance), and other hair shaft dystrophies.

Main difference: In ED73, the hair follicles remain functional and producing hair shafts, but these present structural defects that result in breakage, fragility, or abnormal appearance. In ED70, the problem is in the hair follicle (which stops producing, produces miniaturized hair shafts, or is destroyed), not in the structure of the produced hair shaft. The distinction can be subtle when hair shaft disorders cause extensive breakage that simulates hair loss, but microscopic evaluation of the hair shafts and the presence of intact follicles establishes the correct diagnosis.

Differential Diagnoses

Anagen effluvium vs. telogen effluvium: Both coded under ED70, but with distinct pathophysiology. Anagen effluvium occurs when follicles in the active growth phase are damaged (chemotherapy, radiotherapy, intoxications), resulting in rapid hair loss. Telogen effluvium occurs when follicles prematurely enter the resting phase, with hair loss occurring after 2-3 months.

Alopecia areata vs. androgenetic alopecia: Both under ED70, but with distinct presentations. Alopecia areata presents with circumscribed areas of complete baldness, sudden onset, exclamation mark hairs, generally without miniaturization. Androgenetic alopecia presents with a characteristic pattern (bitemporal and vertex in men, widening of the central part in women), gradual progression, evident follicular miniaturization.

Trichotillomania vs. alopecia areata: Trichotillomania (coded with ED70 plus code for impulse control disorder) presents with irregular areas with hair shafts of varying lengths due to manual traction. Alopecia areata presents with regular areas with complete baldness and characteristic hairs at the borders.

8. Differences with ICD-10

Equivalent ICD-10 code: L63 (Alopecia areata), L64 (Androgenetic alopecia), L65 (Other non-scarring alopecia) and L66 (Scarring alopecia)

Main changes in ICD-11:

The transition from ICD-10 to ICD-11 brought significant structural changes in the coding of alopecia. In ICD-10, alopecia was divided into multiple codes L63-L66, each representing specific types. ICD-11 adopts a more organized hierarchical structure, with ED70 functioning as a comprehensive parent category, under which specific subcategories are found.

ICD-11 offers greater granularity and specificity, allowing more precise coding of subtypes. The terminology was updated to reflect contemporary medical knowledge, and the structure allows better capture of epidemiological data. The possibility of multiple complementary codes (post-coordination) in ICD-11 facilitates complete documentation of complex conditions.

Practical impact of these changes:

For healthcare professionals, the change requires familiarization with the new hierarchical structure and understanding of when to use the general code ED70 versus specific subcategories. Health information systems need to be updated to support the new coding. The transition may temporarily hinder historical epidemiological comparisons, but in the long term will provide more precise and useful data.

The ICD-11 structure facilitates clinical research by allowing more logical grouping of related conditions. For administrative and reimbursement purposes, greater specificity may improve justifications for treatments and diagnostic procedures. Continuing education is essential to ensure smooth transition and consistent coding.

9. Frequently Asked Questions

1. How is alopecia diagnosed?

The diagnosis of alopecia is primarily clinical, based on detailed history taking and thorough physical examination. The clinical history should investigate duration, pattern of hair loss, triggering factors, family history, medications, and hair care practices. Physical examination includes assessment of hair density, scalp characteristics, pull test (gently pulling hairs to evaluate ease of removal), and examination of removed hairs. Complementary tools include dermoscopy (trichoscopy) to evaluate follicular patterns, trichogram for analysis of hair cycle phases, and scalp biopsy when necessary, especially in scarring alopecias. Laboratory tests are requested as clinically indicated to investigate underlying causes such as nutritional deficiencies, hormonal alterations, or systemic diseases.

2. Is treatment available in public health systems?

The availability of alopecia treatments in public health systems varies considerably depending on region and local resources. Basic treatments such as iron supplementation for documented deficiencies and topical medications like minoxidil are often available. More specialized treatments such as intralesional corticosteroid injections for alopecia areata, topical immunotherapy, or systemic therapies may have limited availability. Specialized dermatological consultations and diagnostic procedures such as biopsy are generally accessible through public systems, although waiting lists may exist. Cosmetic treatments such as hair transplantation are rarely covered by public systems, being considered elective procedures. It is important to consult local health services for specific information about availability and access criteria.

3. How long does treatment last?

Treatment duration varies widely depending on the type of alopecia and individual response. Acute telogen effluvium generally resolves spontaneously within 6-12 months after removal of the triggering factor, without need for prolonged treatment beyond correction of nutritional deficiencies if present. Alopecia areata may respond to treatment in 3-6 months, but recurrences are common. Androgenetic alopecia requires continuous and prolonged treatment (generally for years or indefinitely) to maintain results, with first signs of improvement appearing after 3-6 months of regular treatment. Scarring alopecias may require prolonged immunosuppressive treatment to control inflammatory activity. It is essential to maintain realistic expectations, as treatment response is variable and some types of alopecia may not respond completely to available treatments.

4. Can this code be used in medical certificates?

Yes, the code ED70 can and should be used in medical certificates when appropriate. Alopecia, especially in extensive or active forms, may justify temporary leave from professional activities in specific situations, such as during diagnostic investigation requiring multiple procedures, when treatments cause significant adverse effects, or when the psychological impact is severe and documented. However, most cases of alopecia do not require work leave. Medical documentation should be clear regarding the need for leave, relating it to specific aspects of the condition or treatment. For purposes of benefits or insurance, precise coding with ED70 facilitates processing and evaluation of requests.

5. Is alopecia curable?

The possibility of cure depends on the specific type of alopecia. Acute telogen effluvium is generally completely reversible after removal of the triggering factor, with total recovery of hair density. Alopecia areata may enter complete and permanent remission, although recurrences are common and some cases progress to persistent extensive forms. Androgenetic alopecia has no cure, but can be controlled with continuous treatment, stabilizing loss and frequently recovering density partially. Scarring alopecias are permanent in affected areas due to irreversible follicular destruction, but early treatment can prevent progression. It is important to establish realistic expectations with patients, focusing on control, stabilization, and possible improvement rather than promises of complete cure in all cases.

6. Can children have alopecia?

Yes, children can present with various types of alopecia. Alopecia areata is relatively common in children and adolescents, manifesting as circumscribed areas of hair loss. Telogen effluvium can occur after high fevers, severe infections, or significant physical stress. Trichotillomania (compulsive hair pulling) can begin in childhood, often related to emotional stress or anxiety. Tinea capitis (fungal infection of the scalp) is an important cause of localized hair loss in children. Congenital alopecias or those associated with genetic syndromes manifest from birth or early childhood. Diagnosis in children requires careful and sensitive approach, considering psychological and social impact. Treatment should be adapted to age, with special attention to safety and tolerability of medications.

7. Can stress cause hair loss?

Yes, stress can definitely cause hair loss through multiple mechanisms. Intense physical stress (surgeries, severe infections, high fever, rapid weight loss) is a well-established cause of acute telogen effluvium, where a large number of follicles prematurely enters the resting phase, resulting in diffuse hair loss 2-3 months after the stressful event. Chronic emotional stress can contribute to chronic telogen effluvium, with persistent hair loss. Psychological stress can trigger or aggravate alopecia areata in genetically predisposed individuals. Trichotillomania is frequently associated with anxiety and stress, manifesting as compulsive hair-pulling behavior. It is important to note that stress is rarely the sole cause of hair loss, frequently interacting with genetic predisposition and other factors. Stress management through relaxation techniques, exercise, adequate sleep, and psychological support when necessary can be an important component of comprehensive treatment.

8. Does diet influence hair loss?

Nutrition plays an important role in hair health, and nutritional deficiencies can significantly contribute to hair loss. Iron deficiency is a common cause of telogen effluvium, especially in women of reproductive age, even when frank anemia is not present. Insufficient protein can cause diffuse hair loss, as hair is composed mainly of keratin (protein). Deficiencies in zinc, biotin, B-complex vitamins (especially B12), and vitamin D have been associated with hair loss. Extremely restrictive diets or rapid weight loss can trigger telogen effluvium. However, it is important to note that excessive supplementation without documented deficiency does not prevent hair loss and can be harmful. A balanced and varied diet with adequate protein, fruits, vegetables, whole grains, and healthy fats provides nutrients necessary for healthy hair growth. Investigation of nutritional deficiencies through laboratory tests is appropriate in cases of hair loss, allowing targeted supplementation when necessary.

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Conclusion

Proper coding of alopecia using the ICD-11 code ED70 is fundamental for accurate clinical documentation, epidemiological research, public health planning, and ensuring appropriate access to care and treatments. Understanding when to use this code, differentiating it from related conditions, and properly documenting clinical findings are essential competencies for health professionals caring for patients with hair complaints. The systematic approach presented in this guide facilitates consistent and accurate coding, contributing to better care for patients affected by these conditions which, although often not life-threatening, significantly impact quality of life and psychosocial well-being.

External References

This article was prepared based on reliable scientific sources:

1. 🌍 WHO ICD-11 - Alopecia or hair loss
2. 🔬 PubMed Research on Alopecia or hair loss
3. 🌍 WHO Health Topics
4. 📊 Clinical Evidence: Alopecia or hair loss
5. 📋 Ministry of Health - Brazil
6. 📊 Cochrane Systematic Reviews

References verified on 2026-02-03