Is Trichoscopy Really Essential in Diagnosing Hair and Scalp Disorders — Donovan Hair Clinic

When is Trichoscopy Really Helpful and When is it Optional?


There is a lot of confusion as to when a practitioner should use “trichoscopy”(scalp magnification) and when it is actually considered optional. Many patients tell me that their practitioner did not examine their scalp with trichoscopy, and they are therefore concerned that an accurate diagnosis cannot be reached.


The reality is that many clinical situations do not require trichoscopy to make the diagnosis. Trichoscopy may be still helpful to monitor a variety of hair loss conditions over time or to determine the degree of disease activity of the given condition, but trichoscopy may not be actually needed to make the initial formal diagnosis.


This statement generally applies to hair loss conditions in the moderate stages of progression or advanced stages of progression. In such cases, a simple examination of the scalp by a skilled and knowledgeable practitioner can lead to the diagnosis with a very high degree of certainty, 95 to 99% of the time.


The key point therefore is really the ability to make diagnosis in the “very early” stages of the disease. The very early stages of most hair loss conditions helped tremendously through the use of trichoscopy. In fact, many diseases can only be diagnosed properly in the early stages with either a good trichoscopic exam, or a biopsy. Simple examination of the scalp with the naked eye will not lead to the diagnosis because the scalp appears otherwise quite normal when the hair loss condition has only begun. 



For example, the early diagnosis of androgenetic hair loss, frontal fibrosing alopecia, lichen planopilaris, dissecting cellulitis and alopecia areata incognito is made possible through the use of trichoscopy. In such cases,  the scalp may often appear quite normal at first glance, and a simple examination with a naked eye would lead the clinician to conclude that there’s nothing particularly wrong with the hair, and that it looks otherwise normal to him or her. However the use of trichoscopy at that point would allow the well trained practitioner to make the proper diagnosis. In such cases, a biopsy would not needed as the diagnosis has been reached through the use of trichoscopy.


In many disease states,  it may take 2, 3 or even four years from the day the disease starts to the time the hair loss condition finally becomes apparent with the naked eye. Many, many patients live with their hair loss for many years before they can convince a doctor,  family member, or other practitioner that something is indeed wrong with their hair. The use of trichoscopy speeds up the diagnosis and allows hair loss to be diagnosed in the earliest possible stages and allows treatments to be therefore started in earlier stages. This allows a greater chance for the hair loss to be stopped and for hair to be saved.



There are many situations where trichoscopy is not needed. Patients with moderately advanced, and or genetic hair loss, or alopecia areata, or other modern advanced, scarring alopecia‘s do not need trichoscopy to make the initial diagnosis. The diagnosis can be rendered simply by looking at the scalp and sometimes even from across the room. However, one must not forget that the ability to diagnose other conditions that might be present in the early stages is often not possible in that situation.


Consider the 32-year-old patient who comes in with a clear diagnosis of androgenetic alopecia hair loss. The patient also has some itching and some burning in the scalp. The clinician might state that it’s quite obvious that androgenetic hair loss is present. That clinician is indeed correct! However, without the use of trichoscopy that clinician will not recognize easily that the patient not only has a androgenetic hair loss, but also has like in planopilaris – a second diagnosis that was still somewhat hiding. 


That clinician really should say “ I didn’t need trichoscopy to diagnose the androgenetic alopecia but I did need it to make the diagnosis of the other condition – lichen planopilaris. I completely missed the diagnosis of lichen planopilaris because I did not use trichoscopy.”


We must never forget that many patients have two diagnoses, and sometimes even three or four or five diagnoses.  Arriving at one diagnosis should not bring the diagnostic thinking process to a halt. It may be quite easy to diagnose some conditions without trichoscopy. However, once you’re never fool themselves that they have ruled out all their loss conditions if they avoid the use of trichoscopy. 

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