Reading Scalp Biopsies is Not Always Easy — Donovan Hair Clinic

In One Study, Pathologists Don’t Agree on Scarring vs Non Scarring 16 % of the Time

Authors from Brazil set out to retrospectively study how often pathologists disagree with each other on a diagnosis of scarring alopecia versus non scarring alopecia.

Two dermatopathologists independently interpreted the same set of 100 specimens (89 patients including 77 females, age range 4-77). Biopsies were from the University of Campinas, Pathology Laboratory in Brazil files from 2008 to 2018.The samples were serial sectioned and stained by hematoxylin and eosin and Verhöeff methods.

In 16/100 samples, there was no consensus among the two examiners regarding a final diagnosis of scarring alopecia versus non scarring alopecia. 3/16 patients were re-biopsied, and in the second sample, there was finally agreement. In 76/89 (85%) patients, the clinicopathological examination was helpful in confirming scarring alopecia versus non scarring alopecia.


This is a really nice study and reminds us that biopsies are not always easy to read. Disagreement is common. Sometimes disagreement is simply due to one pathologist being less experience than another. But not always.

The authors remind us her that for tough cases where there is confusion or uncertainty, there are four things that are helpful to differentiate scarring and non scarring:

1) Deep serial biopsy sectioning – take more sections to evaluate

2) Elastic tissue stain – use an elastin stain to see if elastin tissues are destroyed (as in scarring alopecia)

3) Obtaining another biopsy

4) Review the history and examine the patient.

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