Dermatologists are increasingly recognizing trichoscopy as a transformative diagnostic tool that significantly improves the accuracy of hair loss evaluation, particularly in distinguishing between scarring and non-scarring alopecia subtypes that can appear clinically similar.
Diagnostic Capabilities Transform Hair Loss Assessment
"The trichoscopy of the scalp is amazing," said Maria Hordinsky, MD, R.W. Goltz Professor at the University of Minnesota Department of Dermatology, during her presentation at the 2025 SDPA Annual Summer Dermatology Conference. "With that instrument called the dermatoscope, one can take a look at the skin of the scalp and see if there's inflammation present, whether it's diffuse and loose like you would see in dandruff."
The technique allows clinicians to identify critical diagnostic features that differentiate scarring from non-scarring conditions. According to Hordinsky, the key distinction lies in scale behavior: "Is it kind of a loose scale, or is there hugging of the scale? Is the scale hugging the hair fiber as it exits out of the skin, which goes along more with the scarring alopecia?"
Specific Patterns Enable Precise Subtype Identification
Amy Spizuoco, DO, FAOCD, a board-certified dermatologist at True Dermatology and clinical instructor at Mount Sinai, outlined the distinct trichoscopic features that characterize different alopecia subtypes. "The main features seen in specific alopecia subtypes include exclamation mark hairs in alopecia areata, yellow dots indicating follicular plugging in telogen effluvium, and miniaturized or vellus hairs in androgenetic alopecia," Spizuoco explained during her presentation on "The Role of Trichoscopy in Clinical Hair Loss Evaluation."
The fundamental difference between scarring and non-scarring alopecia becomes apparent through trichoscopic examination. "Scarring alopecia will show a loss of follicular ostia, or in other words, a loss of hair by the scalp or the follicular opening," Spizuoco noted. "However, with non-scarring alopecia, you will still see the follicular ostia, but it may just be smaller or sparser than you would see in individuals with no hair loss disorders."
Clinical Applications Demonstrate Diagnostic Value
Trichoscopy proves particularly valuable in distinguishing conditions that appear similar on clinical examination. "By the eye, alopecia areata and tinea capitis look very similar, but trichoscopy can distinguish these disorders," Spizuoco explained. "With alopecia areata, examination of hairs is present, but with tinea capitis, there is a black dot pattern. It is important to be able to distinguish these conditions since they are treated in a completely different way."
The technique also provides insights into hair fiber quality and density. "A good picture of the scalp would show you that most of the hair fibers are very uniform," Hordinsky explained. "They're of the same diameter. But if there's pattern hair loss occurring, or abnormal hairs are coming back, there's going to be a lot of variation in fiber diameter and also perhaps in the quality of the hair."
Early Detection Enables Timely Intervention
Hordinsky emphasized the importance of early scarring alopecia detection, particularly noting that trichoscopy can reveal scarring that has already occurred. She also highlighted a critical clinical pearl for managing treatment-resistant cases: "I think it's really important to recognize that when you're working with a patient as a scarring alopecia, and you are doing all the right things that are in the algorithm for the treatment of a scarring alopecia, if your patient does not get better, then you have to think about allergic contact dermatitis."
This consideration becomes crucial because "sometimes the treatments that we prescribe, or the injections that we do, have chemicals in them that your patient might be allergic to," Hordinsky explained. "It's very important to recognize if you're doing everything you can and the patient's not getting better. Then it's time to investigate with testing, to figure out if there's something the patient's coming in contact with that's driving this process."
Implementation Barriers and Solutions
Despite its diagnostic value, trichoscopy adoption faces obstacles. "Barriers are just not knowing the patterns to look for and what each pattern relates to, just like with dermoscopy when we use it for recognition of melanoma or for basal cells," Spizuoco identified.
For clinicians new to the technique, Spizuoco recommends learning basic patterns including "black or yellow dots, exclamation hairs, white halos, and some pigment networks" that are characteristic of different alopecia types.
The technique offers significant practical advantages. "[Trichoscopy is] a great tool to be able to utilize with our patients with hair loss," Spizuoco concluded. "It's very effective, it's cost-effective, it's time-effective, and it's a great diagnostic tool."
