Trichoscopy

Trichoscopy is an examination of the hair and scalp under magnification with a digital video dermatoscope. The doctor sees the hair shafts, the follicle openings, the skin between them and the tiny vessels that the naked eye cannot. The method is non-invasive: the skin is not damaged and the exam does not hurt.

The term "trichoscopy" was introduced in 2006 by the researcher L. Rudnicka, and the method has since earned a firm place in diagnosing hair disorders. For a patient it answers the main question: what exactly is happening to the hair. Conditions that look alike, such as telogen effluvium, androgenetic alopecia or alopecia areata, have different trichoscopic signs and are treated differently.

At the Trichology Institute in Kharkiv, digital trichoscopy on FotoFinder equipment is part of the trichologist consultation in the clinical trichology department. The Institute's doctors do not only use the method, they teach it: Professor Yuliya Ovcharenko is a board member of the International Trichoscopy Society and the author of the courses for doctors "Basic Trichoscopy" and "Trichoscopy for Experts".

Who needs trichoscopy

Trichoscopy is done for everyone who sees a trichologist about their hair or scalp. It matters most if:

you have been shedding noticeably more hair than usual for several weeks, for example after an illness, stress, childbirth or surgery;
your hair is gradually thinning: the parting widens, the crown shows through, the hairline recedes, the ponytail gets thinner;
bald patches have appeared, round or irregular;
the hair breaks, has changed its texture, or short broken hairs are visible;
the scalp is red, flaky, itchy, burning or sore;
you are already on treatment and want an objective check of whether it works.

The exam is painless, so it is also done in children, for example in alopecia areata, which often begins in childhood (see the publication on treating alopecia areata in children).

A separate group is the difficult cases: long treatment without results, an atypical picture, several conditions at once. Here trichoscopy becomes part of the combined clinical, trichoscopic and pathomorphological review that the Institute specialises in.

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What trichoscopy shows

A trichoscopic diagnosis is built from the assessment of several structures:

The hair shaft: thickness, narrowing, fractures, twists, short hairs. Hairs of different thickness in one area point to follicle miniaturisation.
Follicle openings, or "dots": empty; yellow, filled with keratin and sebum; black, where a hair has broken at skin level; white, at sites of fibrosis.
The skin around the follicles: scaling, colour changes, a brown halo around the opening (the peripilar sign), secretion.
Vessels: their type, pattern and number help tell apart inflammatory scalp diseases such as psoriasis, seborrhoeic dermatitis and discoid lupus erythematosus.

How the most common conditions are told apart

Androgenetic alopecia: hairs of varying thickness, a larger share of fine vellus hairs, a predominance of follicular units with a single hair, and a peripilar sign that is more marked at the front than at the back of the head. Involutional hair loss in older age gives a similar picture.
Telogen effluvium: empty follicles, single-hair follicular units, regrowing hairs; the changes are spread evenly over the whole head.
Alopecia areata: yellow and black dots, exclamation mark hairs, regrowing vellus. The picture depends on the stage: exclamation mark hairs and black dots point to an active process, vellus appears in the chronic stage and during recovery (a study by Inessa Serbina).
Trichotillomania: hairs broken at different lengths, flame-shaped remnants, asymmetrically coiled hairs.
Fungal infection of the scalp: comma and corkscrew hairs.

Trichoscopy shows what is happening, but not always why. The picture of telogen effluvium is the same whatever triggered it, so the cause is found through the history and laboratory tests. The signs and algorithms are described in detail in the publication "Trichoscopic differential diagnostic algorithms for non-scarring alopecias".

How trichoscopy goes and how to prepare

Trichoscopy is done during the trichologist consultation. First the doctor asks when the changes began, what came before them, which chronic conditions you have, which medicines you take, how you were treated before and whether relatives have similar problems. Then the doctor examines the hair and scalp.

Next the doctor places the video dermatoscope camera on the skin in several areas: the crown, the front, the back of the head, in the patches and at their edges. The images appear on the screen at once, so you see what the doctor sees, and the doctor can show you what matters. The images are saved so that the same area can be compared at later visits.

Preparation

No special preparation is needed, and the method has no contraindications.
On the day of the exam, do not use hairspray, gel, dry shampoo or thickening powders: they make the skin hard to see.
If you plan to colour your hair, do it after the visit.
If a phototrichogram is planned, the doctor will explain in advance whether a small area needs to be clipped short and when to come back for the second image.
Bring recent test results, medical records, a list of medicines and supplements, and photos of your hair from different periods.

Equipment and methods

Digital trichoscopy at the Institute is performed on the FotoFinder Medicam 1000, a diagnostic system used in dermatology, trichology and dermato-oncology. Its optical live zoom gives continuous adjustable magnification, polarisation allows both dry and immersion examination, and its software modules store images of hair, skin and nails for follow-up over time. The same system is used for dermatoscopy of skin lesions.

Besides the examination, the clinical trichology price list includes two measuring tests:

TrichoScale phototrichogram on FotoFinder equipment. The software analyses images of a defined scalp area and calculates hair density and thickness, the share of fine hairs and the ratio of growing hairs to resting ones.
Quantitative trichoscopy (TrichoLab). Measurement of hair parameters on trichoscopic images: shaft thickness, the number of hairs per follicular unit, the share of fine hairs.

Precise measurement of hair thickness is usually not needed for the diagnosis itself, but it is very useful for checking how well treatment works. That is why measurements are most often done as a baseline before treatment. The Institute's doctors have assessed results this way in their own studies too, with a phototrichogram before and after a course ("Injection options in the therapy of hair pathology").

What happens with the result

The doctor explains the result at the same consultation: what the images show, which diagnosis the signs point to and how clear they are.

Diagnosis. Often the examination, the history and trichoscopy are enough to make a diagnosis. If not, the doctor orders further tests.
Treatment plan. The approach depends on the diagnosis, the stage and the activity of the process. In alopecia areata, trichoscopic signs of activity are weighed together with the extent of hair loss (on assessing the severity of alopecia areata). The doctor chooses the methods and the number of procedures individually.
Follow-up comparisons. At later visits the same area is imaged again and compared with the first images and measurements. This shows changes that are hard to see in a mirror, so treatment can be adjusted in time. A follow-up trichologist consultation within two months of the first one is a separate item in the consultations price list.

Hair grows slowly, so shedding usually decreases first and density changes later. Androgenetic alopecia and alopecia areata are chronic conditions, and regular trichoscopic comparisons help catch a flare before it becomes visible. In difficult cases, a supervision by Professor Yuliya Ovcharenko or an international clinical and pathomorphological consilium on hair diseases is available.

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Related diagnostics

Laboratory tests

Trichoscopy does not show hormonal changes or deficiencies that can cause hair loss. The doctor orders tests after the examination, as indicated, not "everything at once". Hair is affected by androgens, oestrogens, thyroid hormones and prolactin, among others (the publication "Hormones and hair"). The clinic works with leading laboratories in Ukraine, samples are taken on site, and when needed the clinic helps arrange tests abroad. More: laboratory diagnostics.

Scalp biopsy

When the trichoscopic picture is atypical, scarring alopecia is suspected, several conditions are hard to tell apart or treatment does not work, the doctor may suggest a punch biopsy with histology. Trichoscopy helps choose the most informative spot. An example of this route is described in the publication on red scalp syndrome: dermatoscopy showed erythema with telangiectasias, and a biopsy confirmed the diagnosis. How the procedure goes: skin biopsy.

Dermatoscopy of skin lesions

If there is a mole or another growth on the scalp, it is examined by dermatoscopy on the same FotoFinder equipment. This is the work of dermato-oncologist Nazar Tsalin (see also mole and skin lesion checks). With age the scalp can develop other changes, such as actinic keratosis, which has its own dermatoscopic signs ("Scalp ageing and associated conditions").

Doctors

Prices

Consultation of a trichologist using digital trichoscopy	2000/1500 UAH
Consultation of the trichologist, follow up (up to 2 months after the first one)	800 UAH
Online consultation with trichologist	2000 UAH
Quantitative trichoscopy using TrichoLab	1500 UAH
TrichoScale phototrichogram using FotoFinder equipment	2000 UAH

Frequently Asked Questions

How is trichoscopy different from an ordinary look at the hair?

In an ordinary examination the doctor sees the overall picture: where the hair is thinning, whether there are patches, what the skin looks like. Trichoscopy shows the details under magnification: the thickness of each hair, the state of the follicle openings, the tiny vessels and scales. These details tell apart, for example, androgenetic alopecia and telogen effluvium, which can look the same to the naked eye. The digital images are also saved, so the same area can be compared a few months later and changes judged objectively.

Can trichoscopy be done in children and during pregnancy?

Yes. Trichoscopy does not damage the skin, uses no radiation and has no contraindications, so it is done at any age and during pregnancy. A child only needs to sit still for a few minutes while the doctor places the camera on the scalp. In children the method is especially useful for telling alopecia areata apart from a fungal infection or a hair-pulling habit, because these conditions are treated completely differently.

Should I wash my hair before trichoscopy?

No special preparation is needed. The main thing is to come without styling products: hairspray, gel, dry shampoo and thickening powders settle on the skin and hair and hide the follicle openings and vessels. Washing your hair the evening before or in the morning is fine. If you are planning to colour your hair, do it after the exam. If a phototrichogram is planned as well, the doctor will tell you how to prepare the area when you book.

How is a phototrichogram different from trichoscopy?

Trichoscopy is an examination in which the doctor looks for the signs of a specific condition. A phototrichogram is a measurement: the software analyses images of a defined area and counts hair density, thickness and the share of growing hairs. These numbers become a baseline against which later measurements are compared. The Institute's price list includes a TrichoScale phototrichogram on FotoFinder equipment and quantitative trichoscopy (TrichoLab); the doctor decides after the exam whether you need them.

Can a diagnosis be made from trichoscopy alone?

Often trichoscopy, together with the history and the examination, gives enough for a diagnosis. But the method has limits. It shows what is happening to the hair, yet does not always explain the cause: the picture of telogen effluvium, for example, is the same whatever triggered it. In that case the doctor orders laboratory tests. And when the signs are atypical or point to a scarring process, a biopsy with histology becomes decisive.

Trichoscopy looked normal, but my hair is still falling out. What does that mean?

This happens. Increased shedding is often a reaction to an illness, stress, childbirth, a diet or medicines, and it shows a few months after the event. The follicles are not damaged, so the trichoscopic picture can look almost normal. A normal result is useful information too: it makes chronic forms of hair loss less likely. The doctor looks for the cause through the history and tests, and a follow-up trichoscopy some time later shows how the hair is recovering.

How often should trichoscopy be repeated?

The doctor sets the interval depending on the diagnosis and the treatment. Hair grows slowly, so comparing images after a few weeks usually makes little sense: changes in density become visible over months. In chronic conditions such as androgenetic alopecia or alopecia areata, follow-up exams are needed even after a course ends, to catch a flare early. A follow-up consultation within two months of the first one is listed separately in the price list.

I had trichoscopy at another clinic. Should I bring the images?

Yes, bring everything you have: images, reports, phototrichogram results, test results and a list of treatments with dates. Earlier data help show how the condition has changed, even if they were made on other equipment. The doctor will still do an examination on FotoFinder, which becomes the baseline for comparisons at the Institute. In difficult cases, when treatment has not worked for a long time, we review all the data as a second opinion.

Who performs trichoscopy at the Institute?

Trichoscopy is performed by the trichologists of the clinical trichology department during the consultation. The method has been developed here for many years: Professor Yuliya Ovcharenko is a board member of the International Trichoscopy Society, and together with Professor Inessa Serbina she wrote the guidelines "Modern methods of diagnosing non-scarring alopecia" and the publication on trichoscopic algorithms. In difficult cases a supervision by Professor Ovcharenko is available.

Can an online consultation with photos replace trichoscopy?

No. A phone photo shows the overall picture but lacks the magnification and sharpness needed to assess follicle openings, hair thickness and vessels. That is why trichoscopy is done only in person, at the Institute at 17 Danylevskoho St in Kharkiv. An online trichologist consultation is also in the consultations price list: it is useful for discussing results you already have or the course of treatment, and it is best to check what it covers when you book.