What is Trichoscopy?

A Trichoscope is a magnifying device your Trichologist may use during your examination. Like a Dermatoscope that a dermatologist would use, a Trichoscope was developed over recent years specifically for use with scalp and hair disorders.

A Trichoscope allows the hair and scalp to be seen at a magnification of around 50x (which is mostly what I use) all the way up to 200x in some cases!

To a patient, the images a Trichoscope produces can look very strange, and sometimes even a little scary! In fact, I often won’t show these images to a patient unless they are completely comfortable looking at them. Losing your hair can be extremely distressing, so putting these images in front of you (when you do not understand what you are seeing) is not going to help you in any way. Trichoscopy should never be used by clinicians for theatrical purposes or as a means to ‘show off’.

On the other side of the coin, many people are curious and want to see what we see and why things look the way they do. So, without any further ado, lets look at some Trichoscopy!

What does a normal healthy scalp look like?

This image shows a relatively healthy scalp at around 50x magnification. The first thing to notice is that each hair looks roughly the same diameter, there is sometimes a very subtle variability as not all hairs are exactly the same thickness. Many people think only 1 hair comes out of one opening, but as you can see in the image, there are some with more than one hair emerging. These are called follicular units and they come in singles, 2’s, and 3’s! The image above is taken from the top of the scalp just in front of the crown area, where you would generally see very few (if any) units with more than 2 hairs emerging. Larger units are typically found more towards the back of the head. The scalp is a good colour with no redness (inflammation) or scale. The shine you can see is the sebum (natural oils) produced by sebaceous glands attached to the hair follicle beneath the scalp surface.

So, what do we actually look for?

Trichoscopy can be extremely complex, as many of the features we see are not exclusive to just one condition, and there are a vast range of features…… here is an example of a few we may look at:

  • Hair shafts – Variability in hair shaft thickness, as well as colour and shape.
  • Dots – These refer to follicular openings. Different coloured dots mean different things. In this image the dots are yellow, they are empty follicles which have filled with sebum (oil) rich keratotic material. This is a common feature of alopecia areata (as well as other conditions)
  • Scaling – Colour, distribution, and location of scale can be useful. This is my scalp (yep…. Trichologists can suffer too!). The scale has a yellow tinge to it and scalp beneath is quite red and inflamed, a common feature of seborrheic dermatitis.
  • Blood vessels – The type of vascular presentation in a symptomatic area can help us to identify various conditions.

What else is Trichoscopy useful for?

Trichoscopy imagery is extremely useful for monitoring how someone is responding to a given treatment. We may observe improvements in density, hair shaft thickness, scaling, or inflammation. We may also see continued progression of a condition, or no change at all. This information is vital in ensuring correct choice of treatment and may also help to confirm a specific diagnosis later down the line.

Trichoscopy is also used frequently during clinical and scientific studies, as it provides a more accurate means of measuring efficacy of a particular treatment, medication, or product. The equipment used for these purposes is a lot more sophisticated and quite expensive, so you will not typically see these devices in the average clinic.

The bigger picture

Trichoscopy is a valuable tool for any hair loss practitioner to have at their disposal for clinical work (I certainly would not be without mine). However, Trichoscopy only gives us a small part of the picture and will only be a reliable diagnostic tool when all other aspects of the consultation (such as case history, medical information, and lab investigations) are taken into consideration. THE BIGGER PICTURE!