Original Article Access this article online Website: www.ijtrichology.com DOI: 10.4103/0974-7753.125603 Quick Response Code:

Address for correspondence: Dr. Sana A Bhamla, Department of Dermatology, T.N.M. College and B.Y.L. Nair Ch. Hospital, Mumbai Central, Mumbai ‑ 400 008, Maharashtra, India. E‑mail: sana_bhamla@ yahoo.com

Is Trichoscopy a Reliable Tool to Diagnose Early Female Pattern Hair Loss? Sana A Bhamla, Rachita S Dhurat, Punit P Saraogi Department of Dermatology, T.N.M. College and B.Y.L. Nair Ch. Hospital, Mumbai Central, Mumbai, Maharashtra, India ABSTRACT Background: Female pattern hair loss (FPHL) presents with visible patterns of hair loss, thus making a bedside diagnosis possible. However, there are cases of FPHL presenting without any visible hair thinning, making it necessary to subject them to a scalp biopsy to make a diagnosis. Aim: The aim of the following study is to determine if trichoscopy can be used as a bedside tool to diagnose Early FPHL in women presenting without any visible thinning of hair, using >20% hair diameter diversity – anisotrichosis, as the diagnostic criteria. Materials and Methods: Trichoscopy was performed on 20 cases of early FPHL (biopsy proven), 63 normal controls and 29 Grade 2 FPHL Controls. Results and Discussion: In the biopsy proven FPHL cases, 75% showed anisotrichosis on trichoscopy. This finding was significantly higher in FPHL Cases compared to normal controls. As expected, 93% of Grade 2 FPHL controls also showed the same finding. Trichoscopy was found to be 75% sensitive and 61.54% specific in diagnosing early FPHL. Thus, a negative result would be more indicative of absence of disease, however, a positive result would not always indicate the presence of disease. Key words: Anisotrichosis, female pattern hair loss, hair diameter diversity, trichoscopy



he diagnosis of female pattern hair loss (FPHL) is largely made by standard clinical observations based on visible patterns of hair loss. Various global clinical scales have described these patterns such as those proposed by Ludwig,[1] Olsen,[2] Savin,[3] Biondo et al.[4] (Women’s alopecia severity scale [WASS]). However, there is a set of women who present with the chronic hair loss without any discernible reduction in hair density over the crown. Such early forms are often overlooked and clinical evaluation may not be adequate to make the right diagnosis. In a study by Sinclair et al.,[5] it was observed that 56% (32/57) of women with a history of hair loss for >6 months duration, with a completely normal looking scalp, were actually diagnosed as FPHL on triple horizontal scalp biopsy. This diagnosis was based on histopathological terminal/ vellus ratio of  20% hair diameter diversity [HDD]). On the other hand, trichoscopy [6,7] is a noninvasive method (vs. scalp biopsy) for diagnosis of hair loss, which uses videodermoscopy of hair and scalp at higher magnifications (×20 - ×70).[8‑10] This allows a noninvasive measurement of HDD, which is a characteristic feature International Journal of Trichology / Jul-Sep 2013 / Vol-5 / Issue-3

of FPHL, recently termed as “Anisotrichosis.” [11] Trichoscopy has been widely used as a diagnostic as well as a prognostic tool to measure anisotrichosis in cases of overt androgenetic alopecia (AGA) and FPHL.[8,12‑15] Trichoscopy can thus also be used as a tool to diagnose FPHL in early cases. This could be made easier on the bed side by using a photographic scale to determine the presence of  >20% anisotrichosis, rather than having to measure it. The goal of our study was to determine if trichoscopy can be used as a reliable noninvasive tool to diagnose early FPHL in females presenting with diffuse hair loss of  >6 months duration, without obvious scalp hair thinning, using a photographic diversity scale and possibly obviate the need for scalp biopsy in these patients. To the best of our knowledge, no such study has been performed to demonstrate the findings and validity of trichoscopy in early FPHL. MATERIALS AND METHODS

Written informed consent was obtained from all patients and the protocol was approved by the hospital‑based ethics committee. 121

Bhamla, et al.: Trichoscopy: Early FPHL


Scalp biopsy

Cases: 35 female cases with a complaint of progressive hair loss of gradual onset of  >6 months duration, without obvious scalp midline widening were enrolled. These cases were graded as Grade 1 of Hair Loss as per the WASS. All relevant blood investigations were performed.

All the cases were subjected to a triple horizontal scalp biopsy.

Patients with cicatricial alopecia, alopecia areata, trichotillomania, acute telogen effluvium or traction alopecia were excluded from the study. Group 1 Controls: 63 healthy age‑ and sex‑matched female volunteers with no history or findings suggestive of hair loss served as negative controls. Group 2 Controls: 29 female patients with a complaint of progressive, gradual hair loss of  >6 months duration, with obvious scalp midline widening, without thinning of hair on either side (Grade 2 hair loss – WASS) served as positive controls. Procedure Trichoscopy All cases and controls were evaluated for HDD with a trichoscope at the midscalp. All the subjects were asked to shampoo their hair 1 day prior to the procedure. They were asked to avoid oiling or coloring their hair. A clean midline was obtained at the midscalp with a fine toothed comb (kept constant throughout the study for all subjects). Isopropyl alcohol was used as the interface solution. Using the digital camera (Canon Powershot A640 10 MP, Keppal Bay Tower, Singapore) with its optical attachment pressing evenly against the scalp, trichoscopic images were taken at ×20 magnification at the midscalp – at the intersection between nose line and ear implantation line. Images having features of scaling, white or colored hair, with an improper midline and backscattering effect were not accepted for analysis. The optimal captured images were digitalized and displayed on a real time monitor and selected images were stored on a computer. The image was compared with a photographic scale for HDD and was rated as either, Scale 1 – showing >20% HDD, suggestive of FPHL; or Scale 2 – showing 20% HDD [Figure 2]. >20% HDD was significantly higher in FPHL compared to Group 1 control [Figure 3] (31.75%, P 20% HDD) Scale 1

Scale 2

FPHL (n=20)



CTE (n=13)



HDD – Hair diameter diversity; FPHL – Female pattern hair loss; CTE – Chronic telogen effluvium

Table 2: Trichoscopic diagnosis in Group 1 and Group 2 controls Controls

Trichoscopic diagnosis (>20% HDD) Scale 1

Scale 2

Group 1‑negative controls (n=63)



Group 2‑positive controls (n=29)



Figure 3: Group 1 control, normal, showing normal findings on trichoscopy

International Journal of Trichology / Jul-Sep 2013 / Vol-5 / Issue-3


HDD – Hair diameter diversity

Bhamla, et al.: Trichoscopy: Early FPHL

Via trichoscopy, AGA has been characterized by increased percentage of thin hairs, increased hair shaft diameter diversity, increased percentage of single hair units, presence of yellow dots, perifollicular hyperpigmentation.[7,8,12,15] However, these have been studied in white subjects. A study done on Asian population showed that perifollicular pigmentation was less appreciated on the Asian scalp compared to the white population.[14] Even amongst the white population, the number of yellow dots observed in FPHL cases were 20% higher on  ×70 magnification versus ×20 magnification,[12] making it a relatively unreliable finding. Presence of yellow dots is a finding present in alopecia areata, trichotillomania, in addition to AGA;[9] wherein, in a recent study it was found to be significantly higher in alopecia areata.[26] The same study showed that HDD was present in all cases of AGA and was significantly higher than in other forms of hair loss. Inui[14] postulated that >20% HDD is an essential feature to diagnose AGA and FPHL. More so, according to de Lacharrière et al.,[13] diversity in hair diameter was the main and most accurate clinical parameter linked to follicle miniaturization.

evaluation of females with early diffuse hair loss. It is easy to use and interpret a time‑saving and relatively inexpensive tool. One can consider using trichoscopy as an aid for screening of such females and avoid the patient feared scalp biopsy to some extent. A negative result would help in ruling out FPHL; however a positive one still does not obviate the need for a scalp biopsy.

Hence, in our study HDD was considered as sole diagnostic criteria for FPHL, using a photographic scale for bedside use.


Using >20% HDD as a diagnostic parameter, trichoscopy could diagnose 75% of Grade 1 FPHL and 93% of Grade 2 FPHL. This increase in detection from Grade 1 to Grade 2 could be due to the increasing miniaturization with increasing grade of FPHL, further signifying the correlation between HDD and follicle miniaturization.[13]


Trichoscopy is found to be 75% sensitive and 61.54% specific in diagnosing early FPHL. In view of the high sensitivity, a negative result would be more indicative of absence of disease, however, due to the low specificity, a positive result would not always indicate the presence of disease. Since >20% HDD is also a finding observed in a small proportion of normal controls, this occurrence in the normal population should be further elucidated. If possible these normal women should be biopsied to look for an underlying androgenetic process. If not, a long‑term follow‑up of such patients for the development of FPHL should be attempted.

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Based on the above study it can be concluded that trichoscopy is a sensitive, non‑invasive tool for preliminary



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Bhamla, et al.: Trichoscopy: Early FPHL 23. Rakowska A, Slowinska M, Kowalska‑Oledzka E, Rudnicka L. Trichoscopy in genetic hair shaft abnormalities. J Dermatol Case Rep 2008;2:14‑20. 24. Rakowska A, Kowalska‑Oledzka E, Slowinska M, Rosinska D, Rudnicka L. Hair shaft videodermoscopy in netherton syndrome. Pediatr Dermatol 2009;26:320‑2. 25. Slowinska M, Rudnicka L, Schwartz RA, Kowalska‑Oledzka E, Rakowska A, Sicinska J, et al. Comma hairs: A dermatoscopic marker for tinea capitis: A rapid diagnostic method. J Am Acad Dermatol

2008;59:S77‑9. 26. Karadağ Köse Ö, Güleç AT. Clinical evaluation of alopecias using a handheld dermatoscope. J Am Acad Dermatol 2012;67:206‑14. How to cite this article: Bhamla SA, Dhurat RS, Saraogi PP. Is Trichoscopy a reliable tool to diagnose early female pattern hair loss?. Int J Trichol 2013;5:121-5. Source of Support: Nil, Conflict of Interest: None declared.


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Is trichoscopy a reliable tool to diagnose early female pattern hair loss?

Female pattern hair loss (FPHL) presents with visible patterns of hair loss, thus making a bedside diagnosis possible. However, there are cases of FPH...
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