Trichoscopy: A Comprehensive Guide

A trichoscopy is a procedure that examines your scalp up close. More specifically, it’s a diagnostic method that involves holding a microscope device to your scalp to see your hair and follicles. Hair follicles are so tiny that you actually can’t see them without a microscope, and a trichoscopy — a term that wasn’t coined until 2006 — magnifies them.

A trichoscopy device (also known as a dermoscope or dermatoscope) is not much different from the little handheld device a healthcare professional uses to examine your ears or eyes, except it’s trained on your scalp.

If you’re noticing the first signs of hair thinning or you think your hair loss could be related to a scalp condition, getting a trichoscopy can help you and your healthcare professional better understand what’s going on. Read on to learn more about what exactly a trichoscopy is, what it can diagnose and why you might want to consider getting one.

Trichoscopy is based on the science of dermoscopy, a noninvasive clinical evaluation of the skin. The procedure is typically done to observe lesions and other abnormalities of the skin. When performed on the scalp or hair, it’s called trichoscopy (though saying dermoscopy is not incorrect), and it’s used as a method for diagnosing hair loss as well as scalp conditions.

Of course, hair loss is visible to the naked eye (that’s kind of the whole thing). So why would you need a trichoscopy to confirm that you’re losing hair? Well, trichoscopy can illuminate the type of hair loss you’re dealing with, which can help you and your doctor come up with a course of action.

For example, an alopecia areata trichoscopy would likely find yellow dots, black dots, broken hairs, short vellus hairs (peach fuzz), and tapering hairs. A trichoscopy done to confirm androgenetic alopecia (male pattern baldness) would likely show single hair follicles and redness and scaling of the skin around the follicle.

Male pattern baldness and certain scalp conditions can be diagnosed without a trichoscopy, though it can never hurt to get more information on your condition (and speaking of never hurting, the procedure is painless).

Trichoscopy is done using either a handheld lighted device known as a dermascope, which has about 10x magnification, or a video dermatoscope, which has anywhere from 20 to 1,000 magnification capability. Here’s what you should know about before and during a trichoscopy.

• First thing to know: You should not wash your hair for two to three days before your trichoscopic exam, as it may eliminate important physical signs your doctor needs to see.

• Avoid hair dye and other hair cosmetics like hair powder in the weeks leading up to your procedure.

• At the start of your appointment, your hair will be parted or sectioned to allow for better visualization of the scalp. In some cases, a gel or oil may be applied to the scalp to enhance image clarity.

• The dermatologist or healthcare professional will gently guide the trichoscope onto different areas of the scalp. The device allows them to see the scalp and hair follicles in detail, magnifying them several times over.

• The doctor will observe the scalp and hair follicles, paying careful attention to things like hair density, hair diameter, the presence of broken hair, follicular openings that look abnormal, the color of hair follicles, and signs of inflammation or infection.

• A camera may be attached to the dermascope, or the clinician may instead use a video dermoscope to capture images that can be analyzed later. In addition to helping with diagnoses, these images can also be a good tool to track progress in follow-up appointments.

• A few pieces of hair may be plucked from the head for further examination or to be sent to a lab.

During a trichoscopy procedure, a healthcare professional will be looking at the following four basic structures of the scalp and hair.

• Follicular openings — the external opening of the follicle

• Perifollicular skin — the skin around hair follicles

• Hair shafts — the visible part of hair

• Vascular structures — blood vessels on the scalp

Below, we’ll cover what a healthcare provider looks for during an exam and what these trichoscopic findings could potentially tell you about your hair health.

Follicular openings

The hair follicle is tube-shaped. At the innermost part of the tube which extends into the scalp, there’s a hair bulb — it connects to the hair papilla, which supplies the root with blood. But the opening of the follicle on the scalp is all that’s visible with trichoscopy (examining the rest of the follicle would require a scalp biopsy).

When examining follicular openings, your healthcare provider will look for the following.

The size and distribution of hair follicles

• Larger or irregularly distributed follicles can indicate scarring alopecia.

• Normal hair follicles are spaced at regular intervals.

• Visible hair bulbs could be a sign of aplasia cutis congenita (a rare disorder in which skin is missing.)

The color of the follicles

• Black hair follicles generally mean that hair has broken off at the scalp level — this can indicate trichotillomania or another injury like traction alopecia, wherein tight hairstyles that tug at the root cause hair loss. Black dots (sometimes called cadaverized hair) can also be a sign of tinea capitis and alopecia areata (which causes patchy hair loss).

• Yellow dots can indicate alopecia areata, androgenic alopecia, or discoid lupus erythematosus, an autoimmune condition that causes rashes on the scalp or face.

• White dots arranged in a honeycomb pattern can be a sign of a normal scalp for certain skin tones. It can also indicate sun exposure or lichen planopilaris, a rare scalp disorder that can cause hair loss.

• Follicular red dots are a known trichoscopic feature of active discoid lupus erythematosus of the scalp. Red dots that are visible to the eye can be a sign of folliculitis or cellulitis, a potentially serious bacterial skin infection.

• Pink dots could be a sign of frontal fibrosing alopecia, which is hair loss on the front and sides of the scalp and often on the eyebrows.

Hair Shafts

Using a dermascope provides an up-close view of the hair shaft, which is the part of the hair we can see. The hair shaft is made up of keratin. Here’s what a dermatology professional will be looking for in the hair shaft:

• They’ll note the ratio between short vellus hair (which are fine hairs, like peach fuzz) and terminal hair, which is the darker, thicker, and coarser hair we typically associate with hair on the head, underarms, or pubic area. Male pattern baldness and other hair loss disorders can cause hair that should be terminal to turn into vellus hair.

• Fractured hairs, broken hair shafts or splitting hair can be signs of various types of alopecia, an umbrella term for hair loss.

• Irregular hair shapes like comma hair, tapered hair or exclamation mark hairs (narrower at the base) can suggest the onset of certain disorders. Corkscrew hairs or zigzag hairs can be a solid indicator of tinea capitis (scalp ringworm).

• Pigtail hairs twist (corkscrew in shape, like a pig’s tail) and can be a feature of scarring alopecia or diffuse hair loss as a result of chemotherapy.

• Trichotillomania can cause flame hairs (the remains of a pulled or broken hair) or tulip hair, which is when the hair color varies from the opening to the tip.

• Changes in the color of the hair (dark brown hair becomes light brown or red, for example) is a characteristic of telogen effluvium, or hair loss related to injury or stress.

Perifollicular skin

The hair follicle is surrounded by tissue known as perifollicular skin, which can give clues about overall scalp health. Below is what a trichoscopy will look for in the skin around the hair follicles.

• Perifollicular scaling may indicate the presence of psoriasis, seborrheic dermatitis, or, in some cases other fungal infections like lichen planopilaris.

• White pigmentation could be a sign of scarring alopecia (also called cicatricial alopecia). Some pigmentation can be normal, especially in people with darker skin tones.

• Any type of discharge may indicate a bacterial infection or folliculitis decalvans.

• Perifollicular erythema (that’s simply medicalese for redness of the tissue) is a “direct marker” of frontal fibrosing alopecia.

Vascular structures

We don’t often think of scalp and skin conditions as having a vascular component, but it’s just that we don’t see our scalps much. And even if we could, the blood vessels are not always visible to the naked eye. When examining the vascularization of the scalp via a trichoscope, your healthcare provider will look for the following:

• Prominent blood vessels, which can indicate inflammatory disorders like psoriasis.

• Seborrheic dermatitis (that’s dandruff and also a type of eczema), systemic sclerosis (a hardening of the skin), or an autoimmune condition known as discoid lupus erythematosus may cause arborizing vessels (they look like trees) to appear on the scalp.

• Psoriasis sometimes creates dotted vessels arranged in clusters or evenly distributed.

Trichoscopy Side Effects

There are no known adverse effects or risks associated with trichoscopy, and there are no painful or invasive trichoscopic features (like needles) to worry about. So, simply put, trichoscopy is safe and without any known risk factors or side effects. If you like scalp massages or when people play with your hair, you may even find that the dermoscopic procedure feels nice.

The procedure can also be done with epilated — or already shed — terminal hairs, so there’s a chance you won’t come into contact with the dermascope.

The biggest limitation of trichoscopy's diagnostic capability, however, is that it only reveals surface information. In some cases, you might also need to have a scalp biopsy or cultures of bacteria, fungi, or hair. A trichoscopy is not meant to replace a histopathological exam (that’s the study of scalp tissue).

While trichoscopy is an easy and reliable tool for diagnosing hair disorders, it’s not a full-blown solution for hair loss. Think of it as a starting point. While you and a healthcare professional will come up with a treatment plan that appropriately addresses your specific type of hair loss, certain hair loss medications can help slow the progression of hair loss and even aid in hair regrowth in some people.

Finasteride

Finasteride has been proven to slow hair loss and stimulate regrowth. But it’s not a cure-all for all types of hair loss.

The prescription medication works by reducing the amount of dihydrotestosterone (DHT) in the body by more than 90 percent. This is great for people with male pattern baldness, as DHT is a major factor there, but it won’t be a reliable treatment for hair loss without a hormonal component (like telogen effluvium).

Minoxidil

Minoxidil is a topical treatment — you may know it as Rogaine®. Unlike finasteride, Minoxidil isn’t a DHT blocker, so it can be useful for non-hormonal hair loss. It increases blood flow to the scalp (so it’s a vasodilator), flooding the scalp with oxygen and nutrients needed for hair health.

We offer minoxidil foam and minoxidil liquid solution.

Finasteride and Minoxidil Together

Like the best duos do, minoxidil and finasteride complement each other while tackling the problem (read: hair loss) from different angles.

A 2019 meta-analysis found that the combination of oral finasteride and topical minoxidil was more effective and just as safe as using one on its own.

And while finasteride is often thought of as a pill, both medications can be used topically as well (that’s where our topical finasteride & minoxidil spray comes in). Studies show that new hair count is similar in people treated with either topical finasteride or finasteride tablets.

Trichoscopy is an effective, safe, and simple diagnostic tool for finding a hair disorder, including those that have previously eluded diagnosis. Here are a few things to remember:

• Trichoscopy can be valuable in confirming a diagnosis, assessing disease severity, or making a differential diagnosis between types of hair loss that may appear similar — diffuse alopecia areata and telogen effluvium or scarring (non-cicatricial) versus non-scarring alopecia are often hard to distinguish, for example.

• Strictly speaking, you don’t need a trichoscopy to diagnose hair loss or scalp conditions, but it can certainly help you get valuable information about the causes of and treatment for your hair loss.

• Many people wonder if medical procedures will hurt. Trichoscopy does not hurt and requires zero downtime.

To learn more about your scalp and hair health, check out our guide to common scalp conditions.​​ If you’re considering a trichoscopy or have questions about why you’re seeing hair loss, speak with a healthcare professional who can recommend the best hair loss treatments for your specific situation.