Algorithm for examination of a trichological patient

Natalia Barunova, dermatologist, trichologist, member of the Society of Trichologists at the National Alliance of Dermatologists and Cosmetologists, certified trichologist and teacher of the course of the International Trichological Association IAT., head of the trichology department of the Center for Advanced Diagnostics of Hair Problems, BioMi Vita Clinic (Russia, Moscow)

Stages of trichological assistance
First of all, it should be noted that the methods of treating trichological patients in the CIS countries and abroad differ significantly, since in the West trichology has been developing for a long time and now represents a structured industry in which the stages of providing "trichological care" to the population are quite clearly distributed between specialists of different levels, while in our country these stages are "blurred" and do not have clear boundaries. Table 1 schematically presents the stages of trichological diagnostics, which is more typical for countries outside the CIS: after detecting a hair problem (independently or with the help of relatives, friends), the patient seeks specialized trichological, most often non-medical care (consultant trichologist) and only then, if necessary, highly specialized medical care (dermatologist / dermatocosmetologist-trichologist).

This feature is associated with both the low availability of trichologists and the high cost of their services in Western countries, and the presence of a well-developed network of paramedical trichologists who have received the appropriate training and qualifications and are able to provide the services in demand at a high level. In addition, the relationship between a trichologist and a trichologist specialist increases the range of services provided and increases patient compliance. Thus, if a trichology center has a specially trained hairdresser with the skills of a trichologist consultant, the patient can visually improve the condition of his hair at the initial stage of treatment by choosing a hairstyle that increases volume, selecting nanofibers that mask thinning, and, if necessary, using an overlay individually selected for the color and structure of his own hair.

To work successfully in modern conditions, a trichologist needs to be aware of global trends in the field of diagnostics and treatment of hair and scalp diseases, master new diagnostic and treatment methods, constantly improving their professional level. At the current stage, a specialist involved in the diagnostics and treatment of hair and scalp diseases must be familiar with areas of medicine related to dermatology, such as therapy, endocrinology and gynecological endocrinology, psychoneurology, psychoneuroimmunology and psychodermatology.

Diagnostic methods in trichology
The effectiveness of the patient's treatment will depend not only on the practical experience of the specialist, but also, no less importantly, on his/her successful mastery of modern diagnostic methods in trichology, the importance of which is growing every day.

Depending on the aspects of trichological diagnostics under consideration, methods for assessing the condition of hair and scalp can be conditionally divided into:

• specialized and non-specialized;
• methods intended primarily for research purposes and practical work;
• from the point of view of manipulations performed on the patient – ​​non-invasive, semi-invasive and invasive.

Non-specialized methods include ultrasound examination of the human body, as well as laboratory (clinical) diagnostic methods that allow obtaining data on the patient's health based on the study of human biomaterial in vitro using hematological, biochemical, immunological, serological, molecular biological, bacteriological, genetic, cytological and other methods. These methods provide an idea of ​​the general condition of the human body and can be prescribed to the patient by both a trichologist and relevant narrow specialists.

Laboratory diagnostic methods allow us to exclude conditions such as iron deficiency anemia or latent iron deficiency, vitamin and/or chemical deficiency, thyroid dysfunction and hyperandrogenemia, which can be both the main cause of hair loss and factors that aggravate this problem.

It should be remembered that the main task of a specialist is to treat not the disease, but the patient, that is, to correctly interpret the laboratory information received and, having compared it with the patient’s existing picture of the disease, use it for further effective clinical use of the results obtained.

This paper will examine some diagnostic methods that are most important for the effective practical work of a trichologist.

Specialized methods of trichological diagnostics

Today, the range of modern methods for examining a patient with hair and scalp problems, in addition to the classic collection of anamnesis and physical examination of the patient, may include trichoscopy, trichogram and phototrichogram with contrast, specialized diagnostic computer programs that allow measuring hair, its thickness and density, the number of follicular units per unit area, biopsy and numerous types of microscopy, as well as the method of overview photographs.

Let us dwell in more detail on those specialized methods that have the greatest practical significance for daily practice and are most accessible to a practicing specialist - these are trichoscopy, phototrichogram and the method of overview photographs.

Trichoscopy
Today, trichoscopy has become an essential tool for examining a trichological patient and conducting differential diagnostics of hair and scalp diseases. This non-invasive method, which has become widespread since the beginning of the 21st century (the term was introduced by L Rudnicka in 2006), is based on the use of a hand-held dermatoscope or video dermatoscopy of hair and scalp skin and is actively used by trichologists due to its availability, simplicity and non-invasiveness in combination with a fairly high information content.

A distinction is made between trichoscopy using immersion fluid (immersion) and without immersion ("dry"). The use of immersion trichoscopy helps to assess the condition of the vessels and scalp skin, while "dry" trichoscopy is most informative for assessing the presence of flaking, manifestations of seborrhea, perifollicular hyperkeratosis.

This method is an important tool in practical work, allowing differential diagnostics of various types of alopecia. Trichoscopy uses lenses with different magnifications - from 10 to 1,000 times, the most commonly used lenses are those with a magnification range from x20 to x70. The method allows in vivo assessment of the condition of trichoscopic structural units, namely: hair shafts - their structure and diameter, the condition of the mouths of hair follicles and vessels of the scalp, perifollicular epidermis. Trichoscopy is used in differential diagnostics between alopecia areata and trichotillomania, cicatricial and non-cicatricial alopecia. The method has also proven its effectiveness in diagnosing seborrhea and psoriasis of the scalp. Visualization of structural abnormalities of hair shafts during trichoscopy makes it possible to diagnose genetic diseases of hair shafts, such as Netherton Syndrome, monilethrix and others.

Trichoscopy allows us to distinguish normal terminal hair from vellus (vellus-like) hair, the thickness of which is no more than 0.03 mm, and also allows us to distinguish exclamation mark-shaped hairs, characteristic of alopecia areata, the length of which is no more than 1–2 mm.

The method allows to evaluate the condition of the mouths of hair follicles, the changes observed in this case are usually described using the term "point". Black points (cadaverized hairs) characteristic of alopecia areata (AA) (photo 1), yellow points occurring in both alopecia areata and androgenetic alopecia (AGA) (photo 2), as well as yellow points of "3D" format in cicatricial alopecia and red points characteristic of discoid lupus erythematosus are described.

Photo 1. Yellow dots and black dots in GA. Author's observation
Photo 2. Yellow dots in AGA. Author's observation

Trichoscopy can also be used to evaluate the characteristics of cutaneous microvascularization. Thus, twisted and lacy vascular loops are a characteristic sign of scalp psoriasis, and branching vessels inside yellow dots are found in discoid lupus erythematosus.
Disorders of the structure and changes in the color of the scalp that are visualized during trichoscopy include hyperpigmentation in the form of a "honeycomb", indicating excessive exposure of the scalp to insolation (photo 3), peripilar (perifollicular) signs that appear in the early stages of androgenetic alopecia (photo 4), as well as perifollicular fibrosis, characteristic of different forms of fibrous alopecia.

Photo 3. Hyperpigmentation in the form of "honeycomb". Author's observation
Photo 4. Trichoscopy of a patient with AGA. Peripillary signs and yellow dots (highlighted in yellow), vellus hairs (highlighted in red), fillicular units are predominantly single. Author's observation

Characteristic trichoscopic signs of cicatricial alopecia are areas of milky red color (mainly in lichen planus) or ivory color (in the initial stage of frontal fibrosing alopecia), in combination with the absence of hair follicle openings, as well as perifollicular hyperkeratosis in the form of rays resembling a star (characteristic of decalvans folliculitis), or in the form of concentric scales around the openings of the follicles (occurs in lichen planus).
Trichoscopy helps to detect anisotrichosis – the presence of hair of different diameters: terminal, interdeterminate and vellus (a specific sign of androgenetic alopecia), as well as the number of hairs in follicular units and their location relative to each other. Of clinical importance is an increase in the number of single follicular units and a decrease in the number of follicular units with 2, 3 or more hairs, as well as an increase in the distance between follicular units (photo 5).

Photo 5. Trichoscopy of a patient with AGA. Anisotrichosis, increased distance between follicular units. Author's observation

Visually, this will manifest itself as progressive thinning and loss of hair volume, which is typical for androgenetic alopecia. An increase in the number of follicular units with 4 or more hairs is typical for cicatricial alopecia, in particular, flat hair lichen and decalvans folliculitis.

Trichoscopes have recently appeared, allowing examination using UV rays with a wavelength corresponding to the spectrum of the Wood's lamp. Their use is intended to facilitate diagnosis in cases of suspected superficial mycoses (dermatomycosis) of the scalp, folliculitis caused by fungi of the genus Pityrosporum, and various types of porphyria (photo 6).

Photo 6 (a, b). Trichoscopy of pityrosporum folliculitis using the UV spectrum (365 nm) and without ultraviolet light. Author's observations

It is worth remembering that, despite all the advantages, the described method has its limitations and does not give the specialist the right to make a diagnosis based only on the signs revealed by trichoscopy. In addition, the trichoscopic picture is not always obvious and unambiguous. If cicatricial alopecia is suspected, as well as in complex cases and when differential diagnostics are necessary, a biopsy comes to the aid of the trichologist, allowing him to look “inside” the hair follicle (photo 7).

Photo 7. Biopsy of a patient with frontal fibrosing alopecia. Author's observation. The study was performed by PhD Trunova

A biopsy is a highly specialized diagnostic method and requires appropriate qualifications not only from the trichologist who collects the material for further examination, but also from the pathologist/histologist who will evaluate the scalp biopsy samples.

Phototrichogram

Non-invasive methods include standard phototrichogram and phototrichogram with contrast (using specialized computer programs).

This method is generally recognized and widely used in clinical trichological practice due to its high accuracy and availability.
An important feature of the phototrichogram (PTG) method is the ability to use it to identify the subclinical form of androgenetic alopecia already at the early stages of the disease, to conduct differential diagnostics between AGA and diffuse telogen effluvium, and to evaluate the effectiveness of alopecia treatment over time.

The phototrichogram method allows studying the hair growth cycle in vivo and measuring its various parameters, including density and diameter, the percentage of hairs in the growth phase (anagen) and in the loss phase (telogen), the average growth rate, and the number of terminal and vellus (thinned) hairs. In addition, the program allows calculating such an important parameter, which is of great importance for the differential diagnosis of androgenetic alopecia, as the percentage of vellus in telogen, i.e. those hairs that become thinner and prematurely enter the loss phase under the influence of androgens.

To perform a phototrichogram, the specialist selects an area for subsequent measurements, usually located at a standard point in the frontal-parietal zone or in another area of ​​pronounced hair thinning. At the first stage of FTG, hair is shaved with a trimmer in areas measuring 10 x 10 mm in size in the selected areas. If further observation is required, a tattoo mark must be placed in the phototrichogram area to perform repeated phototrichograms in the same area. During the second stage, after 2-3 days, among the shaved hair, it will be possible to detect regrown anagen hair and telogen hair of the same length. The area is tinted with a special dye, and then, using a trichoscope connected to a computer, the images taken at 40-60x magnification are entered into a specialized computer program (in Russia, the most widely used program is TrichoSciencePro©).

Next, using the program, the total number of hairs per square centimeter of skin is calculated, as well as the number of vellus-like, anagen and telogen hairs.

It is diagnostically important that most of the hairs in the telogen phase (photo 8, pink arrows) are vellus-like (parameter "vellus among telogen hairs"), i.e. sensitive to androgens, which makes the diagnosis of androgen-dependent alopecia obvious. In addition, this phototrichogram clearly shows an increase in the number of single follicular units, the presence of peripilar signs, yellow dots, areas of focal atrichia, which also indicates the presence of androgenetic alopecia.

Photo 8. Phototrichogram of a patient with androgenetic alopecia. Author's observation

It should be noted that the phototrichogram method is highly accurate and reproducible only if the procedure is performed by a qualified specialist with the appropriate practical skills and sufficient practical experience in compliance with the diagnostic protocol, since the data calculation in the program occurs in a semi-automatic mode and requires the specialist to have the appropriate qualifications.

Below (photos 9, 10, 11) are some of the errors often observed when performing a phototrichogram (observations of the author).

Photo 9. Image of phototrichogram without using immersion liquid
Photo 10. In this case, calculating the phototrichogram may be difficult due to the fact that the specialist did not remove the bubbles that arose as a result of using the immersion agent.

Photo 11. A version of a correctly taken picture for calculating phototrichogram parameters is presented.

So far, attempts to eliminate the human factor from the procedure of conducting a phototrichogram, replacing it with automatic calculation of the parameters under study, have not been successful. Thus, the automated program for conducting a phototrichogram presented on the Western market, despite the convenient automatic counting mode, causes numerous complaints from specialists due to insufficient accuracy of the counts. Since in the automated mode two or three thin hairs located close to each other can be recognized by the program as one thick hair, then when using such a fully automated method of counting, its accuracy cannot be guaranteed.

Survey Photograph Method

This method has long been used in both dermatology and trichology to study the condition of the skin and hair, as well as to assess the effectiveness of treatment. The standardization of the survey photograph method was first described in 1987 by Lederle, but this method became widespread after its use in clinical studies to assess the effectiveness of finasteride.

During clinical studies, not only are problem areas photographed using stereotactic devices, but the photographs obtained during observation (before and after treatment) are subsequently evaluated with the involvement of a panel of independent experts.

A stereotactic device (SD) for photography is a device that combines a device that fixes the patient's head in one position, a camera with a specially configured flash system, and a special panel or ruler that measures and records the distance between the device and the patient. The main task of a stereotactic device is to create reproducible conditions for shooting the area being studied. At the BioMi Vita clinic, we use a stereotactic device SD-p.1 (Russia), equipped with a patient's head position fixator, a photo system with standardized parameters, and a panel for measuring the distance between the device and the area being photographed. SD allows for reproducing the specified parameters during subsequent sessions and evaluating the treatment results dynamically while maintaining standardized conditions. It is recommended to evaluate the results after 3-4, 6, and 12 months from the start of treatment.

When using a stereotactic device in clinical practice, a specialist will be guaranteed to obtain high-quality images and will avoid errors in assessing the patient's condition due to incorrectly selected shooting parameters and related problems (insufficient sharpness, "overexposure", excessive glare, incorrectly set ISO parameters, etc.).
In addition to the standard survey photograph method, photographing the affected area on the scalp and smooth skin using luminescent diagnostics using narrow long-wave ultraviolet rays is also of interest. The method is effective not only for diagnosing dermatomycosis, but is also of interest for identifying and visualizing porphyria, seborrhea, folliculitis and other diseases (photo 12).

Photo 12. Author's observations. A) overview photograph of the frontal area; B) photograph of the same area during examination in the UV spectrum (365 nm). Blue arrows - orange glow, characteristic of pityrosporum folliculitis. Author's observations

Conclusion

It is important to understand that when making a diagnosis, a combination of methods should be used, combining available specialized diagnostic techniques with anamnesis data and clinical picture. Taking into account the results obtained based on the use of only one of the methods - for example, when interpreting only trichoscopic data without performing a phototrichogram in the differential diagnosis of androgenetic alopecia and diffuse telogen effluvium - a specialist can make a serious mistake in making a diagnosis and will not be able to prescribe adequate treatment in a timely manner. Having such basic specialized methods as trichoscopy, phototrichogram and the method of overview photographs in a doctor's arsenal, combined with practical experience, is the key to correct diagnosis and effective treatment.

In conclusion, a variant of the algorithm for examining a patient with complaints of hair loss and/or thinning is given.

Brief algorithm for examining a trichological patient

Stage I.

1. Initial consultation: after collecting anamnesis and conducting a physical examination, an initial specialized examination is performed - trichoscopy.
2. The issue of the need to use additional examination methods (laboratory, instrumental diagnostics) and the appointment of consultations with related specialists is being resolved.

Stage II.

1. A phototrichogram is performed, the purpose of which is to establish or clarify a diagnosis and monitor the effectiveness of treatment.
2. The specialist uses the method of overview photographs: a) using a stereotactic device, if necessary; b) using diagnostics using UV rays to record the patient's condition at the time of the initial visit and the possibility of monitoring the effectiveness of treatment in the future.
3. Making a preliminary diagnosis.

Stage III.

1. Follow-up consultation based on the results of clinical and laboratory tests.
2. Making a final diagnosis.
3. Developing a treatment and monitoring plan.

First published: KOSMETIK international journal, №1/2013