Scoping Scalp Disorders: Practical Use of a Novel Dermatoscope to Diagnose Hair and Scalp Conditions
March 2013 | Volume 12 | Issue 3 | Original Article | 283 | Copyright © March 2013
Nicole E. Rogers MD
Tulane University School of Medicine, New Orleans, LA
BACKGROUND: Dermoscopy has been widely implemented to diagnose various skin and scalp disorders. However, existing devices that call for direct scalp contact may alter the appearance of hair features or perifollicular structures.
OBJECTIVE: This paper will show how the Canfield DermScope can quickly and easily identify various nonscarring and scarring scalp disorders. Its open design does not change the direction of affected hairs or blanch certain features such as erythema. Features like perifollicular hyperkeratosis and loss of follicular orifices are still easily visible.
METHODS and MATERIALS: The author prospectively photographed patients with hair and scalp disorders in private practice between 2011 to 2012 using the handheld Canfield DermScope device.
RESULTS: The presence of scale, erythema, tufting, miniaturized or broken hairs, and loss of follicular orifices were quickly identified to make a diagnosis.
CONCLUSION: The diagnosis of hair and scalp disorders can be greatly facilitated by the use of the DermScope device.
J Drugs Dermatol.
The DermScope® was introduced by Canfield Scientific (Fairfield, NJ) in 2011. It is a single handheld device with a polarized lens that attaches to any iPhone 4 or iPhone 4S (Apple, Inc, Cupertino, CA). By simply clicking on the camera application, as well as the light switch on the side of the device, one can take photos and then instantly show them to and discuss them with patients (Figure 1). This helps to inform and educate them about their disease process. It also provides a benchmark for the degree of inflammation or hair loss present at any one time. In cases of women with early androgenetic alopecia (AGA) (which can be difficult to diagnose), this device has shortened examination time for the author and virtually eliminated the need for scalp biopsy.
Scalp biopsies have traditionally been the gold standard in diagnosing scalp conditions. However, even traditional histopathology can be difficult to interpret, especially in the context of hair and scalp disorders. What may appear clinically to be AGA may come back as seborrheic dermatitis or lichen planopilaris (LPP), depending on the area biopsied. This can be frustrating to both clinicians and patients alike. Often, the diagnosis only becomes clear with time and response to various treatments.
The DermScope is helpful because it is not cumbersome, does not require a computer station or loose wires, and takes images instantly that can be shown to the patient or family. Previous publications recommend the use of an interface solution, which can increase the visibility of dermal features such as blood vessels. However, the attachment preferred by the author has an open window so images of the hairs in the upright position (or naturally splayed) can be taken. It is not necessary to flatten the hairs or moisten the skin in order to capture an accurate image
Table 1 includes a listing of many different features specific to hair and scalp disorders. Dermoscopy can aid the diagnosis of scarring alopecias by helping to visualize which areas have the most inflammation and should be targeted for biopsy.1 Other features such as black dots or exclamation point hairs can be helpful in diagnosing alopecia areata. In children, it is a valuable tool for diagnosis when biopsy may be poorly tolerated. Parents may be concerned about causing a scar in order to diagnose a condition that is not life-threatening or may resolve with time. The best part is when families watch in amazement and say, “You took that with your iPhone?”
Nonscarring Scalp Disorders
The diagnosis of AGA in women, also called female pattern hair loss (FPHL), can often require months or years. Confounding factors such as surgery, illness, rapid weight loss, or new medications may first suggest a telogen effluvium. Many months or years may be lost waiting for various conditions to be corrected. It is only when hair loss does not slow or stop, or after a large volume of hair has been lost, that the diagnosis of FPHL is often made.
Using the DermScope device, it is possible to look directly at the scalp to examine the caliber and distribution of follicular units. A normal scalp examination will show uniformly thick hairs without any underlying scale and with varied groupings of 1 to 4 hairs per follicle. In women with early-stage hair thinning, there is a great diversity in the caliber of these hairs (Figure 2).2 As more hairs enter a miniaturized state, there is less density and coverage to the scalp. Late-stage FPHL has predominantly single-hair groupings and hardly any 3 to 4 hair follicular units (Figure 3).