Trichoscopy in Ukraine

Trichoscopy is an examination of the scalp and hair with a dermatoscope, an illuminated camera with magnification. The working range is roughly 10 to 70 times: at low magnification the doctor assesses the overall picture of an area, and at high magnification counts the hairs in each follicular unit and looks at what is happening around each follicle opening.

Before this method, diagnosis relied on visual examination, the hair pull test and the trichogram, in which about fifty hairs were plucked with tweezers and their roots examined under a microscope. That was painful and imprecise. Trichoscopy shows more and causes no harm: the dermatoscope is placed on the skin or simply held close to it, no hair is pulled out and no anaesthesia is needed.

The doctor looks at four things: the hair shafts (thickness, shape, breaks), the follicle openings (empty, plugged or lost), the skin around them (scaling, redness, peripilar casts) and the background with its pattern of blood vessels. It is the combination of these signs that distinguishes one type of hair loss from another.

It is important to understand the method's limits. Trichoscopy is not a test that replaces a doctor, nor a machine that produces a diagnosis. It is an examination tool: the conclusion is reached together with your medical history, test results and, in doubtful cases, a biopsy. An image without clinical context is worthless.

MediUkraine is a service that finds and coordinates treatment; it is not a clinic. We choose a clinic with a digital trichoscope and a doctor experienced in hair disorders, arrange the date and support you throughout, including if you are travelling from abroad. Diagnosis and treatment decisions are made by the doctor after an in-person examination.

The main trichoscopic sign of androgenetic alopecia is anisotrichosis, a variation in hair shaft diameter. Thick hairs grow alongside thin, miniaturised ones, because androgen-sensitive follicles produce a weaker hair with each cycle. The threshold is a variation in thickness of more than 20% in men and more than 10% in women, and in a systematic review of trichoscopy for this diagnosis this variation had the highest sensitivity, around 94%.

Yellow dots are follicle openings without a hair, filled with sebum and keratin; in inherited thinning they are scattered unevenly because miniaturisation progresses in patches. The major criteria for female androgenetic alopecia are exactly these: more than four yellow dots in four images of the frontal area at 70-fold magnification, a lower average hair thickness at the front of the head than at the back, and a proportion of thin hairs above 10%.

In alopecia areata the picture is different, and it shows how active the condition is. Exclamation mark hairs, broken hairs that taper towards the base, are the most reliable sign that the disease is progressing right now. Alongside them the doctor sees black dots (hairs broken off at skin level), tapered hairs and Pohl-Pinkus constrictions. Yellow dots occur here too, but mainly in old, inactive patches.

The same signs show whether treatment is working: when it is effective, exclamation mark hairs, black dots and broken hairs disappear first, and short upright regrowing hairs appear in the patch. Yellow dots clear most slowly, so they are not used to judge progress.

Scarring alopecias are the reason trichoscopy should not be put off. The key finding is the loss of follicle openings: where openings should be, there is a smooth white or milky-pink area. Around the surviving hairs there is redness and tubular scaling that encircles the hair, sometimes with pustules; in frontal fibrosing alopecia the fine vellus hairs along the hairline disappear as well. A follicle opening that has been destroyed does not recover, so every week of delay means hair that will not grow back.

Telogen effluvium has no specific signs of its own, and it is better to say so plainly. Trichoscopy shows empty openings, a predominance of follicular units with a single hair, the peripilar sign and short upright regrowing hairs, but each of these also occurs in other conditions. The diagnosis is made largely by ruling out the patterns of other alopecias, based on the history and test results.

That is why the doctor examines not only the problem area but also the back of the head. In inherited thinning this area is affected last and serves as an internal control: if hair thickness at the front and back is the same, androgenetic alopecia is unlikely, and diffuse thinning with no difference between areas points instead to telogen effluvium. Comparing the two areas often settles the diagnosis.

Trichoscopy also picks up problems the patient did not come in with. In fungal infection of the scalp, comma hairs and corkscrew hairs are visible; these signs have a specificity of around 99–100% and allow treatment to start without waiting for a culture. In trichotillomania the hairs are broken off at different lengths with frayed ends, while traction alopecia causes thinning where the hairstyle pulls.

A phototrichogram is a different method, and the two should not be confused. Trichoscopy is qualitative: it describes what can be seen in an area. A phototrichogram measures: the hair on an area of roughly 1.8 cm² is trimmed and photographed straight away and again two to three days later, the hairs are tinted if needed, and software calculates density, growth rate and the ratio of growing to resting hairs. It takes two visits instead of one, but gives you figures to compare the result against six months later.

A digital trichoscope with an image archive differs from a hand-held magnifier not in magnification but in memory. "It seems to be falling out less" is an unreliable measure. When images are linked to specific areas and taken under the same lighting, at three and six months the doctor can put two pictures side by side and see the changes.

It is also worth being clear about what trichoscopy cannot do. It does not show the cause of a systemic disorder: iron deficiency, thyroid problems or an autoimmune process are found through blood tests. It does not replace a scalp biopsy when the picture is unclear or a scarring process is involved: histology remains decisive. And it depends on conditions: styling product residue, a device without polarisation and the doctor's experience affect the conclusion more than one might like.

You see the result of trichoscopy straight away, as the images appear on the screen during the examination. A written report describing the findings and the image files are provided the same day; ask for your own copy, even if you plan to be treated at the same clinic.

A trichoscopy description on its own is not yet a diagnosis. The doctor compares the findings with your history and test results: a full blood count, iron and ferritin, TSH and free T4, vitamin D and, for women where indicated, sex hormones. Routine test results are ready in 1–3 working days, so the follow-up consultation is usually a few days after the examination.

If a phototrichogram was done, the figures are available at the second visit, two to three days after the first. They become the baseline (density, the proportion of thin hairs and the ratio of growth phases) against which the effect of treatment is later compared.

If trichoscopy shows signs of scarring, the sequence changes. A biopsy is ordered as soon as possible rather than "if needed", the histology report takes about 1–2 weeks, and anti-inflammatory treatment starts without waiting for it.

Follow-up trichoscopy is done at three and six months, always on the same areas. Hair responds slowly: with the right treatment, the first changes appear no earlier than 3–4 months, and the effect is properly assessed at 6–12 months. The comparison is based on images and figures, not impressions.

If nothing has changed after six months, the diagnosis or the treatment plan should be reviewed rather than the same prescriptions continued. If you live abroad, part of the follow-up can conveniently be done remotely: you keep the report and images, and MediUkraine can arrange a video consultation with the same doctor if needed.