The Five Levels of Difficulty in Diagnosing Hair Loss

Hair Loss Diagnostic Difficulty: Do some diagnoses require more expertise than others?

A novice wine taster can distinguish red wine from white wine. A slightly more advanced wine taster can tell a merlot from a pinot noir. A master sommelier can not only tell a pinot noir from a merlot but can tell where in the world the grapes were harvested and the exact year they were harvested. There are levels of expertise to most things.

There are also many levels of expertise to diagnosing hair loss.  That comes as a surprise to some who believe that diagnosing hair loss is straightforward.

In my view, there are five levels of difficulty in diagnosing hair loss. Level 1 hair loss conditions can be easily made by most practitioners. Level 2 hair loss conditions can generally be made by some but not all practitioners. From there, the likelihood of a correct diagnosis starts dropping off as we enter into level 3, 4 and 5 hair loss conditions.

Difficult Diagnoses Are Associated with Delay in Diagnosis

I would estimate that it takes five to 25 times longer on average for a patient with a level 5 hair loss condition to finally be given the right diagnosis compared to a patient with a level 1 hair loss condition. Some patients with a level 5 hair loss condition never get the diagnosis. Some only get the diagnosis once it has progressed a little further (ie very early FFA progresses to become early FFA).

It is not always the fault of the practitioner. It is not always the fault of the educational system that trains practitioners. Sometimes of course it is. Often it’s the reality of human hair loss and how challenging some conditions are difficult to diagnose. You would not fault your neighbor for not being able to distinguish a 2010 merlot red wine from a 2015 merlot red wine. Similarly, we can not fault a practitioner for missing a very early FFA. 

A patient with “very early” FFA might not be properly diagnosed until they develop “early” FFA. A patient with “early” LPP might not be correctly diagnosed until they have developed more “classic” (or what we call typical) LPP.

Clearly, we have a ways to go in hair loss medicine to facilitate early diagnosis but this article helps give perspective.

Level of Difficulty: Five

Expertise Required to Make Correct Diagnosis: Extremely High

Description:

Expect a high proportion of missed diagnoses and even when the diagnosis is proposed, expect some to be wrong. These diagnoses are more likely to be accurately made by practitioners with considerable experience. It must be noted that even those practitioners with significant experience are expected to miss a good proportion of these diagnoses as well. It should also be noted that scalp biopsies may or may not convincingly capture the diagnosis of level five conditions.

Examples of Level 5 Hair Loss Conditions:

Alopecia areata incognito

Early stages of female androgenetic alopecia

Early stages of lichen planopilaris

Chronic telogen effluvium

Very early frontal fibrosing alopecia

Lupus hair

Acne necrotic

Alopecia mucinosa

Level of Difficulty: Four

Expertise Required to Make Correct Diagnosis: Very High

Description:

Expect a moderate proportion of missed diagnoses and even when the diagnosis is proposed, expect some to be wrong. These diagnoses are more likely to be accurately made by practitioners with considerable experience. It should be noted that even those practitioners with experience are expected to miss a small proportion of these diagnoses but it is a lower proportion compared to level 5 conditions. It should also be noted that scalp biopsies may or may not convincingly capture the diagnosis but biopsies will capture the diagnosis with greater consistency and frequency than level 5 conditions.

Examples of Level 4 Hair Loss Conditions:

Erosive pustular dermatosis 

Very early male androgenetic alopecia

Early frontal fibrosing alopecia

Non-Frontal Frontal Fibrosing Alopecia Variants (Occipital FFA, Isolated Eyebrow)

Subtle Trichotillomania

Classic (typical) dissecting cellulitis

Fibrosing Alopecia in a Pattern Distribution

Subtle scalp psoriasis

Subtle scalp seborrheic dermatitis

Persistent chemotherapy induced alopecia (PCIA)

Atypical traction alopecia

Senescent alopecia 

Early Stages of central centrifugal cicatricial alopecia

Early stages of folliculitis decalvans

LPP-FD phenotypic spectrum (LPPFDPS)

Alopecia neoplastica

Hair Shaft Disorders (Monilethrix, Trichorrhexis invaginata, etc)

Loose Anagen Hair Syndrome

Level of Difficulty: Three

Expertise Required to Make Correct Diagnosis: High

Description

Expect a proportion of missed diagnoses. These diagnoses are more likely to be accurately typically made by practitioners with at least moderate experience and training in hair loss. Those with considerable experience are expected to make a very high proportion of these diagnoses and only a rare diagnosis will be missed. It should also be noted that scalp biopsies generally capture the diagnosis but may not be performed if an expert is confident in the diagnosis.

Examples of Level 3 Hair Loss Conditions:

Advanced central centrifugal cicatricial alopecia

Classic (typical) frontal fibrosing alopecia, males

Classic (typical) lichen planopilaris

Classic (typical) folliculitis decalvans

Classic (typical) frontal fibrosing alopecia, females

Alopecia areata diffusa

Level of Difficulty: 2

Expertise Required to Make Correct Diagnosis: Moderate 

Description

Expect a low proportion of missed diagnoses. These diagnoses are  likely to be accurately made by practitioners with at least some experience and training in hair loss. Those with more experience are expected to make nearly all of these diagnoses. It should also be noted that scalp biopsies generally capture the diagnosis but are rarely done given that the diagnosis can be reached without need for biopsy.

Examples of Level 2 Hair Loss Conditions:

Classic (Typical) female androgenetic alopecia

Advanced seborrheic dermatitis

Advanced scalp psoriasis

Advanced trichotillomania

Early “patchy” alopecia areata

Alopecia areata ophiasis, early stage

Atypical telogen effluvium

Level of Difficulty: 1

Expertise Required to Make Correct Diagnosis: Novice

Description

Expect a very low proportion of missed diagnoses. These diagnoses are typically made by most practitioners with basic training in hair loss. Those with considerable experience are expected to make all of these diagnoses. It should also be noted that scalp biopsies generally capture the diagnosis but are rarely done given that the diagnosis can be reached without need for biopsy.

Examples of Level 1 Hair Loss Conditions:

Classic (typical) female androgenetic alopecia

Classic (typical) traction alopecia

Classic (typical presentation) telogen effluvium

Classic ‘patchy” alopecia areata

Classic (typical) male androgenetic alopecia

Alopecia areata ophiasis, developed

Alopecia areata totalis (alopecia totalis)

Alopecia areata universalis (alopecia universalis)