What to do when doctor and pathologist can’t agree on the diagnosis - 6 options
When Pathologists and Clinician Don’t Agree on Diagnosis
I’ve selected this question below for this week’s question of the week. It allows us to review the challenges that exist in making some tough diagnosis and what steps to take .
Question
My biopsy reports says I have a “non scarring non inflammatory alopecia “ but my doctor is pretty sure I have a scarring alopecia. What do you recommend in these kind of situations to figure out really what is the correct diagnosis ?
Answer
The diagnosis of early forms of hair loss and especially early scarring alopecia can be challenging. It’s not so uncommon for a biopsy report to show one finding but the doctor to feel it’s not correct. There are six options when the pathologist and specialist (and patient) opinion don’t match up.
1) The current pathologist can fully review the case with the treating doctor. New cuts or new stains can be ordered.
In a busy medical establishment, doctors often have little time available to chat about cases as much as they would like. In tough cases, it can be helpful for the doctor and pathologist to chat. In many parts of the world, pathologists who read slides are fully certified dermatologists too and understand the clinical details with great ease.
A doctor might say to the pathologist “In your report you say there is no scarring but look at this photo of her scalp - it must be a scarring alopecia.
Sometimes a pathologist will ask the lab to make more “cuts” from the biopsy specimen and put them on new slides. Sometimes a pathologist will order new special histological stains to see if more clues can be uncovered. One such stain in the case of scarring alopecias is a Verhoeff-Van Gieson (VVG) stain or other elastin stain to show what has happened to the delicate elastic network in the scalp. A destroyed elastin network is more in keeping with a scarring alopecia. This can not be seen with routine stains so if any doubt exists and elastin stain can be ordered.
2) One can get another opinion on the biopsy from another pathologist.
Sometimes another pathologist in the department or from another center altogether can be called upon to provide a second opinion. This removes the need for getting another biopsy from the patient and so can be helpful in challenging situations.
3) One can get another scalp biopsy
Sometimes, another biopsy is needed. A tiny 4 mm biopsy contains just 0.035 % of all the hairs on the scalp. In other words, it’s not always possible to diagnose what is happening up on the patient’s scalp with a sample that has only 0.035% of all the follicles.
It’s not practical or recommended to take bigger biopsies or to take 5, 10 or 15 samples. However, there’s no doubt that in really tough cases of hair loss, having more hairs to look at under the microscope can sometimes be incredibly helpful.
That said usually 1 or 2 samples is fine. But if one sample seems to render an unusual or unexpected finding that goes completely against what the doctor feels the diagnosis really is, it might be helpful to get another biopsy.
4) One can get another clinical opinion from other experts
In challenging cases, There’s another route to take out that does not involve the pathologist or the biopsy or getting more biopsies. It involves asking for a second opinion from colleagues.
Sometimes, another doctor can listen to the story and examine the scalp and make sense of all the findings.
5) One can wait another few weeks or months to see what happens
Waiting is also an option in some cases although waiting does carry the risk of further permanent loss if the diagnosis is an active scarring alopecia.
However, there are situations where the pathology report indicates the patient has a scarring alopecia yet the treating doctor really feels the diagnosis is not a scarring alopecia but rather a non scarring alopecia like seborrheic dermatitis and telogen effluvium. In some cases, it might make sense to have the patient use an antidandruff shampoo for 1-3 months and fix any underlying triggers that were thought to be responsible for the telogen effluvium (like low iron levels) and meet back with the patient in a few months. If the shedding has slowed and redness has disappeared, it’s very unlikely that a scarring alopecia was actually the correct diagnosis. If the hair loss is worse and symptoms are worse and shedding is still high, it might be appropriate to start really considering that a diagnosis of scarring alopecia might have been right after all.
6) One can start treatment assuming it is one diagnosis and see if the scalp responds the way it would be expected.
In very challenging cases, where doubt exists, the clinician might decide to undertake a simple treatment plan in order to evaluate the effect of such a trial. This is typically done by a more experienced clinician who knows what to look for as the weeks and months of the treatment trial go by.
For example, in situations where a scarring alopecia is thought to be occurring but there is some degree of doubt, a clinician might start a topical steroid and possibly doxycycline or ora antihistamines. These are a relatively safe option and may assist in stopping an inflammatory process if truly one is present. One can then also observe what happens when those treatments are the stopped. A non scarring and relatively non inflammatory alopecia won’t be too bothered by stopping topical steroids, doxycycline and an antihistamine because they would have been doing almost nothing anyways. However, a patient with true scarring alopecia will likely experience some degree of a “flare” if these a stopped. The clinical treatment trials are tricky and require a good deal of experience on the part of the physician
Conclusion
It’s not all that uncommon that a bit of uncertainty exists between what a scalp biopsy report says and what the clinician feels is really the diagnosis. Fortunately, this type of uncertainty is not a daily event but it does happen from time to time.
Getting the correct diagnosis should always be the goal if it is possible. For that reason, options 1, 2 and 3 are the preferred route to take in challenging “diagnostic dilemmas” but these steps are not always easy or possible for various reasons.