Are there some types of hair loss where a physician can tell the diagnosis of a person’s hair loss by simply looking at a photograph? Which types of hair loss would you say an up close examination is really important?
Thanks for the great question. There is really ONLY ONE condition in human beings where I can tell with 100 % certainly what is going on from a photo without any additional information from the patient and without seeing the scalp up close myself. Just one. This condition is adult onset alopecia totalis and adult onset alopecia universalis whereby a patient loses all their scalp hair. These are autoimmune conditions. No other condition looks similar to these in adults - not even chemotherapy related hair loss looks quite the same (and has quite the same story).
For nearly EVERY OTHER condition an up close examination of the scalp is important - if the patient is looking for a diagnosis with a high degree of accuracy. (If of course a patient just wants an educated best guess, photos may suffice).
Many people don’t realize that many hair loss conditions can look the same on a photograph. By using the word same, I mean identical. I mean that the two hair loss conditions can perfectly mimic each other. Female pattern hair loss can easily look like telogen effluvium on a photograph and sometimes female pattern hair loss with a bit of scalp redness from seborrheic dermatitis or psoriasis can closely resemble early the scarring alopecia lichen planopilaris on a photograph. Up close however, these conditions may start to take on a different appearance.
Male balding in the crown with a bit of coexistent seborrheic dermatitis can look similar to lichen planopilaris or folliculitis decalvans (both scarring alopecias).
Folliculitis can sometimes look like folliculitis decalvans. The non scarring hair loss condition alopecia areata can sometimes look like the scarring hair loss condition pseudopelade especially with small early patches.
If people are satisfied with best guesses and satisfied with playing a game of “could be this or could be that” pictures are fine. Personally, I’m not a fan of guessing games in my professional life. In my practice, I assume that every patient wants an accurate diagnosis and I don’t enjoy practicing medicine with “best guesses.” For this reason, I don’t do consultations for patients who wish to email photos to our office in order to get a diagnosis. It just doesn’t work perfectly. Photos together with a detailed story plus blood tests plus biopsy report can sometimes work - but not always.
For every 100 males who step into my office with what looks like classic male balding in the crown, probably 80 have just male balding. Another 18 have male balding plus another condition or maybe ever a third condition as well. I would estimate that 2 or so of these 100 patients don’t actually even have male balding and have another reason for their hair loss all together. All 100 of these males look like male balding on a photo. If I diagnosed these males simply based on a photo, I would be correct 80 % of the time. But I would have gotten 2 % of diagnoses completely wrong. In another 18 %, I’d be right about the male balding but I would have missed something else going on.
A patient with a chronic cough deserves to know if they have a bad cold, an allergy or something more serious. The treatment is going to be different depending on which diagnosis it actually is. A person with heart burn type symptoms deserves to know if they have acid reflux or impending heart attack. The treatment is going to be different depending on which diagnosis it actually is.
Thanks again for the great question. My strong view is that a person with hair loss deserves to know their diagnosis with as close to 100 % accuracy as possible. The treatment is going to be different depending on which diagnosis it actually is.