10.5826/dpc.1401a1
Introduction: Although trichoscopy has been used successfully in the diagnosis of androgenetic alopecia (AGA), its utility in monitoring the therapeutic outcome is not clear.
Objectives: To investigate the value of trichoscopy in the follow-up of treatment response in patients with AGA.
Methods: Ninety-five patients with AGA were included. Trichoscopic images were obtained on a 1 cm2 circular area in the left frontoparietal scalp pre- and post-treatment in all and in 61 patients, respectively. Two doctors evaluated those images who are less experienced (doctor A) and experienced (doctor B) in hair diseases and trichoscopy. Terminal, vellus and total hair count (THC, VHC, ToHC) and terminal to vellus hair (T/V) ratio were determined. These numerical data were also calculated by TrichoScan analysis of the same area. The agreement between trichoscopy and TrichoScan data was assessed.
Results: The agreement between doctor A and TrichoScan was moderate for THC and ToHC pre-treatment and good post-treatment; poor for VHC and T/V ratio pre- and post-treatment. The agreement between doctor B and TrichoScan was excellent for THC, VHC and ToHC; good for T/V ratio pre- and post-treatment.
Conclusions: Trichoscopy, when performed by a doctor experienced in hair diseases and trichoscopy, can be used as a sensitive method in monitoring the treatment response in patients with AGA which is based on the determination of THC, VHC, ToHC and T/V ratio. If it is to be performed by a less experienced doctor, it can be preferred as a sensitive follow-up method using THC and ToHC.
text/xml
2160-9381
3687
en
Deren özcan
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
dermoscopy
The Value of Trichoscopy in the Follow-up of Treatment Response in Patients With Androgenetic Alopecia
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2024-01-31
2023-07-18
2024-01-31
2024-02-21
e2024001
Dermatol Pract Concept
Introduction: Although trichoscopy has been used successfully in the diagnosis of androgenetic alopecia (AGA), its utility in monitoring the therapeutic outcome is not clear.
Objectives: To investigate the value of trichoscopy in the follow-up of treatment response in patients with AGA.
Methods: Ninety-five patients with AGA were included. Trichoscopic images were obtained on a 1 cm2 circular area in the left frontoparietal scalp pre- and post-treatment in all and in 61 patients, respectively. Two doctors evaluated those images who are less experienced (doctor A) and experienced (doctor B) in hair diseases and trichoscopy. Terminal, vellus and total hair count (THC, VHC, ToHC) and terminal to vellus hair (T/V) ratio were determined. These numerical data were also calculated by TrichoScan analysis of the same area. The agreement between trichoscopy and TrichoScan data was assessed.
Results: The agreement between doctor A and TrichoScan was moderate for THC and ToHC pre-treatment and good post-treatment; poor for VHC and T/V ratio pre- and post-treatment. The agreement between doctor B and TrichoScan was excellent for THC, VHC and ToHC; good for T/V ratio pre- and post-treatment.
Conclusions: Trichoscopy, when performed by a doctor experienced in hair diseases and trichoscopy, can be used as a sensitive method in monitoring the treatment response in patients with AGA which is based on the determination of THC, VHC, ToHC and T/V ratio. If it is to be performed by a less experienced doctor, it can be preferred as a sensitive follow-up method using THC and ToHC.
Deren özcan
2024/01/31
10.5826/dpc.1401a1
e2024001
Department of Dermatology, Başkent University Faculty of Medicine, Ankara, Turkey
2160-9381
dermoscopy
en
e2024001
Suchonwanit P, Rojhirunsakool S, Khunkhet S. A randomized, investigator-blinded, controlled, split-scalp study of the efficacy and safety of a 1550-nm fractional erbium-glass laser, used in combination with topical 5% minoxidil versus 5% minoxidil alone, for the treatment of androgenetic alopecia. Lasers Med Sci. 2019;34(9):1857-1864. DOI:10.1007/s10103-019-02783-8. PMID: 30982177.
The Value of Trichoscopy in the Follow-up of Treatment Response in Patients With Androgenetic Alopecia
https://dpcj.org/index.php/dpc/article/download/3687/2432
              The Value of Trichoscopy in the Follow-up
                 of Treatment Response in Patients
                    With Androgenetic Alopecia
                                             Seçil Yigen İritaş1, Deren Özcan2


1 Department of Dermatology, Medipol University Faculty of Medicine, Istanbul, Turkey
2 Department of Dermatology, Başkent University Faculty of Medicine, Ankara, Turkey



Key words: Androgenetic alopecia, dermoscopy, hair loss, follow up treatment response, tricoscopy
Citation: İritaş SY, Özcan D. The Value of Trichoscopy in the Follow-up of Treatment Response in Patients With Androgenetic Alopecia.
Dermatol Pract Concept. 2024;14(1):e2024001. DOI: https://doi.org/10.5826/dpc.1401a1
Accepted: October 18, 2023; Published: January2024
Copyright: ©2024 İritaş et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: Both authors have contributed significantly to this publication.
Corresponding Author: Seçil Yigen İritaş, MD, Doğu neighbourhood, Bilezik street, Pendik portre apartment 4b, Pendik/İstanbul.
Phone: 05052252428 E.mail: secilyigen@gmail.com




  ABSTRACT             Introduction: Although trichoscopy has been used successfully in the diagnosis of androgenetic alo-
                       pecia (AGA), its utility in monitoring the therapeutic outcome is not clear.
                       Objectives: To investigate the value of trichoscopy in the follow-up of treatment response in patients
                       with AGA.
                       Methods: Ninety-five patients with AGA were included. Trichoscopic images were obtained on a
                       1 cm2 circular area in the left frontoparietal scalp pre- and post-treatment in all and in 61 patients,
                       respectively. Two doctors evaluated those images who are less experienced (doctor A) and experienced
                       (doctor B) in hair diseases and trichoscopy. Terminal, vellus and total hair count (THC, VHC, ToHC)
                       and terminal to vellus hair (T/V) ratio were determined. These numerical data were also calculated by
                       TrichoScan analysis of the same area. The agreement between trichoscopy and TrichoScan data was
                       assessed.
                       Results: The agreement between doctor A and TrichoScan was moderate for THC and ToHC
                       pre-treatment and good post-treatment; poor for VHC and T/V ratio pre- and post-treatment. The
                       agreement between doctor B and TrichoScan was excellent for THC, VHC and ToHC; good for T/V
                       ratio pre- and post-treatment.
                       Conclusions: Trichoscopy, when performed by a doctor experienced in hair diseases and trichoscopy,
                       can be used as a sensitive method in monitoring the treatment response in patients with AGA which
                       is based on the determination of THC, VHC, ToHC and T/V ratio. If it is to be performed by a less
                       experienced doctor, it can be preferred as a sensitive follow-up method using THC and ToHC.




Original Article | Dermatol Pract Concept. 2024;14(1):e2024001                                                                          1
Introduction                                                       growth parameters that are necessary for assessing the treat-
                                                                   ment response in patients with AGA were evaluated.
Androgenetic alopecia (AGA), characterized by the progres-
sive miniaturization of genetically susceptible hair follicles
under the impact of androgen hormones, is the most common          Objectives
form of non-cicatricial alopecia [1-3]. It causes significant
                                                                   Herein, we aimed to investigate the value of trichoscopy in
psychosocial impairment, hence necessitating an effective
                                                                   the follow-up of treatment response in a large number of
treatment [1,2]. Besides hair transplantation, there are also
                                                                   patients with AGA, by evaluating all necessary hair growth
several non-surgical treatment options for managing AGA,
                                                                   parameters and by comparing with TrichoScan analysis.
including topical minoxidil, oral anti-androgens, 650-900
nm low-level laser therapy, and platelet-rich plasma [1,2,4].
Any non-surgical treatment aims to stop hair loss, transform       Methods
vellus hairs into terminal hairs and stimulate hair regrowth.
It is possible to achieve these goals with the currently avail-
                                                                   Patients
able non-surgical treatments [1,2]. However, their effects         The study was approved by local Institutional Review Board
are not permanent as AGA is, by nature, a chronic and pro-         (Project No: KA18/324), and informed consent was obtained
gressive disease for which long-term non-surgical treatments       from all patients.
may be required, even for a lifetime [1]. Therefore, the treat-       This prospective study included patients between 16 and
ment response should be monitored regularly using objective        65 years of age who presented to our clinic with the complaint
methods to develop and maintain an effective treatment plan        of hair loss and were diagnosed with AGA between October
and to prevent the financial loss of an unbeneficial therapy.      2018 and August 2019. The diagnosis of AGA was made by
    Several methods can be used in the follow-up of treat-         the characteristic patterned alopecia (diffuse hair thinning
ment response in patients with AGA, such as scalp biopsy,          over the central scalp with preservation of the frontal hair-
global photographing of the scalp, trichogram, phototricho-        line in females and frontotemporal recession and/or loss of
gram, and TrichoScan [2,5-7]. However, most of them are of         hair over the vertex in males) along with the trichoscopic
little use to the clinician because they are time-consuming,       presence of >20% hair diameter diversity. The hair-pull test,
costly, or difficult/impractical to apply [5-7]. Among these       trichoscopy, and laboratory examination (total blood cell
methods, TrichoScan is still the most objective method per-        count, blood levels of ferritin, and thyroid-stimulating hor-
formed [5,6]. It combines epiluminescence microscopy with          mone) were performed; the triggering factors (high ­fever,
automatic digital image analysis and is able to quantitatively     major surgical intervention, drugs, heavy diet, emotional
analyze hair growth and hair loss [6]. On the other hand,          stress) were questioned to exclude telogen effluvium, dif-
it is a paid software that only works with certain handheld        fuse lichen planopilaris and diffuse alopecia areata. The
and video dermoscopes, limiting its widespread use [5]. So,        Hamilton-Norwood (H-N, stages I-V) and Ludwig (stages
there is a need for other cheaper, easy, and reliable tools for    I and II) classifications were used to determine the grade of
monitoring the therapy of AGA.                                     AGA in male and female patients, respectively [14].
    Trichoscopy is a non-invasive, simple, and easy method            Male patients received 5% minoxidil topical solution
that has been successfully utilized for the diagnosis of           or foam and female patients received 2% minoxidil topical
AGA [7,8]. The main diagnostic trichoscopic features of AGA        solution twice daily for treatment. All patients were invited
are hair diameter diversity, increased proportion of thin and      to a follow-up visit 3 months after the start of treatment.
vellus hairs, a large number of single-hair pilosebaceous units,
yellow dots and peripilar sign [1,8]. Trichoscopy was also used    Trichoscopic Analysis
to assess the therapeutic outcome in many studies conducted        An examination area was determined at the intersection of
to evaluate or compare the efficacy of different treatment mo-     vertex and left temporal region of each patient. A cardboard
dalities in AGA [9-13]. Hair diameter and hair density were        template with a circle-shaped hole of approximately 1 cm2 in
the two most frequently analyzed trichoscopic parameters           its middle was placed on the area to be examined (Figure 1A)
for that purpose in those studies [9-11]. Yet, although it is      and the hairs in that area were cut to a length of 0.5–1 mm.
a frequently preferred method, the reliability of trichoscopy      Another template with a 0.562 cm2 circle-shaped hole, which
in monitoring the treatment response needs to be clarified.        is equivalent to the area analyzed by TrichoScan, was divided
Only a few studies assessed the compatibility of trichoscopic      into four equal sections horizontally and longitudinally by
analysis results with that obtained with TrichoScan, the most      using two strings and was placed on the examination area
objective method currently available [12,13]. However, in          (Figure 1B). Digital trichoscopic photographs (FotoFinder
those studies, the number of patients was low and not all hair     Systems GmbH, 2007, Medicam 800 HD) with a 20 fold



2                                                                      Original Article | Dermatol Pract Concept. 2024;14(1):e2024001
magnification were obtained from the whole examination                  separately. The diameter of each hair was determined with the
area and from each section (Figure 1C). A dot-shaped tat-               help of a guide ruler image on the screen. As defined by the
too was placed in the center of the examination area using              TrichoScan software, hairs that are 0.04 mm and thicker were
a tattoo device (Mei-cha) to ensure that all the assessments            considered as terminal hairs, while those thinner than 0.04 mm
were made from the same area. The whole procedure took                  were defined as vellus hairs. To facilitate counting and to reduce
12-15 minutes. The same procedure was reperformed on the                any possible errors, vellus hairs were marked with red dots and
same examination area at 3-month follow-up.                             terminal hairs with yellow dots using the free-of-charge Micro-
    Two doctors who are less experienced (doctor A) and                 soft Paint program (Figure 1D). Both doctors then determined
experienced (doctor B) in hair diseases and trichoscopy eval-           terminal hair count (THC), vellus hair count (VHC), total hair
uated trichoscopic images on their own desktop computers.               count (ToHC) and terminal to vellus hair (T/V) ratio.
While doctor A was a research assistant in the 4th year of
dermatology residency, doctor B was an associate profes-                TrichoScan Analysis
sor of dermatology who has been dealing with hair diseases              TrichoScan analysis (TrichoScan® HD, Professional Ver-
and trichoscopy for more than 10 years. Doctor A evaluated              sion 3, FotoFinder Systems GmbH, 2007) was carried out on
the trichoscopic images twice with 1 month interval. Both               the same examination area determined for trichoscopy at the
­doctors were blinded to the Trichoscan data, and their own             same session of obtaining trichoscopic images.
and each other trichoscopic analysis results.                               To create an adequate contrast between the hair in the
    Doctor A and doctor B calculated the total number of                examination area and the scalp, after cutting the hairs, a
hairs by counting and summing the hairs in the four sections            black hair dye (Goldwell Topchic Permanent Hair Color)




Figure 1. (A) A cardboard template with a circle-shaped hole of approximately 1 cm2 in its middle placed on the area to be examined.
(B) A template with a circle-shaped hole equivalent to the area analyzed by TrichoScan divided into four equal sections by using two strings
and placed on the examination area. (C) Digital trichoscopic photographs with a 20-fold magnification obtained from the examination area.
(D) Vellus hairs marked with red dots and terminal hairs with yellow dots using Microsoft Paint program on trichoscopic images.



Original Article | Dermatol Pract Concept. 2024;14(1):e2024001                                                                            3
and a hair color cream (Rondo Coiffeur 6% Creme Oxyd)              post-treatment; poor for VHC and T/V ratio both pre-
were mixed at 1:1 ratio and was applied to the examination         and post-treatment. The agreement between doctor B and
area. The mixture was gently cleaned using alcohol gauze           TrichoScan was excellent for THC, VHC, and ToHC and
after 15 minutes. THC, VHC, ToHC and T/V ratio were cal-           good for T/V ratio both pre- and post-treatment. The CCC
culated with TrichoScan analysis. The same procedure was           values and respective 95% CIs regarding the agreement be-
repeated at 3-month follow-up.                                     tween trichoscopy and TrichoScan data for doctor A and
                                                                   doctor B pre- and post-treatment are given in Table 2.
Assessments                                                           After 3 months of treatment, doctor A, doctor B, and
The numerical data, namely THC, VHC, ToHC and T/V ra-              TrichoScan analysis detected a significant increase in THC
tio obtained by doctor A and doctor B with trichoscopy be-         and ToHC and no significant change in VHC. The hair
                                        rd
fore treatment and at the end of the 3 month of treatment          counts and T/V ratio determined by doctor A, doctor B, and
were compared with the TrichoScan analysis results. The            TrichoScan analysis, and the p values regarding the change in
inter-observer agreement was calculated by comparing the           mean hair counts post-treatment are given in Table 3.
trichoscopic analysis results obtained by doctor A with that          Intra-observer agreement was excellent for VHC, ToHC,
of doctor B. The initial examination results of doctor A were      and T/V ratio and high for THC pre-treatment; excellent for
used for these assessments. The trichoscopic analysis results      all four parameters post-treatment. Inter-observer agreement
determined by doctor A twice were compared in order to             was excellent for THC and ToHC; high for VHC and T/V
determine the intra-observer agreement.                            ratio both pre- and post-treatment. The ICC and respective
                                                                   P values regarding intra- and inter-observer agreement pre-
Statistical Analysis                                               and post-treatment are given in Table 4.

Statistical analysis was conducted using IBM SPSS (Statisti-
cal Package for the Social Sciences software version 25, SPSS      Conclusions
Inc.) and MedCalc v16.0 (MedCalc Software). Descriptive
statistics for numerical variables were expressed as mean ±        Any successful treatment in AGA should increase the number
SD or median (range), where appropriate; number of cases           of terminal hairs while reducing the number of vellus hairs
and percentages were used for categorical data.                    and increasing the hair density. Therefore, a helpful method
    The agreement between trichoscopy and TrichoScan
data for doctor A and doctor B before and after treatment
                                                                    Table 1. General characteristics of 76 male and
was calculated with the concordance correlation coeffi-
                                                                    19 female patients with androgenetic alopecia.
cient (CCC) (excellent [>0.99], good [0.95-0.99], moderate
                                                                        General characteristics             Males       Females
[0.90-0.94], poor [<0.90]) with a 95% confidence interval
                                                                    Mean age±SD, years                     29.5±5         38±13
(CI). Intra- and inter-observer agreement was determined
by intra-class correlation coefficient (ICC) (excellent [0.95-      H-N stage of AGA, N (%)
                                                                     Stage I                              8 (10.5)
1.00], high [0.85-0.94], moderate [0.70-0.84], unacceptable
                                                                     Stage II                             20 (26.3)
[0.00-0.69]) which was calculated by using the ‘Two-Way              Stage III                            13 (17.1)
Mixed Effect Model”; P < 0.001 was considered significant.           Stage III vertex                     17 (22.4)
    Whether there was a difference between pre- and                  Stage IV                             11 (14.5)
post-treatment measurements was analyzed using t-test for            Stage IV A                            1 (1.3)
dependent samples when the parametric test assumptions               Stage V                               6 (7.9)
were met, and wilxocon test when the assumptions were not           Ludwig stage of AGA, N (%)
                                                                      Stage I                                           12 (63.2)
met. The probability of type I error in all analyzes was de-
                                                                      Stage II                                           7 (36.8)
termined as 0.05.
                                                                    Mean duration of AGA, years              6.2            4.8
                                                                    Previous treatments, N (%)
Results                                                               No treatment                        58 (76.3)     16 (84.2)
                                                                      Topical minoxidil spray/foam        12 (15.8)      2 (10.5)
The study included 95 patients with AGA (76 males and 19              Oral biotin                          4 (5.2)         0 (0)
females). The general characteristics of the patients are listed      Oral finasteride                     1 (1.3)         0 (0)
in Table 1. Of the 95 patients, 34 patients (35.8%) were lost         PRP injections                       1 (1.3)         0 (0)
                                                                      Oral multivitamin complex             0 (0)         1 (5.2)
to follow-up; thus, we could not perform trichoscopic and
                                                                      Oral biotin                          4 (5.2)         0 (0)
TrichoScan analyses at the 3rd month of treatment.
    The agreement between doctor A and TrichoScan was              AGA = androgenetic alopecia; H-N = Hamilton-Norwood;
moderate for THC and ToHC pre-treatment and good                   PRP = platelet-rich plasma; SD = standard deviation.



4                                                                      Original Article | Dermatol Pract Concept. 2024;14(1):e2024001
        Table 2. The concordance correlation coefficient values along with the level of agreement
       regarding the agreement between trichoscopy and TrichoScan data for doctor A and doctor
                                     B pre- and post-treatment.
                         Pre-treatment                                          Post-treatment
   Parameters            CCC (95% CI)          Level of agreement                CCC (95% CI)         Level of agreement
 Doctor A
  THC                        0.9443            Moderate                              0.9755           Good
                        (0.9179-0.9624)                                         (0.9602-0.9849)

  VHC                        0.8199            Poor                                  0.8974           Poor
                        (0.7433-0.8752)                                         (0.8366-0.9364)

  ToHC                       0.9412            Moderate                              0.9631           Good
                        (0.9131-0.9604)                                         (0.9403-0.9773)

  T/V ratio                  0.8161            Poor                                  0.8719           Poor
                        (0.7395-0.8718)                                         (0.7989-0.9195)
 Doctor B
  THC                        0.996              Excellent                            0.9991           Excellent
                        (0.9944-0.9975)                                          (0.9985-9994)

  VHC                        0.990              Excellent                            0.9948           Excellent
                        (0.9862-0.9938)                                         (0.9914-0.9968)

  ToHC                       0.9971             Excellent                            0.999            Excellent
                        (0.9956-0.9980)                                         (0.9984-0.9994)

  T/V ratio                  0.9734            Good                                  0.9875           Good
                        (0.9607-0.9821)                                         (0.9793-0.9925)

CCC = concordance correlation coefficient; CI = confidence interval; THC = terminal hair count; ToHC = total hair count;
T/V ratio = terminal to vellus hair ratio; VHC = vellus hair count


   Table 3. The hair counts and terminal to vellus hair ratio determined by doctor A, doctor B and
   TrichoScan analysis, and the P values regarding the change in mean hair counts post-treatment.
                  Parameters                                Pre-treatment                 Post-treatment                  P
 Doctor A
  THC, mean±SD                                               96.38±22.506                 103.34±24.993                0.001
  VHC, mean±SD                                               36.81±14.162                  37.11±12.232                0.856
  ToHC, mean±SD                                             133.16±25.699                 140.46±28.065                <0.001
  T/V ratio, median (range)                                 2.81 (0.88-7.50)              2.97 (1.14-5.66)
 Doctor B
  THC, mean±SD                                               98.16±21.254                 102.59±23.474                 0.022
  VHC, mean±SD                                               34.24±13.175                  35.08±12.191                 0.569
  ToHC, mean±SD                                             132.40±24.880                 137.67±28.065                 0.025
  T/V ratio, median (range)                                 3.1 (1.12-8.15)               3.03 (1.16-6.16)
 Trichoscan
   THC, mean±SD                                              98.61±21.304                 103.11±23.593                 0.027
   VHC, mean±SD                                              33.99±13.342                  34.69±11.984                 0.635
   ToHC, mean±SD                                            132.65±25.172                 137.80±26.379                 0.029
   T/V ratio, median (range)                                3.22 (1.11-8.67)              3.09 (1.20-6.39)

SD = standard deviation; THC = terminal hair count; ToHC = total hair count; T/V ratio = terminal to vellus hair ratio; VHC = vellus
hair count


to be used in monitoring the treatment outcome in patients            present study, when the experienced doctor in hair diseases
with AGA must be able to objectively analyze the hair growth          and trichoscopy determined all those four hair growth pa-
parameters, namely THC, VHC, ToHC, and T/V ratio. In the              rameters by trichoscopy, the results were similar to those


Original Article | Dermatol Pract Concept. 2024;14(1):e2024001                                                                    5
       Table 4. The intra-class correlation coefficient and respective P values regarding intra- and
                           inter-observer agreement pre- and post-treatment.
                                    Pre-treatment                                      Post-treatment
          Parameters                 ICC (P value)        Level of agreement            ICC (P value)          Level of agreement
 Intra-observer agreement
    THC                             0.879 (< 0.001)      High                           1.000 (< 0.001)      Excellent
    VHC                             0.997 (< 0.001)      Excellent                      0.999 (< 0.001)      Excellent
    ToHC                            0.999 (< 0.001)      Excellent                      1.000 (< 0.001)      Excellent
    T/V ratio                       0.988 (< 0.001)      Excellent                      0.997 (< 0.001)      Excellent
 Inter-observer agreement
    THC                             0.972 (< 0.001)      Excellent                      0.987 (< 0.001)      Excellent
    VHC                             0.899 (< 0.001)      High                           0.948 (< 0.001)      High
    ToHC                            0.972 (< 0.001)      Excellent                      0.980 (< 0.001)      Excellent
    T/V ratio                       0.884 (< 0.001)      High                           0.928 (< 0.001)      High

ICC = intra-class correlation coefficient; THC = terminal hair count; ToHC = total hair count; T/V ratio = terminal to vellus hair ratio;
VHC = vellus hair count


determined by TrichoScan analysis. On the other hand, only            follow-up methods, usually with global photographic assess-
THC and ToHC determined by the less experienced doctor                ment of hair growth by investigators and patients [18-24]. In
were consistent with the Trichoscan analysis measurement.             our study, we performed a similar method described in some
The change in mean hair counts post-treatment detected by             of the prior studies to determine hair growth parameters by
both doctors, particularly by the experienced doctor, using           trichoscopy [18-24]. We counted the hairs manually on the
trichoscopy resembled the change detected by TrichoScan. In           images we obtained and saved with the video dermoscope.
other words, both trichoscopy and TrichoScan determined               In order to make the most accurate comparison, we chose
a similar treatment outcome. Considering the repeatability            the hair diameter used by the Trichoscan analysis to define
and reproducibility of the trichoscopic analysis, the intra-          vellus and terminal hairs. Trichoscopic analysis was not a
and inter-observer agreement were either excellent or high            time-consuming procedure in our study, which took a maxi-
for all hair growth parameters studied.                               mum of 15 minutes.
    Previous studies used both handheld and video dermo-                  Bilgiç et al compared TrichoScan analysis with manual
scopes to assess the efficacy of different treatment modalities       hair counting on trichoscopic images using the software “im-
for AGA [9-13,15-24]. With a handheld dermoscope, some                age analysis tool” [12]. Two independent dermatologists ex-
studies evaluated changes in the trichoscopic findings of AGA         amined 90 images obtained from 30 male patients with AGA
during the treatment period, including hair diameter diver-           during the treatment period and determined only the hair
sity, single-hair pilosebaceous units, yellow dots, and perip-        density. The averages of those two ToHC measurements were
ilar sign [15,16]. In others, trichoscopic images were saved          compared with the results of the TrichoScan analysis, and
on a computer after they were obtained with a handheld der-           the concordance was found to be unsatisfactory. They identi-
moscope equipped with a camera or by a video dermoscope               fied several hair fibers which were undetected by TrichoScan
[17,18]. Hair density was calculated manually as the number           due to crossing and overlapping hairs, multiple hairs in the
of hairs per cm2 on the trichoscopic images. Hair diameter            follicular unit, and the presence of unequable hair thickness
was measured with the help of different software programs             throughout its length. In the study of Gassmuller et al [13],
to determine mean hair diameter or to define vellus and ter-          3 evaluators manually outlined the length and thickness of
minal hairs, which were counted manually thereafter [17].             hairs on 90 trichoscopic images obtained from 10 patients
The hair diameter to define terminal and vellus hairs varied          independently; the software “hair measure tool” automati-
between different studies [15-17]. Hairs less than 0.04 mm            cally measured the hair density, thickness, and length. The
or 0.03 mm in diameter were counted as vellus hairs, while            comparative assessment showed a strong correlation be-
hairs thicker than 0.04 mm or 0.05 mm in diameter were                tween the evaluation of hair growth parameters using man-
counted as terminal hairs. The change from baseline in mean           ual identification of hairs and TrichoScan analysis. Manual
hair diameter and hair density and also THC and VHC at                evaluators obtained higher values of hair density as very thin
different time intervals were the most common primary ef-             hairs were not analyzed by TrichoScan owing to the low
ficacy outcome of the studied treatment modality [18-21].             camera resolution. The agreement between different evalu-
Trichoscopic analysis was performed alone or with other               ators was best for total hair density and parameters related



6                                                                          Original Article | Dermatol Pract Concept. 2024;14(1):e2024001
to hair length and worst for the parameters related to hair           3. Sperling LC, Cowper SE, Knopp EA. An atlas of hair pathology
thickness. Considerable variability was noted in the same                with clinical correlations. CRC Press ; 2012: 42,43.
                                                                      4. Alessandrini AM, Bruni F, Piraccini BM, Starace M. The Effective-
evaluator’s results of manually identified hairs. It was sug-
                                                                         ness and Tolerability of Preformed Growth Factors Vehiculated
gested to be due to the tedious and time-consuming nature
                                                                         Through Iontophoresis on Patients with Androgenetic Alopecia
of the procedure, making it nearly impossible to repeatedly              and Telogen Effluvium: A Clinical Study. Dermatol Pract Con-
count hundreds of hairs without any error. In our study, the             cept. 2021;11(3):e2021082. DOI:10.5826/dpc.1103a82. PMID:
doctor’s experience in hair diseases and trichoscopy affected            34123571. PMCID: PMC8172030.
the compatibility of trichoscopic evaluation of VHC and T/V           5. Chamberlain AJ, Dawber RP. Methods of evaluating hair
                                                                         growth. Australas J Dermatol. 2003;44(1):10-18. DOI:10.1046/j
ratio with TrichoScan analysis results. The less experienced
                                                                         .1440-0960.2002.t01-1-00631.x. PMID: 12581076.
doctor counted more vellus and fewer terminal hairs than
                                                                      6. Rolf Holmann, TrichoScan: A Novel Tool For The Analysis
TrichoScan, possibly because of identifying some terminal                of Hair Growth InVivo, JID Symposium Proceedings 2003;
hairs or some other fibers as vellus hairs or as TrichoScan did          8(109):115.
not detect all vellus hairs. Nevertheless, the less experienced       7. Shapiro J. Hair Loss: Principles of Diagnosis and Management of
doctor determined a similar outcome at the 3rd month of                  Alopecia. London; 2002: 83-121.
                                                                      8. Miteva M, Tosti A. Hair and scalp dermatoscopy. J Am Acad
treatment as did the experienced doctor and the trichoscan
                                                                         ­Dermatol. 2012;67(5):1040-1048. DOI:10.1016/j.jaad.2012.02
analysis; a significant increase in THC and ToHC, while no
                                                                          .013. PMID: 22405573.
significant change in VHC.                                            9. Elmaadawi İH, Mohamed BM, Ibrahim ZAS, et al. Stem cell
    To see how professional experience affects our results, we            therapy as a novel therapeutic intervention for resistant cases of
chose one of the researchers of our study as an experienced               alopecia areata and androgenetic alopecia. J Dermatolog Treat.
doctor who works mainly in the field of hair diseases and                 2018;29(5):431-440. DOI:10.1080/09546634.2016.1227419.
                                                                         PMID: 27553744.
trichoscopy. Both doctors determined similar trichoscopic
                                                                     10. Jha AK, Udayan UK, Roy PK, Amar AKJ, Chaudhary RKP. Orig-
analysis results and treatment outcomes. However, while the
                                                                         inal article: Platelet-rich plasma with microneedling in androge-
trichoscopic measurements of the experienced doctor were                 netic alopecia along with dermoscopic pre- and post-treatment
quite consistent with the TrichoScan results, the hair growth            evaluation. J Cosmet Dermatol. 2018;17(3):313-318. DOI:10
parameters, particularly VHC and T/V ratio calculated by                 .1111/jocd.12394. PMID: 28771982.
the less experienced doctor, needed to be in better agreement        11. Nichols AJ, Hughes OB, Canazza A, Zaiac MN. An Open-­
                                                                         Label Evaluator Blinded Study of the Efficacy and Safety of a
with the result of TrichoScan analysis. Based on our results,
                                                                         New Nutritional Supplement in Androgenetic Alopecia: A Pi-
we believe that the education of young dermatologists is
                                                                         lot Study. J Clin Aesthet Dermatol. 2017;10(2):52-56. PMID:
important to improve their knowledge and experience of                   28367262. PMCID: PMC5367873.
trichoscopic examination. Thus, they will be able to perform         12. Bilgiç Temel A, Gülkesen KH, Dicle Ö. Automated digital image
trichoscopy more accurately and use it to assess the thera-              analysis (TrichoScan) in male patients with androgenetic alope-
peutic outcome in AGA.                                                   cia; comparison with manual marking of hairs on trichoscopic
                                                                         images. Skin Res Technol. 2018;24(3):515-516. DOI:10.1111
    In conclusion, trichoscopy, when performed by a doctor
                                                                         /srt.12449. PMID: 29363174.
experienced in hair diseases and trichoscopy, can be utilized
                                                                     13. Gassmueller J, Rowold E, Frase T, Hughes-Formella B. Validation
as a sensitive method in monitoring the treatment response               of TrichoScan technology as a fully-automated tool for evalua-
in patients with AGA, which is based on the determination                tion of hair growth parameters. Eur J Dermatol. 2009;19(3):224-
of THC, VHC, ToHC, and T/V ratio. If it is to be performed               231. DOI: 10.1684/ejd.2009.0640. PMID: 19220982.
by a less experienced doctor, it can also be used as a sensi-        14. Gupta M, Mysore V. Classifications of Patterned Hair Loss: A Re-
                                                                         view. J Cutan Aesthet Surg. 2016;9(1):3-12. DOI:10.4103/0974-
tive follow-up method, preferably using THC and ToHC pa-
                                                                         2077.178536. PMID: 27081243. PMCID: PMC4812885.
rameters. In our opinion, encouraging trichoscopy training
                                                                     15. Ray R, Sharma A. Comparison of 5% minoxidil lotion monother-
for young dermatologists will ensure a more successful and               apy versus its combination with autologous platelet rich plasma
widespread use of trichoscopic examination in assessing the              in androgenetic alopecia in hundred males. Med J Armed Forces
therapeutic outcome of AGA.                                              India. 2021;77(3):355-362. DOI:10.1016/j.mjafi.2020.11.010.
                                                                         PMID: 34305291. PMCID: PMC8282514.

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Original Article | Dermatol Pract Concept. 2024;14(1):e2024001                                                                            7
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8                                                                           Original Article | Dermatol Pract Concept. 2024;14(1):e2024001
