Telemedicine Alopecia Assessment: Highlighting Patients With Skin of Color

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Alopecia has been one of the more common concerns reported at teledermatology (TD) visits during the COVID-19 pandemic. In light of the growing use of TD, a team of experts were consulted to develop workflows for virtual hair and scalp examinations, with particular consideration for skin of color patients.



Practice Gap

In accordance with World Health Organization guidelines on social distancing to limit transmission of SARS-CoV-2, dermatologists have relied on teledermatology (TD) to develop novel adaptations of traditional workflows, optimize patient care, and limit in-person appointments during the COVID-19 pandemic. Pandemic-induced physical and emotional stress were anticipated to increase the incidence of dermatologic diseases with psychologic triggers.

The connection between hair loss and emotional stress is well documented for telogen effluvium and alopecia areata.1,2 As anticipated, dermatology visits increased during the COVID-19 pandemic for the diagnosis of alopecia1-4; a survey performed during the pandemic found that alopecia was one of the most common diagnoses dermatologists made through telehealth platforms.5

This article provides a practical guide for dermatology practitioners to efficiently and accurately assess alopecia by TD in all patients, with added considerations for skin of color patients.

Diagnostic Tools

The intersection of TD, as an effective mechanism for the diagnosis and treatment of dermatologic disorders, and the increase in alopecia observed during the COVID-19 pandemic prompted us to develop a workflow for conducting virtual scalp examinations. Seven dermatologists (A.M., A.A., O.A., N.E., V.C., C.M.B., S.C.T.) who are experts in hair disorders contributed to developing workflows to optimize the assessment of alopecia through a virtual scalp examination, with an emphasis on patients of color. These experts completed a 7-question survey (Table) detailing their approach to the virtual scalp examination. One author (B.N.W.) served as an independent reviewer and collated responses into the following workflows.

Survey Questions on Telemedicine Scalp Examination

Telemedicine Previsit Workflow

Components of the previsit workflow include:

• Instruct patients to provide all laboratory values and biopsy reports before the appointment.

• Test for a stable Wi-Fi connection using a speed test (available at A speed of 10 megabits/second or more is required for high-quality video via TD.6

Vertex scalp

FIGURE 1. Patient photograph of the vertex scalp prior to a teledermatology appointment. Instruct the patient to put their chin down. Taking the photograph with the hair parted from the nape of the neck to the mid frontal point of the hairline is particularly valuable for surveying hair density and diagnosing certain scalp disorders.

• Provide a handout illustrating the required photographs of the anterior hairline; the mid scalp, including vertex, bilateral parietal, and occipital scalp; and posterior hairline. Photographs should be uploaded 2 hours before the visit. Figures 1 and 2 are examples of photographs that should be requested.

Right and left temporal areas

FIGURE 2. Patient full-view photograph of the face, including eyebrows and eyelashes, prior to a teledermatology appointment. Other helpful images include the right and left temporal areas and the occipital area, if relevant (not shown).


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