BIOPSY QUESTIONS

For 95 % of patients, a single “trichoscopically guided” biopsy is sufficient. What this means is that after a good history and good clinical examination and good trichoscopic examination, one uses the trichoscope to determine where to take the biopsy. Most of the time, the answer lies there. The pathology lab will influence how the biopsy is processed. Some labs can only do vertical sections, some do both and some do horizontal on suspected non scarring and vertical sectioning on scarring. It’s always important to ask the lab over time, how they do things. Now, for the first few biopsies, that’s not generally done. But over time, you want to ideally strike up a conversation with the pathologist. Some use one biopsy and cut it in vertical and horizontal sections (they do alot with one tiny specimen!!). Some like two biopsies ! Some like one for horizontal sectioning and one for vertical sectioning plus special immunofluorescence testing. So having a chat with the pathologist is really nice over time. For 95 % of my patients (even very complex cases), a single biopsy is sufficient. Random biopsies anywhere on the scalp are of little use (let’s say pretty close to useless). A single carefully thought out trichoscopically guided biopsy is the way to go! Of course if there are two of three DISTINCT confusing morphologies, then taking two or three biopsies is a consideration too. But if the basic pattern is the same, a single biopsy is sufficient. One ALWAYS needs to have a differential diagnosis on the page before the biopsy gets shipped off (such as “dear pathologist, I’m thinking lichen planopilaris or some sort of scarring alopecia. If the hair specialist truly has no clue at all what it could, then more history and more examination is needed before committing to the biopsy.