July 2023 703 Volume 22 • Issue 7 Copyright © 2023 BRIEF COMMUNICATION Journal of Drugs in Dermatology SPECIAL TOPIC Minimizing Bias in Alopecia Diagnosis in Skin of Color Patients Eliza Balazic BS, a* Eden Axler BS, a* Christy Nwankwo BA, b Randie Kim MD, c Kristen Lo Sicco MD, c Kseniya Kobets MD, a* Prince Adotama MD c* a Division of Dermatology, Department of Medicine, Albert Einstein College of Medicine, Montefore Medical Center, Bronx, NY BUniversity of Missouri Kansas City School of Medicine, Kansas City, MO c The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, NY * Authors Balazic and Axler contributed equally. Drs. Adotama and Kobets contributed equally. Alopecia is one of the most common dermatologic conditions affecting Black patients, with a signifcantly negative impact on quality of life. 1,2 Timely and accurate diagnosis is therefore critical in order to reverse or halt progression of disease. 3 Unfortunately, lack of representation of skin of color (SOC) patients in the current literature may contribute to misdiagnosis as providers may be unfamiliar with the clinical spectrum of alopecia presenting in darker scalps. 4 Some scarring alopecia subtypes such as Central Centrifugal Cicatricial Alopecia (CCCA) are more prevalent in certain racial groups. However, focusing solely on patient demographics and gross clinical fndings may obscure accurate diagnoses. To distinguish alopecia fndings in Black patients, a dedicated approach using a combination of clinical exam fndings and patient history, along with trichoscopy and biopsy, is essential to prevent misdiagnosis and improve clinical and diagnostic outcomes. We present three cases of alopecia in patients of color which the initial suspected clinical diagnosis did not correspond with trichoscopic and biopsy results. We challenge clinicians to reexamine their biases and fully evaluate patients of color with alopecia. An examination should include a thorough history, clinical examination, trichoscopy, and potentially a biopsy, particularly when fndings do not correlate. Our cases highlight the challenges and disparities that exist in diagnosis of alopecia in Black patients. We emphasize the need for continued research regarding alopecia in skin of color and the importance of a complete workup for alopecia to improve diagnostic outcomes. J Drugs Dermatol. 2023;22(7):703-705. doi:10.36849/JDD.7117 ABSTRACT INTRODUCTION A lopecia is one of the most common dermatologic conditions affecting Black patients, with a signifcantly negative impact on quality of life. 1,2 Timely and accurate diagnosis is therefore critical in order to reverse or halt progression of disease. 3 Unfortunately, lack of representation of skin of color (SOC) patients in the current literature may contribute to misdiagnosis as providers may be unfamiliar with the clinical spectrum of alopecia presenting in darker scalps. 4 In particular, vertex alopecia in SOC patients can be subject to bias as certain scarring alopecias, such as central centrifugal cicatricial alopecia (CCCA), occur at a higher prevalence in patients of African descent 5 and classically presents as hair loss in the vertex of the scalp. 6 Other forms of alopecia may present with vertex involvement in patients of color, so clinicians should fght the urge to jump to a diagnosis of CCCA without performing a thorough examination. Trichoscopy, or scalp dermoscopy, allows dermatologists to evaluate alopecia based on visualization of morphologic patterns and can provide diagnostic clues to help clinicians avoid misdiagnosis of alopecia. Key studies have defned trichoscopic fndings in SOC. 7,8 While trichoscopy does not replace the need for biopsy, it is a critical tool in the initial evaluation of hair loss. We aim to highlight the importance of challenging bias in the clinical diagnosis of alopecia in SOC. The diagnosis of alopecia based on gross clinical morphology alone can lead to misdiagnosis of alopecia type in Black patients. Barriers to early diagnosis must be reduced to ensure quality care is given to patients of all racial backgrounds. Herein, we present three cases of vertex alopecia in which the initial suspected clinical diagnosis did not correspond with trichoscopic and biopsy results. To distinguish alopecia fndings in Black patients, a dedicated approach using a combination of clinical exam fndings and patient history, along with trichoscopy and biopsy, may be essential to prevent misdiagnosis and improve clinical and diagnostic outcomes. doi:10.36849/JDD.7117 Do Not Copy Penalties Apply To order reprints or e-prints of JDD articles please contact sales@jddonline.com This document contains proprietary information, images and marks of Journal of Drugs in Dermatology (JDD). No reproduction or use of any portion of the contents of these materials may be made without the express written consent of JDD. If you feel you have obtained this copy illegally, please contact JDD immediately at support@jddonline.com JO07022