Scalp disease is the area where clinical memory is least reliable and patient expectation is highest. Three months into a treatment for alopecia areata or a scarring alopecia, neither you nor the patient can reconstruct what the scalp looked like at the start, and the conversation becomes an argument about impressions.
Fix the method before the first prescription. Use the same three views every time — vertex, and both temporal-parietal — with the parting in the same place, the same light, and the patient seated at the same distance. Take the photographs yourself or with a fixed protocol rather than accepting the patient's phone pictures, which vary in everything that matters. Record the Severity of Alopecia Tool score in the notes at the same visit.
This takes two minutes and it does two things: it makes a real response visible when the patient cannot feel it yet, and it makes a non-response undeniable at the point you need to stop an expensive drug.
- Fix three standard views and reuse them at every visit.
- Keep the parting, lighting and distance constant; changing any of them invalidates the comparison.
- Record a numerical severity score alongside the images, not instead of them.
- Photograph before the first dose, not at the first review.
- Show the patient the baseline image at review — it is the most effective adherence intervention available in this clinic.
Why it matters
Without a baseline image, both continuing a failing drug and stopping a working one become matters of opinion.
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