High Rates of Misdiagnosis in Hair, Scalp Disorders Among Patients With Skin of Color

A new systematic review, highlighting the persistent challenges in accurately diagnosing hair and scalp disorders in patients with skin of color (SoC), found that more than half of patients were initially misdiagnosed.1

Published in the International Journal of Dermatology, the new study showed that misdiagnosis is not just common but potentially severe and often preventable with thorough diagnostic workups. Researchers analyzed 21 reports involving 30 patients, identifying diagnostic pitfalls linked to atypical presentations, limited representation of SoC in medical training, and premature diagnostic closure.

The authors recommend incorporating more SoC-specific imagery and case discussions into dermatology curricula, along with a stronger emphasis on biopsy in unclear cases. | Image Credit: Prostock-studio - stock.adobe.com

Hair and scalp disorders often present differently in patients with SoC, with certain conditions, such as central centrifugal cicatricial alopecia (CCCA), more common and others less frequent than among White patients. Yet, images of these presentations remain underrepresented in dermatology education, noted the researchers. Additionally, prior research has shown that dermatology trainees report less confidence treating patients with SoC, underscoring a systemic gap in training.

Reports assessed by the researchers were identified in Embase, MEDLINE, Scopus, and Web of Science up until March 2025. Eligible studies described SoC patients with hair or scalp disorders who were initially misdiagnosed or presented diagnostic challenges. Misdiagnosis was defined as an incorrect initial diagnosis that led to treatment, later revised to the correct one; challenging diagnosis referred to cases where the working diagnosis changed during workup.

Of the 30 patients, 63% were misdiagnosed, including several life-threatening misdiagnoses. Two initial diagnoses of benign or unrelated conditions were later found to be malignant, including T-cell lymphoblastic lymphoma/leukemia and malignant angioendothelioma. Severe misdiagnoses also included an initial erythematosus flare diagnosis that was later diagnosed as neurosyphilis.

One recurrent error was over-reliance on clinical patterns without confirmatory testing, leading to premature diagnoses. Five Black patients with vertex alopecia were presumed to have CCCA based on presentation alone. Subsequent evaluation revealed alopecia areata in 2 cases via trichoscopy and lichen planopilaris in 3 cases via biopsy.

“Our study highlights the importance of completing a thorough history and physical examination for hair and scalp disorders in patients with SoC. Trichoscopy and scalp biopsy helped clarify unclear clinical presentations and corrected misdiagnoses,” explained the researchers, noting that while both diagnostic approaches were crucial for achieving the correct diagnosis, scalp biopsies were more accurate, helpful in half of cases, while trichoscopy led to a correct diagnosis in 33% of cases.

A previous study abstract, published in 2022, highlighted the diagnostic benefit of scalp biopsy, showing that the tool corrected diagnoses in nearly 70% of cases. Patients who received a scalp biopsy were more likely to report improved symptom control, condition resolution, and satisfaction with their treatment plan.2

Eleven patients had challenging cases, 67% of whom were female and 91% were Black. In these cases, biopsy was diagnostic 100% of the time. Most patients (70%) included in the study were Black, while 17% were Asian, 10% were Hispanic/Latino, and 3% were Indigenous. Women made up 53% of cases.

The review was limited by potential reporting bias, cultural and health care system differences, and the lack of a control group to estimate the true prevalence of misdiagnosis. Many included reports were single-patient case studies, limiting generalizability.

Still, the authors emphasized that the findings should prompt both educational and clinical reforms. They recommend incorporating more SoC-specific imagery and case discussions into dermatology curricula, along with a stronger emphasis on biopsy in unclear cases.

References

1. McMullen E, Joseph M, Mannala S, et al. Misdiagnosis of hair and scalp disorders in adult patients with skin of color. Int J Dermatol. Published online July 4, 2025. doi:10.1111/ijd.17899

2. Romisher A, Cohen A, Douglas A. Scalp biopsy increases diagnostic accuracy and treatment outcomes in African American females with alopecia. J Am Acad Dermatol. 2022;83(3). doi:10.1016/j.jaad.2022.06.460