|Year : 2022 | Volume
| Issue : 1 | Page : 25-30
Trichoscopic findings in various alopecias at tertiary referral center: A cross-sectional study
Mamatha P, V Neha, Shishira R Jartarkar, Shalini Sampath, Rakesh R Madireddy
Departments of Dermatology, Venereology and Leprosy, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
|Date of Submission||21-May-2021|
|Date of Acceptance||25-Jan-2022|
|Date of Web Publication||30-Jun-2022|
Dr. Mamatha P
P-45, 6th Main, Sector-10, LIC Colony, Jeevan Bhima Nagar, Bengaluru - 560 075, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Hair disorders are a common complaint that baffles dermatologists due to multiple causes. Trichoscopy is a noninvasive technique used to diagnose and monitor the progression of various hair disorders. Purpose: To observe the trichoscopic patterns of various hair disorders to assist with differentiation. Methods: This was a cross-sectional observational study done in 256 patients with alopecia. After a detailed history, clinical examination, and relevant investigations, trichoscopy was performed using a Dermlite (3Gen LLC, Sanjuan Capistrano, CA, USA) dermoscope. Results: Out of 256 patients, 154 were male and 102 were female. Most of the cases were in the age group of 21–40 years (66.4%). Nonscarring alopecias (93.35%) were common compared to scarring alopecias (5.8%). The most common alopecia noted in our study was Androgenetic alopecia 125 patients (48.82%), followed by telogen effluvium 48 patients (19.1%), the common trichoscopic follicular features noted were short vellus hair 161 (62.8%), yellow dots (61%), hair diameter variation 125 (48.82%), and black dots (21.87%). The commo interfollicular features are seen were arborizing vessels 109 (42.6%) and pigmentation in 12 patients (4.68%). Significant findings observed in each group were hair diameter diversity in androgenetic alopecia, exclamatory mark in Alopecia Areata, comma hair in tinea capitis. Cicatricial alopecias are characterized by loss of follicular ostia along with inflammatory signs such as perifollicular scales and casts. Conclusion: Trichoscopy is a very valuable and useful tool to diagnose various hair disorders by understanding the various trichoscopic patterns specific for each disease.
Keywords: Broken hair, nonscarring, scarring alopecia, trichoscopy, yellow dots
|How to cite this article:|
Mamatha P, Neha V, Jartarkar SR, Sampath S, Madireddy RR. Trichoscopic findings in various alopecias at tertiary referral center: A cross-sectional study. J Dermatol Dermatol Surg 2022;26:25-30
|How to cite this URL:|
Mamatha P, Neha V, Jartarkar SR, Sampath S, Madireddy RR. Trichoscopic findings in various alopecias at tertiary referral center: A cross-sectional study. J Dermatol Dermatol Surg [serial online] 2022 [cited 2022 Oct 6];26:25-30. Available from: https://www.jddsjournal.org/text.asp?2022/26/1/25/349430
| Introduction|| |
Alopecia is defined as complete or partial loss of hair from the scalp and other hair-bearing sites of the body. Alopecia has been classified into scarring and nonscarring alopecias and hair shaft disorders. In nonscarring alopecia, hair follicles are preserved with potential for hair regrowth. In scarring alopecia, the hair follicle is irreversibly destroyed due to the destruction of stem cells in the bulge area of the outer root sheath and replaced by fibrous scar tissue.
Nonscarring alopecias are further classified into patchy and diffuse alopecias. The nonscarring alopecias include androgenetic alopecia, alopecia areata, anagen/telogen effluvium, loose anagen hair syndrome, alopecia mucinosa, pressure-induced alopecia, syphilitic alopecia, trichotillomania, and tinea capitis.
The scarring alopecias are classified into primary and secondary scarring alopecias. They include lupus erythematosus, lichen planus, pseudopelade of Brocq, kerion, folliculitis decalvans, dissecting cellulitis of the scalp, keratosis pilaris spinulosa decalvans, radiation dermatitis, and malignancy.
Various methods used for the evaluation of hair loss are hair pull test, wood's lamp examination, light and electron microscopy of hair, scalp biopsy, and dermoscopy.
Dermoscopy of the hair and scalp is known as trichoscopy. It provides a noninvasive, option to establish the diagnosis of hair disorders. The term trichoscopy was coined by Lidia Rudnicka and Malgorzata Olszewska in the year 2006.
Trichoscopy magnifies subtle clinical surface features of skin lesions as well as exposes some subsurface skin structures normally not visible even with a magnifying lens. It has a blocking filter against light reflection from the skin surface.
Dermoscopy of normal healthy scalp shows follicular units containing 2–4 terminal hairs and 1 or 2 vellus hairs. In darker races, a prominent brown homogeneous honeycomb pigment network is seen over the scalp.
Trichoscope patterns observed in various hair disorders are follicular patterns (white dots, yellow dots, black dots), interfollicular patterns (vascular and pigment patterns), and hair shaft characteristics.
Trichoscopy helps in differentiating nonscarring hair loss from scarring hair loss enabling faster diagnosis and preventing unnecessary biopsies.
In spite of being a noninvasive technique, it is not widely used in daily practice, so this study is being taken up to provide valuable insights into the diagnosis and monitoring of hair disorders.
The objective of the study is to understand the utility of trichoscopy in the examination and diagnosis of various hair disorders, by observing different trichoscopic patterns.
| Methods|| |
This is a cross-sectional observational study, which was carried out on a total of 256 patients with alopecia in the Department of Dermatology, Venerology, and Leprosy at Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bangalore, Karnataka, India.
Institutional Ethical Committee clearance was obtained.
The study was done for 1 year from June 2019 to June 2020. Inclusion criteria are patients with hair disorders who are willing to give written informed consent. Exclusion criteria were patients with active bacterial infections and patients who are not willing to undergo investigation. Informed written consent of the participating patients was taken. A prestructured proforma was used to collect the baseline data. A detailed history was taken and standard textbook criteria were followed while making a diagnosis. The clinical and dermatological examination was done. The hair and scalp were evaluated using a dermoscope (Dermlite, 3Gen LLC, Sanjuan Capistrano, CA, USA) with × 10 and polarized filters for follicular and interfollicular patterns. Dermoscopic photographs were taken with One plus 6T phone. Investigations such as potassium hydroxide were done in suspected cases of tinea capitis, biopsy in doubtful cases of nonscarring and scarring alopecia. Hair microscopy in hair shaft disorders.
Data were entered in MS Excel and assessed with IBM SPSS Version 21.0 Software. Variables are summarized in percentages and proportions.
| Results|| |
A total of 256 patients were included in our study, of which 154 patients (60.20%) were males and 102 patients (39.80%) were females. The maximum number of patients were in the age group of 21–40 years (66.4%). The details are tabulated in [Table 1]. Nonscarring alopecias (93.35%) were common compared to scarring alopecias (5.85%). Among nonscarring alopecias, 125 patients (48.82%) were of androgenetic alopecia, 50 patients (19.63%) were alopecia areata, 48 patients (18.75%) were telogen effluvium. Among scarring alopecias, discoid lupus erythematosus was common, seen in 7 patients (2.73%) followed by lichen planopilaris 5 patients (1.95%) other conditions that are seen include tinea capitis 8 patients (3.12%), trichotillomania 6 patients (2.3%), pseudopelade of Brocq, wooly hair, traction alopecia.
|Table 1: (Demographic characteristics) - distribution of patients according to age/gender and individual alopecia|
Click here to view
The duration of the disease ranged from 1 month to 48 months. Most cases were <6 months (32.8%).
The most common Trichoscopic follicular features noted were yellow dots (61%), short vellus hair (62.8%), and black dots (21.87%). The most common interfollicular features noted were arborizing vessels (32%) and pigmentation (8.6%). Trichoscopy findings of each type of alopecia are shown in [Table 2].
Androgenetic alopecia was seen in 125 patients of which 80 patients were male and 45 patients were female. The most common Trichoscopic findings of androgenetic alopecia are hair diameter diversity (100%), yellow dots (90%), short vellus hair (59%), and perifollicular halo (70%), honeycomb pigment network (38%) [Figure 1] and [Figure 2].
|Figure 1: Androgenetic alopecia: (a) Loss of hair with diffuse hair thinning in the vertex region. (b and c) Trichoscopy showing variability in the diameter of the hair shafts, miniaturization of hair (blue arrows) and perifollicular halo (red circle) (×20)|
Click here to view
|Figure 2: Female pattern hair loss: (a) Diffuse thinning of hair in the frontal and vertex area with a central widening of the partition. (b) Trichoscopy shows the diversity of hair shafts (blue arrows), perifollicular halos (green circle), and empty hair follicles (×20)|
Click here to view
Fifty patients were diagnosed to have alopecia areata. In alopecia areata, broken hairs were seen in all patients (100%), other findings were black dot (80%), yellow dots (86%), short vellus hair (60%), and exclamatory marks hair (72%) [Figure 3]. Forty eight patients were of telogen effluvium. Short vellus hair is seen in all patients [Figure 4]. Tinea capitis was seen in 8 patients (3.2%). Black dots, broken hair, and comma hairs were seen in all the patients [Figure 5].
|Figure 3: Alopecia areata: (a) Two well-circumscribed patchy hair loss present on the vertex area of scalp. (b) The trichoscopic field is filled with exclamation marks (blue arrow), broken hair (green arrow), black dots (red arrow), and pigtail hair (yellow circle (×10)|
Click here to view
|Figure 4: Telogen effluvium: (a) Diffuse thinning of the hair in the frontal and temporal areas. (b) On trichoscopy, decreased hair density and minimal variation in hair diameter (red circle) is seen (×10)|
Click here to view
|Figure 5: Tinea capitis: (a) Well circumscribed patchy hair loss with black dots on the right parietal region of the scalp. (b) Trichoscopic findings shown are black dots (blue arrow), broken hair (green arrow), and comma hair (pink arrow with circle) (×10)|
Click here to view
Six patients were diagnosed with trichotillomania. Trichoscopic findings observed were black dots, broken hair, “V” sign, follicular hemorrhage [Figure 6]. Fifteen cases were of scarring alopecia, among scarring alopecias discoid lupus erythematosus was most common. Various Trichoscopic features observed were loss of follicular ostia, follicular keratotic plugs, follicular hemorrhage, perifollicular scales, and arborizing vessels [Figure 7].
|Figure 6: Trichotillomania: (a) Localised ill-defined patchy hair loss present on the parietal region of the scalp. (b) Trichoscopic field shows flame hair (black circle), tulip hair (green arrow), broken hair (blue arrow), black dots (orange arrow), and “V” sign (red arrow) (×20)|
Click here to view
|Figure 7: Discoid lupus erythematosus: (a) Multiple, erythematous, scaly, atrophic, hypopigmented patches present on the frontal area and vertex of the scalp. (b) Dermoscopic findings show arborizing vessels (black arrow), loss of pigment network (orange arrow), scaling, follicular plugs (green arrow), and brown to blue-gray dots (blue arrow). (c) follicular plugs (blue arrow), brown-black pigmentation seen (red circle) (×10)|
Click here to view
Lichenplanopilaris were seen in 5 patients (1.95%) apart from the loss of follicular ostia, black dots, perifollicular/interfollicular pigmentation was observed in all patients [Figure 8]. Hair casts and arborizing vessels are also seen. 2 patients are diagnosed as pseudopelade of brocq, loss of follicular ostia is seen [Figure 9]. One case of wooly hair is seen in which there is sparse hair with kinking. One case of folliculitis decalvans is seen in which there is a follicular pustule with perifollicular scaling [Figure 10].
|Figure 8: Lichen planopilaris: (a) Well-defined patches of hair loss with perifollicular scaling seen on the vertex. (b) The Trichoscopic field is filled with follicular plugging and peripilar casts (black and red arrow) and perifollicular pigmentation (yellow arrow with circle) (×20)|
Click here to view
|Figure 9: Pseudopelade of brocq: (a) Multiple skin-colored atrophic patches of hair loss seen on the vertex and parietal regions of the scalp. (b) On trichoscopy, loss of follicular ostia (red arrows) are seen (×10)|
Click here to view
|Figure 10: Folliculitis decalvans: (a) Multiple erythematous papules on the scalp with areas of patchy hair loss present on the vertex of the scalp. (b) Trichoscopic features seen are perifollicular tubular scaling (red arrow) and compound follicles containing 5 or more hairs (green arrow) (×40)|
Click here to view
| Discussion|| |
Hair loss is the most common complaint in any dermatology practice. Although it is medically benign condition, it can have a significant psychosocial impact for patients. Trichoscopy provides a noninvasive option that can be used to establish the diagnosis and monitor the progression in hair disorders.
Androgenetic Alopecia is the most common form of hair loss in our study. In Androgenetic Alopecia, hair diameter diversity was present in all patients. Hair diameter diversity is the presence of hairs with different calibers, which reflects progressive hair miniaturization. Yellow dots correspond to follicular Ostia filled with keratin and sebum. Hair diameter diversity was seen in all patients in our study which is in concordance with studies conducted by Inui et al., where they evaluated 50 Asian men with Androgenetic Alopecia. It is also similar to studies conducted by Hu R et al., Chiramel et al. and Kibar et al.,,
In this study, yellow dots were seen in 95% of patients, but it was seen only in 23.3% in a study by Inui et al., while it was 87.5% in the study by Chiramel et al. and 68% in a study by Kibar et al.,,
Peripilar sign is characterized by the presence of a brown depressed halo of approximately 1 mm in diameter at the follicular ostium around the emergent hair shaft. It is due to perifollicular inflammation.
In our study, it was seen in 68.75% of cases, which was in concordance with Inui et al. where it was 66%.
White dots correspond to empty follicular ostia and sweat gland openings. They were seen in 62.5% of cases in our study, whereas it was only 26.2% in Ruiming et al. study. The honeycomb pigment pattern was seen in 35% of cases in our study. It occurs due to chronic sun exposure. It was in concordance with the studies conducted by Ruiming et al. (32.6%) and Kibar et al. (37.3%)., Trichoscopic features of androgenetic alopecia among various studies are compared in [Table 3].
|Table 3: Comparison of trichoscopic findings in androgenetic alopecia with other studies|
Click here to view
In female pattern hair loss (FPHL), the dermoscopic features are similar to male pattern hair loss. In FPHL, short vellus hair (<0.003 mm diameter) seen in the frontal scalp is a sign of severe miniaturization. FPHL is diagnosed when 10% or more than 7 vellus hairs are detected in the frontal scalp. In our study, it was seen in 66.7% of patients. Trichoscopy criteria for diagnosing FPHL have been devised by Rakowska et al., based on a Trichoscopy study of 131 females. It was a comparative analysis of the frontal and occipital areas visualized in patients of chronic telogen effluvium (39), FPHL (59) and healthy controls (33).
In our study, 50 patients had alopecia areata. The incidence of yellow dots was 85.7% in our study, whereas it was 63.7% in a study by Inui et al. and 81.8% in Mane et al. study. Yellow dots are the most sensitive dermoscopic features of Alopecia areata. Black dots, short vellus hairs, and broken hairs correlated with disease activity. Black dots were seen in 79.59% of cases in this study, which showed all in the active stage of the disease.
Exclamation mark hairs are characteristic of Alopecia areata. They appear as broken hair with thickened, pigmented tip. They were seen in 71.4% of cases in this study. It was comparable with the study of Chiramel et al. where they had seen in 70.8% of cases, but it was less in a study by Inui et al. (31.7%) and Hegde et al. (18.6%).,, This difference may be attributed to variation in disease duration and severity.
Short vellus hairs were observed in telogen effluvium cases in our study. Specific findings were not observed as it is usually a diagnosis of exclusion.
In Trichotillomania, various findings observed in our study were broken hairs, black dots, follicular hemorrhage, perifollicular erythema, longitudinal split, fraying of hair, and coiled hair. These findings were consistent with other studies. In 4 patients “V” sign was also noted. “V” sign is created when 2 hairs emerging from one follicular opening are broken at an equal level. In our study, 2 cases were seen in children, other cases were seen in females having underlying psychological problems.
Non inflammatory type of tinea capitis was noted more in our study. It is characterized by comma hair as seen in other studies. Black dots due to broken hair shaft is a common finding. Inflammatory tinea capitis has features of erythema, scaling, pustules and blotchy pigmentation.
Scarring alopecia is associated with destruction of hair follicles, so they manifest with permanent areas of hair loss. Early confirmation of the diagnosis is necessary to halt the progression of the disease. In our study, 15 cases of scarring alopecia were noted. All cases were associated with loss of follicular ostia on dermoscopy. This was in concordance with the findings of Karadag Kose and Gluec, Harries et al. and Tosti et al.,, Discoid lupus erythematosus is the most common scarring alopecia noted in our study. In our study, the following features are observed on Trichoscopy in all cases of Discoid lupus erythematosus – loss of follicular ostia, follicular hemorrhage, perifollicular scales, arborizing vessels, follicular keratotic plugs, linear branching vessels. Perifollicular halo was seen in 4 cases. These findings are consistent with other studies. Blue-grey dots are seen in 3 cases which correspond to melanophages in the papillary dermis.
Five cases of Lichen planopilaris were noted in our study. Dermoscopic features observed in our study were loss of follicular ostia, hair casts, perifollicular pigmentation, erythema, white dots, and arborizing vessels.
These findings were similar to studies done by Harries et al. and Tosti et al., The characteristic feature of lichen planopilaris is the presence of perifollicular casts which is a layer of scales around the hair shaft.
Two cases of pseudopelade of Brocq were noted in our study, in which loss of follicular ostia was observed in all two cases. No specific findings were seen for the pseudopelade of Brocq. It is usually a diagnosis of exclusion. Similar findings were seen in a study by Kandil AH et al.
One case of folliculitis decalvans was noted in our study. It is characterized by a follicular pustule with an emerging hair shaft and perifollicular scaling. This finding was similar to other studies.
| Conclusion|| |
Nonscarring alopecias were more common compared to scarring alopecias. Among nonscarring alopecias, androgenetic alopecia was the most common. Hair diameter diversity was most characteristic of both male and FPHL. Alopecia areata is characterized by exclamatory hair and black dots. Black dots are not specific for alopecia areata but present whenever there is broken hair. Scarring alopecia is characterized by loss of follicular Ostia. They also have scaling and hair casts. A single finding of Trichoscopy is not diagnostic of any condition, but rather the constellation of Trichoscopy findings together with history helps in proper diagnosis. Thus, through Trichoscopy which is a noninvasive technique and in-office procedure, we can diagnose various alopecias and obviate the need for biopsy. Even if a biopsy is needed, trichoscopy guided biopsies yield a definitive pathological diagnosis. We can easily diagnose hair shaft disorders through trichoscopy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shapiro J, Wiseman M, Lui H. Practical management of hair loss. Can Fam Physician 2000;46:1469-77.
Mirmirani P, Willey A, Headington JT, Stenn K, McCalmont TH, Price VH. Primary cicatricial alopecia: Histopathologic findings do not distinguish clinical variants. J Am Acad Dermatol 2005;52:637-43.
Rudnicka L, Olszewska M, Rakowska A, Kowalska-Oledzka E, Slowinska M. Trichoscopy: A new method for diagnosing hair loss. J Drugs Dermatol 2008;7:651-4.
Guttikonda AS, Aruna C, Ramamurthy DV, Sridevi K, Alagappan SK. Evaluation of clinical significance of dermoscopy in alopecia areata. Indian J Dermatol 2016;61:628-33.
] [Full text]
Jain N, Doshi B, Khopkar U. Trichoscopy in alopecias: Diagnosis simplified. Int J Trichology 2013;5:170-8.
Karadağ Köse Ö, Güleç AT. Clinical evaluation of alopecias using a handheld dermatoscope. J Am Acad Dermatol 2012;67:206-14.
Ross EK, Vincenzi C, Tosti A. Videodermoscopy in the evaluation of hair and scalp disorders. J Am Acad Dermatol 2006;55:799-806.
Inui S, Nakajima T, Itami S. Scalp dermoscopy of androgenetic alopecia in Asian people. J Dermatol 2009;36:82-5.
Hu R, Xu F, Han Y, Sheng Y, Qi S, Miao Y, et al.
Trichoscopic findings of androgenetic alopecia and their association with disease severity. J Dermatol 2015;42:602-7.
Chiramel MJ, Sharma VK, Khandpur S, Sreenivas V. Relevance of trichoscopy in the differential diagnosis of alopecia: A cross-sectional study from North India. Indian J Dermatol Venereol Leprol 2016;82:651-8.
] [Full text]
Kibar M, Aktan S, Bilgin M. Scalp dermatoscopic findings in androgenetic alopecia and their relations with disease severity. Ann Dermatol 2014;26:478-84.
Rakowska A, Slowinska M, Kowalska-Oledzka E, Olszewska M, Rudnicka L. Dermoscopy in female androgenic alopecia: Method standardization and diagnostic criteria. Int J Trichology 2009;1:123-30.
Inui S, Nakajima T, Nakagawa K, Itami S. Clinical significance of dermoscopy in alopecia areata: Analysis of 300 cases. Int J Dermatol 2008;47:688-93.
Mane M, Nath AK, Thappa DM. Utility of dermoscopy in alopecia areata. Indian J Dermatol 2011;56:407-11.
] [Full text]
Hegde SP, Naveen KN, Athanikar SB, Reshme P. Clinical and dermatoscopic patterns of alopecia areata: A tertiary care centre experience. Int J Trichology 2013;5:132-6.
Abraham LS, Torres FN, Azulay-Abulafia L. Dermoscopic clues to distinguish trichotillomania from patchy alopecia areata. An Bras Dermatol 2010;85:723-6.
Slowinska M, Rudnicka L, Schwartz RA, Kowalska-Oledzka E, Rakowska A, Sicinska J, et al.
Comma hairs: A dermatoscopic marker for tinea capitis: A rapid diagnostic method. J Am Acad Dermatol 2008;59:S77-9.
Harries MJ, Trueb RM, Tosti A, Messenger AG, Chaudhry I, Whiting DA, et al.
How not to get scar(r)ed: Pointers to the correct diagnosis in patients with suspected primary cicatricial alopecia. Br J Dermatol 2009;160:482-501.
Tosti A, Torres F, Misciali C, Vincenzi C, Starace M, Miteva M, et al.
Follicular red dots: A novel dermoscopic pattern observed in scalp discoid lupus erythematosus. Arch Dermatol 2009;145:1406-9.
Kandil AH, Abdelshafy AS, El-Kashishi KA. Diagnostic value of Dermoscopic findings of hair and scalp in cicatricial alopecia. J Clin Invest Dermatol 2018;6:5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3]