Trichoscopy: how it may help the clinician

Telogen effluvium: a 360 degree review

Telogen effluvium (TE) is one of the most common presentations of diffuse non-cicatricial alopecia and is generally self-limited. Multiple causes are associated with TE onset and its maintenance, with stress being felt the most common factor. The multifactorial etiologies involved in TE makes it a complex disorder to diagnose and treat often placing this entity into a "waste basket" diagnosis. By critically assessing the available scientific literature we aimed to review the multifaceted aspects of TE. Our objectives were to review the pathogenesis with the role of stress (including Coronavirus 19-associated TE), as well as to describe the main clinical findings, its differential diagnosis and the current knowledge on TE treatments along with the future treatment's insights.

The dermatoscope in the hair clinic: Trichoscopy of scarring and nonscarring alopecia

Trichoscopy is currently regarded as an essential part of the hair loss consultation. It allows visualization of morphologic structures that are not obvious to the naked eye, including peri- and interfollicular skin surface abnormalities and changes to hair shaft thickness and shape. In this paper, we aim to discuss current knowledge on trichoscopy of the most common forms of scarring and nonscarring alopecias.

Trichoscopy pattern in alopecia areata: A systematic review and meta-analysis

BACKGROUND

The incidence of alopecia areata (AA) has increased over the last few decades. Trichoscopy is a noninvasive procedure performed in dermatology clinics and is a helpful tool in determining the correct diagnosis of hair loss presentations.

OBJECTIVE

Through mapping the researches that have been done to represent the spectrum of trichoscopic findings in AA and to identify the most characteristic patterns.

METHODS

Thirty-nine studies were eligible for the quantitative analysis. Meta-analysis and subgroup analysis were performed.

RESULTS

Thirty-nine studies (29 cross-sectional, five retrospective, two descriptive, one case series, one observational, and one cohort) with a total of 3204 patients were included. About 66.7% of the studies were from Asia, 25.6% from Europe, and 7.7% from Africa. The most characteristic trichoscopic findings of AA were as follows; yellow dots, black dots, broken hairs, short vellus hairs, and tapering hairs.

CONCLUSION

There is no single pathognomonic diagnostic trichoscopic finding in AA rather than a constellation of characteristic findings. The five most characteristic trichoscopic findings in AA are: yellow dots, black dots, broken hairs, short vellus hairs, and tapering hairs. Yellow dots and short vellus hairs considered the most sensitive clues for AA, while black dots and tapering hairs are the most specific ones. Furthermore, trichoscopy is a useful tool that allows monitoring of response during the treatment of AA. Treatment responded cases will show an increase in short vellus hairs, but loss of tapering hairs, broken hairs, and black dots, while yellow dots are the least responsive to the treatment.

Dermoscopic Findings of Alopecia in Patients with Hypothyroidism

Background

Thyroid hormones are essential for the growth and maintenance of hair follicles. Numerous studies have evaluated the relationship between thyroid disorders and hair loss. However, no study has assessed the dermoscopic results in patients with hypothyroidism and hair loss.

Objectives

This study aimed to investigate dermoscopic findings of alopecia in patients with hypothyroidism.

Methods

This analytic cross-sectional study was performed on patients with hair loss referred to dermatology clinics of Guilan University of Medical Sciences, Iran. Hypothyroid patients and an equal number of euthyroid individuals were compared. After recording the demographic and clinical characteristics, all patients were subjected to hair dermoscopy.

Results

A total of 164 patients with and without hypothyroidism with hair loss were studied. The frequency of hair shaft abnormalities (P < 0.001) and vellus hair (P < 0.001) significantly differed between the two groups. Dermoscopic findings related to scale abnormalities (P = 0.002) and their perifollicular type (P < 0.001) significantly differed between the groups. Vascular changes (P < 0.001), perifollicular concentric type (P = 0.012), and interfollicular red loops type (P = 0.005) were significantly higher in patients with hypothyroidism. Also, based on the multiple logistic regression model, the chance of abnormalities of the hair shaft, scales, and vascular changes increased by 3.24, 2.73, and 3.53, respectively, in hypothyroidism compared to euthyroidism.

Conclusions

Regarding the promising results of this study, we could detect possible dermoscopic signs of inflammation in hypothyroid patients with hair loss. Further investigations are needed because there is a shortage of evidence on this novel diagnostic method.

Trichoscopic signs of tinea capitis: a guide for selection of appropriate antifungal

BACKGROUND

Tinea capitis is the most common pediatric dermatophyte infection. Optimal treatment regimen differs according to the type of the dermatophyte involved.

OBJECTIVES

The aim of this work was to study the trichoscopic signs in relation to isolated organism in a sample of Egyptian patients with tinea capitis and the possibility of using them as a guide for selection of appropriate antifungal.

METHODS

This study was carried out on 60 subjects with tinea capitis. Patients were mycologically examined, both direct microscopy with KOH preparation and culture of the scraped hair materials on Sabouraud dextrose agar. Culture mounts were used for identification of the organism. Trichoscopic examination of all patients was performed using the Dermlite DLIII dermoscope.

RESULTS

There was significant higher prevalence of both comma and corkscrew hair in endothrix infection and T. violaceum-infected cases. On the other hand, there was significant higher prevalence of zigzag, barcode hairs, and white sheaths in ectothrix infection and M. canis-infected cases.

CONCLUSION

While some trichoscopic findings are nonspecific, others were found to be more specific. Finding zigzag hairs and barcode hairs points to ectothrix infection (M. canis), and it is recommended to start treatment with griseofulvin. On the other hand, finding comma hairs and corkscrew hairs without zigzag hairs and barcode hairs points to endothrix infection (T. violaceum), and it is recommended to start treatment with terbinafine in the usual dose.

Pemphigus scalp lesions: is trichoscopy helpful in clinical diagnosis?

BACKGROUND

Pemphigus is an autoimmune intraepidermal bullous disease which can affect skin and∕or mucous membranes. Trichoscopy is a non-invasive tool that can help in the clinical diagnosis especially if the patient is presented with only scalp lesions. We conducted this study to investigate the trichoscopic features of pemphigus scalp lesions.

METHODS

A total of 100 patients with confirmed diagnosis of pemphigus entered the study; Seventy-nine patients were diagnosed as pemphigus vulgaris (PV) and 21 as pemphigus foliaceus (PF). Trichoscopy of the scalp lesions was performed, and three dermatologists examined separately the trichoscopic images of each patient. The results were re-checked simultaneously by the examiners. Association between variables was analyzed by using different tests including: chi-square test or Fischer's exact test, independent T-Test or Mann-Whitney nonparametric test and logistic regression model when applicable.

RESULTS

Mean age of the patients was 45.41 ± 11.13 years, and 58% of cases were male. The most common trichoscopic features observed among all cases were diffuse scaling (71/100), presence of any types of vessels (67/100), and extravasation (63/100). Positive anagen pull test, extravasation, yellow hemorrhagic crust, and polymorphic vessels were more commonly seen in PV than PF cases (P value < 0.05), and by having data of these variables, we can differentiate between PV and PF scalp lesions with 74% sensitivity and 91% specificity.

CONCLUSION

Trichoscopy can help in clinical diagnosis of pemphigus scalp lesions but should be followed by other modalities such as biopsy and direct immunofluorescence for definite diagnosis.

Trichoscopic Patterns of Nonscarring Alopecia's

BACKGROUND

Hair loss (alopecia) is a common problem and is a major cause of psychological stress and anxiety among affected individuals. It is of utmost importance to diagnose these cases at the earliest and treat them accordingly. Trichoscopy provides a noninvasive option that can be used for early diagnosis and monitoring the progression of the hair disorders.

AIMS AND OBJECTIVES

To perform trichoscopy and document the findings in patients with nonscarring alopecia's.

MATERIALS AND METHODS

A total of 100 cases satisfying the inclusion criteria were screened for general physical examination and scalp examination including hair shaft and root, and tests for hair anchorage and fragility were also done. The lesions were examined through dermoscope, photographs were taken, and findings were documented.

RESULTS

Among the total of 100 cases screened, 57 were female and 43 were male. The mean age of the study group was 26 ± 14.8 years. Females were affected by alopecia areata (AA) and female pattern hair loss (29.8%) equally, whereas males were most commonly affected by AA (41.8%). The common trichoscopic follicular features noted were broken hair (48%), black dots (48%), single hair follicle unit (45%), short vellus hair (44%), upright hair (41%), and yellow dots (40%). The common interfollicular features seen were honeycomb pigmentation (26%) and arborizing red lines (12%).

CONCLUSION

The emergence of newer hair signs on trichoscopic studies aids in identification and has a definitive role in the diagnosis of clinically difficult cases, so it is recommended to use trichoscopy in the routine examination of nonscarring alopecia's.

Clinico-Dermoscopic Pattern of Beard Alopecia Areata: A Cross-Sectional Study

Background:

Alopecia areata (AA) is an autoimmune condition affecting hair-bearing regions of the body. Few studies worldwide have focused exclusively on beard alopecia areata (BAA).

Aims:

To describe the clinical associations, comorbidities, and dermoscopy of BAA.

Materials and Methods:

Forty-six patients with BAA were recruited for this hospital-based cross-sectional study. Patients with disease onset of less than 1 month, patches showing extension, and appearance of new patches within the past 1 month were grouped under active disease. Dermoscopy was performed using handheld polarized dermoscope. Chi-square test was applied to know the various associations. P value <0.05 was considered statistically significant. STATA 11.2 was used for analysis of data.

Results:

The mean age was 31.07 ± 8.72 years. The majority (50%) belonged to 20–29 age group. Twenty-two (48%) patients had active disease. Fourteen (30.43%) patients had extra-beard manifestation of AA. Statistically significant association was noted between active disease and extra-beard manifestation (P = 0.034). Diabetes mellitus and hypertension were noted in one and three patients, respectively. Alcohol abuse was noted in six patients and smoking in five patients. Dermoscopic findings such as black dots, short vellus hair, tapering hair, nonfollicular white dots, regrowing hair, yellow dots, and black dots were similar to findings noted in AA. Uncommon findings such as peripilar sign, i-hair, perifollicular hemorrhage, and tulip hair were observed in BAA.

Limitations:

Small sample size, lack of follow-up.

Conclusion:

Trichoscopy of BAA may reveal newer nonfollicular findings, in addition to the follicular findings already described in literature for AA.

A survey on the pattern of dermoscopy use among dermatologists in India

INTRODUCTION AND BACKGROUND

Dermoscopy is being increasingly used for improving dermatological diagnosis. Use of dermoscopy in the early recognition of skin malignancies, especially melanoma, is well established. Of late, its use in general clinical dermatology is growing with the recognition of new and specific patterns in conditions such as hair disorders, inflammatory disorders, and infections/infestations. This cross-sectional survey aims to assess the common patterns of dermoscopy use by Indian dermatologists.

METHODS

This was across-sectional survey. An online questionnaire was used to collect data. The questionnaire focused on the frequency of dermoscopy use by Indian dermatologists, reasons for using it or not, and the training they had received on dermoscopy.

RESULTS

Of the total 150 valid responses, eighty two (54.7%) participants reported that they were using dermoscopy routinely in their clinical practice. Lack of familiarity and lack of proper training were the important reasons cited for not using dermoscopy regularly. Among the dermatologists using dermoscopy, consensus on effectiveness was highest for hair disorders.

CONCLUSIONS

Dermoscopy use by dermatologists in India is mainly in the context of inflammatory dermatosis and hair disorders rather than skin tumors. Lack of familiarity with the technique appears to be main factor limiting the use of dermoscopy in India.

LIMITATIONS

Small sample size is the major limitation of this study. It is possible that a large number of dermatologists who do not use dermoscopy might not have responded to the survey, there by affecting the results and their interpretation.

The diagnostic value of trichoscopy in systemic sclerosis

BACKGROUND/OBJECTIVES

Systemic sclerosis is a connective tissue disease, which is characterized by fibrosis of the skin and internal organs, presence of specific antibodies and vascular involvement. Capillaroscopy is a useful method for the diagnosis and follow-up of patients with systemic sclerosis. Trichoscopy is a rapid, non-invasive technique, which has become a standard procedure in differential diagnosis of scalp and hair diseases. The aim of this study was to assess whether trichoscopy may be applied in imaging microvessels in patients with systemic sclerosis.

METHODS

The study included 17 patients with systemic sclerosis, and 31 healthy patients. In every patient 10 trichoscopy images were taken with Fotofinder II.

RESULTS

In patients with systemic sclerosis trichoscopy of the frontal scalp area revealed polymorphic microvessels in 64,7% of patients, spider vessels (76,4%), capillary loops (52,9%), arborising vessels (41,1%) and avascular areas (35,2%). In healthy individuals these features were observed in polymorphic microvessels 6,4% of patients, spider vessels 6,4%, capillary loops 100%, arborising vessels 16,1%, avascular areas 9,6%, respectively.

CONCLUSIONS

In conclusion, the presence of polymorphic vessels in frontal area in trichoscopy is characteristic for systemic sclerosis.

Validity of trichoscopy in the diagnosis of primary cicatricial alopecias

BACKGROUND

There are limited data on the validity of dermatoscopy in primary cicatricial alopecias (PCAs) and its subtypes, including lichen planopilaris and discoid lupus erythematosus. Trichoscopic features of PCAs, their prevalence, and validity were evaluated in this study.

METHODS

One hundred patients with PCA underwent dermatoscopy. Biopsy specimens were obtained after the site was marked with a dermatoscope. The control group comprised 100 patients with non-cicatricial alopecia and 100 normal individuals. Finally, the prevalence, sensitivity, and specificity of trichoscopic features were evaluated using SPSS and Stata software.

RESULTS

The absence of follicular opening, perifollicular scale, and presence of one scarring pattern or white patch were sensitive and specific patterns in the trichoscopy of PCAs. The presence of tortuous branching vessels and follicular keratotic plugging was 100% specific for a diagnosis of discoid lupus erythematosus.

CONCLUSIONS

Some trichoscopic features can help a dermatologist to differentiate between non-cicatricial alopecia and PCA. Moreover, a group of dermatoscopic features can be helpful in the diagnosis of PCA subtypes.

Clinical, Trichoscopic, and Histopathological Features of Primary Cicatricial Alopecias: A Retrospective Observational Study at a Tertiary Care Centre of North East India

BACKGROUND

The primary cicatricial alopecias (PCAs) are a rare group of diseases where hair follicle is the primary target of destruction. There are a few studies on histopathological and trichoscopic features of PCA.

AIMS

To study the clinical, trichoscopic, and histopathological characteristics of PCAs of the scalp and to find out the concordance between trichoscopic and histopathological diagnosis.

MATERIALS AND METHODS

We retrospectively analyzed the clinical, trichoscopic, and histopathological features of 24 PCA patients. Fisher's Chi-square exact test was done to find the significant trichoscopic and histopathological features. Cohen's kappa coefficient was used to determine the agreement between histopathological and trichoscopic diagnosis.

RESULTS

A total of 24 patients of PCA were seen with a male: female ratio of 2:1. There were 10 (41.7%) patients of discoid lupus erythematosus (DLE), 5 (20.8%) of lichen planopilaris (LPP), 3 (12.5%) of dissecting cellulitis of scalp, and 2 (8.3%) each of pseudopelade of brocq, folliculitis decalvans, and frontal fibrosing alopecia. The important histopathological findings of DLE were follicular plugging, vacuolar changes in the basal layer, necrotic keratinocytes, and superficial and deep perifollicular and perivascular lymphocytic infiltrate. Histopathology of LPP showed vacuolar changes in the basal layer and lichenoid infiltrate involving the infundibulum and isthmus. Trichoscopy of DLE showed follicular plugging, yellow dots, and thick arborizing blood vessels. The peripilar cast was important finding in LPP. The characteristic yellow dot with three-dimensional structure was noted in dissecting cellulitis of the scalp. The Cohen's kappa agreement was 0.89 between histopathological and trichoscopic diagnosis.

CONCLUSION

The diagnosis of PCA is challenging because of overlapping features clinically and histopathologically. Trichoscopy may provide quick and reliable diagnosis and obviate the necessity of scalp biopsy in busy clinics.

Trichoscopic Findings of Hair Loss in Koreans

Background

Trichoscopic findings of hair loss have been well described for the differential diagnosis of alopecia; however, critical findings were not thoroughly investigated or compared among all ethnic groups, including Asians.

Objective

We aimed to find any characteristic trichoscopic findings in Korean alopecia patients and to verify whether those findings are closely related to previously reported observations.

Methods

Three hundred and twenty-seven patients with hair loss of various causes and 160 normal scalps were analyzed. Trichoscopic examination was performed with a polarized-light handheld dermoscope.

Results

A total of 35 patterns of trichoscopic features were represented, and certain features were significantly common or observed exclusively in a particular type of alopecia as follows: yellow dots, exclamation mark hairs, and proximal tapering hairs (alopecia areata), trichoptilosis and pointed hairs (trichotillomania), corkscrew hairs, septate hyphae hairs, and comma hairs (tinea capitis), diffuse white area, fibrotic white dots, and tufting hairs (primary cicatricial alopecia), hair diameter diversity and peripilar sign (androgenetic alopecia), and short nonvellus hairs (telogen effluvium).

Conclusion

The characteristic trichoscopic features for the differential diagnosis of alopecia in Koreans, shown as follicular, perifollicular, and hair shaft patterns, are similar to those of Caucasians; however, the frequencies of the pigment patterns are different between Koreans and Caucasians because of the contrast effect of the skin and hair color. Therefore, racial difference should be considered in the trichoscopic evaluation for differential diagnosis.

Evaluation and diagnosis of the hair loss patient: part II. Trichoscopic and laboratory evaluations

The use of trichoscopy for evaluating a number of hair and scalp disorders is gaining popularity. It is a simple and noninvasive in vivo tool for visualizing hair shafts and the scalp. Recently, alopecias have been classified according to their trichoscopic findings. The second part of this 2-part continuing medical education article reviews recent advances in this field and describes a systematic approach for using the differential diagnostic findings of trichoscopy in alopecia.

Extensive pili multigemini over the back

Pili multigemini is a rare disorder where more than one hair exists in a single hair follicle. Papillar tips that divide into several tips will produce several hair shafts, so that characteristically do not fuse again. This disorder is relatively frequent on the beard of adult men and on the scalp of children. However, extensive areas of pili multigemini in other locations have rarely been described.

A case of trichotillomania with recently defined trichoscopic findings

Trichotillomania (TTM) is an impulse control disorder characterized by repetitive behavior of hair pulling resulting in secondary alopecia. It is among the psychocutaneous diseases known to be associated with psychiatric comorbidity, social, and functional impairment. Although most of the time, an experienced dermatologist easily recognizes the key features of TTM, a history and physical examination alone might not be enough to make a definitive diagnosis. As an effective noninvasive technique for the evaluation of scalp and hair diseases, trichoscopy also has proven to be a valuable tool in the diagnosis of TTM. Currently, new trichoscopic findings of TTM have been described. Here, we report a case of TTM with recently defined trichoscopic features.

Scalp dermatoscopic findings in androgenetic alopecia and their relations with disease severity

Background

Clinicians are searching for new methods to diagnose and predict the course of androgenetic alopecia noninvasively.

Objective

Our aim is to evaluate trichoscopic findings and their relations with disease severity in androgenetic alopecia.

Methods

The videodermatoscopic findings of 143 female and 63 male patients with androgenetic alopecia were compared with each other, with those of healthy subjects (n=100), and with those of patients with other nonscarring alopecias (n=208). Mann-Whitney U-test, χ² analyses, and logistic regression analysis were used for statistical analysis.

Results

No statistically significant relation was found between trichoscopic findings and severity in male androgenetic alopecia (MAGA) on the basis of the modified Hamilton Norwood scale (among 7 degrees); however, multihair follicular unit and perifollicular pigmentation were related to low severity whereas white dots, honeycomb pattern pigmentation, and brown dots were related to high severity. On the other hand, according to the Ludwig classification, arborizing red lines were related to low severity and brown dots were related to high severity, whereas there was no difference in stages between the Ebling and Olsen classifications in female androgenetic alopecia (FAGA). In the characteristic trichoscopic findings in this study, perifollicular pigmentation was found as a normal feature of the scalp, whereas multihair follicular unit and honeycomb pigment pattern, which were previously considered as normal features, were observed to be related to androgenetic alopecia.

Conclusion

No relation was found between MAGA severity and trichoscopic findings, as well as between FAGA severity according to different disease severity classifications and trichoscopic findings.

Vellus hairs in the frontal scalp in early female pattern hair loss

Background:

Dermoscopy of the scalp (trichoscopy) is a technique to evaluate the skin of the scalp and the hair disorders. It clinically helps to establish early female pattern hair loss (FPHL) without the need for more invasive techniques.

Objectives:

This work intends to demonstrate new adjunct criteria for the clinical diagnosis of FPHL by determining the number of short vellus hairs encountered in the frontal area of the scalp of female patients with FPHL.

Materials and Methods:

We retrospectively reviewed the trichoscopy images from 45 women affected by FPHL in initial stages, at 20 fold magnification dermoscopy at 2 cm from the hairline into the frontal area of the scalp.

Results:

A total of 45 patients images included had more than 20% variability at dermoscopy, criteria utilized to diagnose and included them in the study. All patients were graded as Ludwig I severity, 14 patients had frontal accentuation. The average number of vellus hairs in the frontal area at 20-fold magnification of all patients was of 12.02 vellus hair in the frontal area. When comparing the Ludwid I pattern group versus the Ludwig I with frontal accentuation pattern group there was no statistical difference between the two clinical groups.

Conclusions:

All 45 patients analyzed in this study were clinically diagnosed with FPHL. The number of vellus hairs in the frontal area was greater than the average found in normal subjects. Most patients (80%) with FPHL had more than or equal to seven vellus hairs per 20-fold magnification field in the frontal area, therefore we suggest that the presence of more than 6 vellus hairs in the frontal scalp at 20-fold magnification can be used as an additional criterion of FPHL.

Clinical and dermatoscopic patterns of alopecia areata: a tertiary care centre experience

BACKGROUND

Dermatoscopy is a new noninvasive tool for the diagnosis of various skin and hair disorders. Dermatoscopy of alopecia areata (AA) shows various specific features, which may aid in confirming the diagnosis.

AIMS

The aim of this study was to determine the various clinical patterns and the dermatoscopic features of AA.

MATERIALS AND METHODS

A total of 75 patients of AA were evaluated with a dermatoscope (magnification ×25 and ×60).

RESULTS

The mean age of onset of AA was 23.58 years. Males were more commonly affected. Scalp was most commonly involved. Patchy alopecia was the most common pattern observed. 10 patients showed concomitant nail changes. The dermatoscopic features included yellow dots (YDs) in 43 (57.33%) patients, black dots (BDs) in 63 (84%) cases, broken hairs (BHs) in 28 (37.33%) cases, short vellus hair (SVH) in 51 (68%) patients and tapering hair (TH) in 14 (18.67%) cases.

CONCLUSION

The most common dermatoscopic finding observed was BDs, followed by SVHs, YDs, BH and TH.

Trichoscopic findings in alopecia areata and their relation to disease activity, severity and clinical subtype in Turkish patients

BACKGROUND/OBJECTIVE

Trichoscopic studies of alopecia areata are helpful in the non-invasive diagnosis and prediction of the course of the disease. The objective was to determine the relationship of trichoscopic findings in alopecia areata with disease activity, severity and clinical subtype in Turkish patients.

METHODS

Trichoscopic examinations of 39 patients with alopecia areata were compared with 309 alopecia patients including psoriasis (n = 31), seborrhoeic dermatitis (n = 112), female androgenetic alopecia (n = 138), male androgenetic alopecia (n = 63), female androgenetic alopecia of male pattern (n = 5), telogen effluvium (n = 22) and trichotillomania (n = 4). A χ(2) test and logistic regression analysis were used for the statistical analysis. The odds ratios were calculated by cross tabulation.

RESULTS

There was no relationship between the alopecia areata subtype and trichoscopic findings. On the other hand, a honeycomb hyperpigmentation pattern, cumulus-like clustered white dots, white dots and black dotted pigmentation related to severe disease, while exclamation mark hairs related to mild disease. Exclamation mark hairs were found to be related to active disease while atypical red vessels and white dots were negatively related to disease activity.

CONCLUSION

In our study, further characteristic trichoscopic findings were detected in alopecia areata such as clustered white dots, multi-hair follicular unit, hidden hairs and black dotted pigmentation, in addition to previous findings. Hence, it is concluded that the identification and prediction of alopecia areata might be straightforward with the help of these new signs such as activation and severity findings.