Dermatoscopy of hair shaft disorders

Giant Morpheaform Basal Cell Carcinoma Mimicking Scarring Alopecia: Exception Prone to Neglect

A 74-year-old woman in good general health presented with a 5-year history of progressive hair loss over several years, interpreted as female androgenetic alopecia (AGA), and was treated with topical 5% Minoxidil without improvement. The patient's relevant medical history revealed infiltrating, triple-negative apocrine carcinoma of the right breast four years before, treated by quadrantectomy, radiation, lymphadenectomy and chemotherapy, with no recurrence at the last follow-up. On examination, there was an asymptomatic 15 × 15 cm firm and whitish area of scarring alopecia on the central scalp. Dermoscopy revealed multiple arborizing vessels and many telangiectasia. The clinical considerations included mainly cutaneous metastasis of breast carcinoma (alopecia neoplastica), pseudopelade of Broque and morpheaform basal cell carcinoma (BCC). A histopathologic examination revealed characteristic changes of morpheaform BCC with basaloid islands and cords of atypical basaloid cells diffusely infiltrating the dermis, embedded in a sclerotic and hypervascularized stroma. Secondary alopecia neoplastica due to morpheaform BCC on the scalp is an exceedingly rare entity, possessing subtle clinical features that may mimic both scarring and non-scarring alopecia. Delayed recognition may contribute to aggressive behavior and extensive local destruction. Treatment with hedgehog inhibitors in locally advanced BCC of the scalp, both in adjuvant and neoadjuvant modalities, is promising.

Hair and Nail-On-Chip for Bioinspired Microfluidic Device Fabrication and Biomarker Detection

The advent of biosensors has tremendously increased our potential of identifying and solving important problems in various domains, ranging from food safety and environmental analysis, to healthcare and medicine. However, one of the most prominent drawbacks of these technologies, especially in the biomedical field, is to employ conventional samples, such as blood, urine, tissue extracts and other body fluids for analysis, which suffer from the drawbacks of invasiveness, discomfort, and high costs encountered in transportation and storage, thereby hindering these products to be applied for point-of-care testing that has garnered substantial attention in recent years. Therefore, through this review, we emphasize for the first time, the applications of switching over to noninvasive sampling techniques involving hair and nails that not only circumvent most of the aforementioned limitations, but also serve as interesting alternatives in understanding the human physiology involving minimal costs, equipment and human interference when combined with rapidly advancing technologies, such as microfluidics and organ-on-a-chip to achieve miniaturization on an unprecedented scale. The coalescence between these two fields has not only led to the fabrication of novel microdevices involving hair and nails, but also function as robust biosensors for the detection of biomarkers, chemicals, metabolites and nucleic acids through noninvasive sampling. Finally, we have also elucidated a plethora of futuristic innovations that could be incorporated in such devices, such as expanding their applications in nail and hair-based drug delivery, their potential in serving as next-generation wearable sensors and integrating these devices with machine-learning for enhanced automation and decentralization.

Trichoscopy beyond scalp. A narrative review

Dermoscopy is becoming an indispensable tool in everyday practice, with an expanding range of applications. Trichoscopy is effective not only in establishing the diagnosis of scalp disorders but also in the follow-up of treatment. The MEDLINE database was searched using the terms "dermoscopy" and "trichoscopy" in combination with each of the following: "axilla," "pubic area," "beard," "eyebrows," "eyelashes," and "body hairs." We included case reports, case series, and review articles mentioning the previous terms. By providing an updated review from the literature, we aimed to emphasize the potential uses of trichoscopy in detecting diseases in hairy locations other than the scalp. Various inflammatory conditions, infections, and infestations are discussed.

Eyebrow and Eyelash Alopecia: A Clinical Review

Madarosis is characterized by either complete or partial loss of eyebrow or eyelash hair. Etiologies for madarosis are varied, and accurate diagnosis is the first step in clinical management. Many studies have described findings related to specific causes of madarosis, but few have summarized the collective literature. The purpose of this review is to provide an updated overview on the symptomatology, diagnosis, trichoscopy findings, and treatment of eyebrow and eyelash alopecia.

Advances in nanotechnology-based hair care products applied to hair shaft and hair scalp disorders

OBJECTIVE

Nanotechnology has been intensively applied to the development of novel cosmetic products for hair and scalp care during the last decades. Such a trend is corroborated by the fact that about 19% of the total nanocosmetics registered in the StatNano database are intended for hair and scalp care. Nanotechnology-enabled formulations based on nanoparticles, cyclodextrins, liposomes and nanoemulsions have emerged as novel approaches due to chemical stability and their controlled release. Regarding hair care formulations, nanocarriers can target the hair shaft, hair follicle and scalp. Therefore, they have been used to treat several hair disorders, including dandruff and other hair-damaging conditions.

METHODS

This review addressed the most important nanocarriers applied to hair-related disorders improvement. Furthermore, the application for hair photoprotection and improvement of hair colour duration by nanotechnological formulations is also approached. Besides, we provided an overview of the current scenario of available nano-based commercial hair products and novel patented inventions.

RESULTS

From the patent search, the Patent Cooperation Treaty was pointed as the most important depositing agency while the United States of America has been the most depositing country. On the contrary, according to the StatNano database, Brazil stands out in the hair care worldwide market, and it is also the main producer of hair cosmetics based on nanotechnology.

CONCLUSION

As nano-based products offer several advantages over conventional cosmetics, it is expected that in future, there will be more research on nanocarriers applied to hair disorders, as well as commercial products and patent applications.

Pili Torti: A Feature of Numerous Congenital and Acquired Conditions

Pili torti is a rare condition characterized by the presence of the hair shaft, which is flattened at irregular intervals and twisted 180° along its long axis. It is a form of hair shaft disorder with increased fragility. The condition is classified into inherited and acquired. Inherited forms may be either isolated or associated with numerous genetic diseases or syndromes (e.g., Menkes disease, Björnstad syndrome, Netherton syndrome, and Bazex-Dupré-Christol syndrome). Moreover, pili torti may be a feature of various ectodermal dysplasias (such as Rapp-Hodgkin syndrome and Ankyloblepharon-ectodermal defects-cleft lip/palate syndrome). Acquired pili torti was described in numerous forms of alopecia (e.g., lichen planopilaris, discoid lupus erythematosus, dissecting cellulitis, folliculitis decalvans, alopecia areata) as well as neoplastic and systemic diseases (such as cutaneous T-cell lymphoma, scalp metastasis of breast cancer, anorexia nervosa, malnutrition, cataracts, and chronic graft-vs.-host disease). The condition may also be induced by several drugs (epidermal growth factor receptor inhibitors, oral retinoids, sodium valproate, and carbamide perhydrate). The diagnosis of pili torti is based on trichoscopic or microscopic examination. As pili torti is a marker of numerous congenital and acquired disorders, in every case, the search for the signs of underlying conditions is recommended.

Recent developments in dermoscopy for dermatology

BACKGROUND

Dermoscopy is considered to be a bridge between clinical observation and histopathological examination, allowing the in vivo examination of skin microstructures that are not visible to the naked eye, from the epidermis to the superficial dermis. Dermoscopy has undergone rapid development, witnessing the history from natural light to polarized light, from handheld dermoscopy to videodermoscopy, and from classic dermoscopy to digital dermoscopy. Its application extends from the initial differential diagnosis of pigmented skin diseases (melanocytic and nonmelanocytic) to general dermatology, including appendage (nail and hair) abnormalities and diseases related to infection and inflammation.

AIMS

We aimed to provide the latest developments in dermoscopy from the perspective of handheld dermoscopy, videodermoscopy, fluorescence-advanced videodermatoscopy, polarized transilluminating dermoscopy, and digital dermoscopy.

METHODS

In this review, we searched the PubMed, Embase, Web of Science, and Cochrane Library databases for reviews, case reports, and observational studies on dermoscopy.

RESULTS

We provided an updated review of dermoscopy based on published literature.

CONCLUSION

Dermoscopy is an indispensable diagnostic tool in dermatology, and it is expected to be further developed in the future.

Lichen Simplex Chronicus on the Scalp: Broom Fibers on Dermoscopy; Gear Wheel Sign and Hamburger Sign on Histopathology

Lichen simplex chronicus (LSC) is characterized by lichenification of the skin because of primary excessive scratching. Herein, we present two cases of scalp LSC with a patch showing localized hair loss and paroxysmal severely itching on that area. Dermoscopy examined the presence of broom hair fibers while histopathological examination revealed gear wheel sign, hair shafts split in two (the hamburger sign), and decrease in the size of the sebaceous glands.

Hair abnormality in Netherton syndrome observed under polarized light microscopy

BACKGROUND

Trichorrhexis invaginata, the main diagnostic feature of Netherton syndrome, is often difficult to detect, especially in adult patients.

OBJECTIVE

We sought to describe a characteristic feature of hairs in Netherton syndrome using a polarized light microscope and the underlying histopathologic changes.

METHODS

Hairs obtained from 8 patients with Netherton syndrome were observed under polarized light, and we evaluated the correlation between number of band-like patterns and disease severity.

RESULTS

Under polarized microscopy, the hair shafts of 8 patients showed a characteristic band-like pattern under polarized light that was not observed in healthy control individuals or patients with atopic dermatitis. This discontinuity of polarized light shows a band-like pattern in which the bands mostly ranged from 0.1 to 1.0 mm in width. The observed ratio of this finding was significantly higher than that of trichorrhexis invaginata observed under light microscopy, and patients with severe dermatitis tended to have a higher ratio than those with less severe dermatitis.

LIMITATIONS

Comparative examination among other congenital ichthyoses was not performed.

CONCLUSIONS

A band-like pattern in hairs with polarized light microscopy can be seen in Netherton syndrome and may have potential utility as a diagnostic marker.

Trichoscopy in the Differential Diagnosis of Pseudonits

AIM

The purpose of the study was to describe the trichoscopic features of pseudonits and to assess the usefulness of trichoscopy in their differential diagnosis.

METHODS

A retrospective study was performed on those patients seen for the suspicion of head or pubic lice and who underwent trichoscopy with polarized light at ×10 magnification for a more accurate diagnosis. Forty-two patients (28 males/14 females, mean age: 34.5 years, range: 7-59) were evaluated.

RESULTS

In 30 cases, trichoscopy confirmed the suspicion of head (24 cases) or pubic (6 cases) lice, whereas in 12 cases it allowed for a final diagnosis of seborrheic dermatitis (5 cases), hair casts (3 cases), trichobacteriosis (2 cases), white piedra (1 case), and trichorrhexis nodosa (1 case), by showing different types of pseudonits.

CONCLUSION

Hair examination using trichoscopy in routine clinical practice may provide useful information for the correct diagnosis, ranging from common head and pubic lice infestations to rarer shaft abnormalities. Differentiating pseudonits from nits is essential to make the correct diagnosis in order to prevent unnecessary treatment, anxiety, and/or embarrassment.

Dermatoscopy of Parasitic and Infectious Disorders

The use of dermatoscopy in the diagnosis and management of parasitic and infectious skin disorders has been defined as entodermoscopy, and several studies have confirmed its advantages in dermatology. Dermatoscopic patterns of several parasitic, viral, and fungal skin infections have been identified and herein described. A noninvasive, fast, and accurate diagnosis plays an important role in containing the spread of contagious skin disorders.

Trichoscopy of Dark Scalp

Trichoscopy (dermoscopy of the hair and scalp) is a technique that improves diagnostic accuracy and follow-up with hair and scalp disorders. Although several studies of trichoscopy have been made in Caucasian and Asian populations, little has been published regarding trichoscopy findings in skin of color, despite the great prevalence of hair diseases in populations with this kind of skin. The aim of this review was to describe the trichoscopic features of normal scalp and of hair disorders in patients with dark skin phototypes. This will help dermatologists to distinguish between unique trichoscopic features of dark skin, and allow them to provide more accurate diagnoses and treatments for these patients.

Alternative uses of dermoscopy in daily clinical practice: An update

Dermoscopy is a noninvasive diagnostic tool that is currently being used for neoplastic skin lesions, several inflammatory and infectious diseases, and skin appendage disorders. As the clinical applications of dermoscopy beyond pigmented lesions are constantly increasing, the aim of this article is to provide an update on this topic. This comprehensive review substantiates how several diseases may show peculiar dermoscopy features so as to enhance the diagnosis and avoid (in selected cases) unnecessary histologic confirmation. In other cases, dermoscopy features may be shared with other conditions, with the advantage of narrowing down the differential diagnosis by ruling out those dermatoses with similar clinical aspect but different dermoscopic presentation.

Hair disorders in patients with cancer

Cytotoxic chemotherapies, molecularly targeted therapies, immunotherapies, radiotherapy, stem cell transplants, and endocrine therapies may lead to hair disorders, including alopecia, hirsutism, hypertrichosis, and pigmentary and textural hair changes. The mechanisms underlying these changes are varied and remain incompletely understood, hampering the development of preventive or therapeutic guidelines. The psychosocial impact of chemotherapy-induced alopecia has been well documented primarily in the oncology literature; however, the effect of other alterations, such as radiation-induced alopecia, hirsutism, and changes in hair color or texture on quality of life have not been described. This article reviews clinically significant therapy-related hair disorders in oncology patients, including the underlying pathophysiological mechanisms, severity grading scales, patient-reported quality of life questionnaires, management strategies, and future translational research opportunities.

Lichen simplex chronicus on the scalp: exuberant clinical, dermoscopic, and histopathological findings

Lichen simplex chronicus is a skin disease that mostly affects female patients, with a peak incidence between ages 35 and 50 years. On the scalp, it appears as a single or multiple oval lesions, showing scaling and hair shaft loss or breakage. An important dermoscopic feature of the disease are the "broom fibers." Histopathology reveals the "hamburger" and the "gear wheel" signs. The aim of this report is to demonstrate a case of lichen simplex chronicus on the scalp with typical and exuberant clinical, dermoscopic, and histopathological findings.

Polarized transilluminating dermoscopy: Bedside trichoscopic diagnosis of trichothiodystrophy

Trichothiodystrophy is a rare autosomal recessive disorder resulting in a broad range of systemic abnormalities. Polarizing microscopy of the hair reveals the pathognomic "tiger tail" of alternating light and dark bands, but the need for a microscope prevents rapid bedside diagnosis. We describe a new technique for the bedside diagnosis of trichothiodystrophy using a handheld polarizing dermatoscope, precluding the need for microscopic examination.

Blowing Bubbles: Dermoscopy of Bubble Hair

Exposing wet hair to high temperatures can create gas bubbles within the hair shaft, leading to brittle, dry hairs in a disorder known as bubble hair abnormality. We present a case of a 61-year-old woman who presented for hair breakage over her crown. She regularly dried her damp hair with a blow dryer. Dermoscopy revealed multiple bubbles within the hair shaft, and diagnosis of bubble hair abnormality was confirmed by light microscopy. Our unusual case highlights the ease of acquisition of this abnormality by means of a common hair dryer, and the utility of dermoscopy to make a fast and accurate diagnosis within the office.

A Practical Approach to the Diagnosis and Management of Hair Loss in Children and Adolescents

Hair loss or alopecia is a common and distressing clinical complaint in the primary care setting and can arise from heterogeneous etiologies. In the pediatric population, hair loss often presents with patterns that are different from that of their adult counterparts. Given the psychosocial complications that may arise from pediatric alopecia, prompt diagnosis and management is particularly important. Common causes of alopecia in children and adolescents include alopecia areata, tinea capitis, androgenetic alopecia, traction alopecia, trichotillomania, hair cycle disturbances, and congenital alopecia conditions. Diagnostic tools for hair loss in children include a detailed history, physical examination with a focused evaluation of the child’s hair and scalp, fungal screens, hair pull and tug test, and if possible, light microscopy and/or trichoscopy. Management of alopecia requires a holistic approach including psychosocial support because treatments are only available for some hair loss conditions, and even the available treatments are not always effective. This review outlines the clinical presentations, presents a diagnostic algorithm, and discusses management of these various hair loss disorders.

Scanning Electron Microscopy Study of Hair Shaft Damage Secondary to Cosmetic Treatments of the Hair

Introduction and Background:

Cosmetic procedures for hair, such as bleaching, dyeing, and straightening, are commonly used around the world. It has been suggested that excessive use of such procedures can cause damage to the hair shaft. We aimed to assess hair shaft changes using scanning electron microscopy (SEM) in female volunteers who frequently use hair treatment procedures such as bleaching, dyeing, or straightening.

Methods:

A cross-sectional, controlled study in a sample of 25 female volunteers (19 study group and 6 controls) in the age group of 18–45 years. The study group was composed of volunteers who regularly used different cosmetic hair treatment procedures such as bleaching, dyeing, and straightening (any one of these or a combination). The control group had never used any specific hair treatment procedure. The hair shaft damage as seen on SEM was assessed using a standardized scoring system and compared among the two groups statistically. The hair shafts were also examined clinically and with light microscopy.

Results:

No significant differences were seen between the test and control groups with regard to normal clinical examination and light microscopy findings. A higher degree of hair shaft damage was evident under SEM in the study group as compared to the control group. This difference was statistically significant.

Conclusions:

Regular use of procedures such as bleaching, dyeing, or straightening can lead to subtle changes in the hair shaft which can be detected early by SEM.

Prognosis and Management of Congenital Hair Shaft Disorders with Fragility-Part I

Hair shaft disorders are characterized by congenital or acquired abnormalities of the hair shaft. The objective was to review the literature regarding the prognosis and treatment options of hair shaft disorders. We used keywords in the search engines PubMed and Medline to identify all publications in the English language related to the prognosis and management of hair shaft disorders. Data were extracted from 96 articles that met search criteria. Findings were limited to case reports and small case series, as no studies were found. Disorders that improve in childhood include pili torti, trichorrhexis invaginata, wooly hair, and pili trianguli et canaliculi. Others, such as trichorrhexis nodosa, monilethrix, pili annulati, and pili bifurcati improve with minoxidil. Oral retinoids have improved hair abnormalities in trichorrhexis invaginata and monilethrix. There is no specific treatment for congenital hair shaft abnormalities. Gentle hair care is the mainstay of care for hair shaft disorders associated with fragility. Practices for gentle care include no brushing, backcombing, chemical products, tight braids, heat exposure, or mechanical grooming. Any inherited or congenital disorder requires genetic counseling as part of management.

Hair Breakage in Patients of African Descent: Role of Dermoscopy

Dermoscopy represents a useful technique for the diagnosis and follow-up of hair and scalp disorders. To date, little has been published regarding dermoscopy findings of hair disorders in patients of African descent. This article illustrates how dermoscopy allows fast diagnosis of hair breakage due to intrinsic factors and chemical damage in African descent patients.

Trichodystrophies: A hair-raising differential diagnosis

The appearance of an individual's hair is said to be reflective of internal health. Patients with hair shaft disorders commonly present with fragile, lusterless, sparse hair in addition to psychosocial distress. Hair shaft disorders may be hereditary or acquired and may present in children or adults. Due to the varied presentations, the differential diagnosis for hair is broad and often confusing. The authors present a question-by-question guide to help clinicians arrive at the correct diagnosis.

The value of trichoscopy in the differential diagnosis of scalp lesions in pemphigus vulgaris and pemphigus foliaceus

BACKGROUND

Trichoscopy is becoming increasingly popular in diagnosing hair and scalp diseases. Scalp involvement in pemphigus is common. The scalp may be the first or only site of clinical manifestation of the disease.

OBJECTIVE

The aim of this study was to analyze whether trichoscopy may be useful in aiding differential diagnosis of scalp lesions in patients with pemphigus vulgaris and pemphigus foliaceus.

METHODS

Trichoscopy was performed in 19 patients with scalp lesions in the course of pemphigus (9 patients with pemphigus vulgaris and 10 with pemphigus foliaceus). In all patients, the diagnosis of scalp pemphigus was confirmed by histopathology. The working magnification was 20-fold and 70-fold.

RESULTS

The most frequently observed trichoscopy features of pemphigus lesions were: extravasations (18/19; 94.7%) and yellow hemorrhagic crusts (11/19; 57.9%). Yellow dots with whitish halo were observed in 6/19 (31.6%) patients with pemphigus. White polygonal structures were observed in pemphigus foliaceus (6/10; 60%), but not in pemphigus vulgaris. Vascular abnormalities were more frequent in pemphigus vulgaris, when compared to pemphigus foliaceus, and were associated with a severe course of disease. Linear serpentine vessels were the most frequent vascular abnormality in patients with pemphigus vulgaris and pemphigus foliaceus (77.8% and 30%, respectively).

CONCLUSION

Trichoscopy may serve as a useful supplementary method in the differential diagnosis of pemphigus, especially in cases of desquamative or exudative lesions limited to the scalp. Extravasations, yellow hemorrhagic crusts, yellow dots with whitish halo, white polygonal structures and linear serpentine vessels are trichoscopy features which may suggest the diagnosis of pemphigus.

Evaluation and diagnosis of the hair loss patient: part I. History and clinical examination

Hair loss (alopecia) is a common problem and is often a major source of distress for patients. The differential diagnosis of alopecia includes both scarring and nonscarring alopecias. In addition, many hair shaft disorders can produce hair shaft fragility, resulting in different patterns of alopecia. Therefore, an organized and systematic approach is needed to accurately address patients' complaints to achieve the correct diagnosis. Part 1 of this 2-part continuing medical education article on alopecia describes history taking and the clinical examination of different hair loss disorders. It also provides an algorithmic diagnostic approach based on the most recent knowledge about different types of alopecia.

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.

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.