Dermoscopy in the diagnosis of hair and scalp disorders

Trichoscopic Findings in Androgenetic Alopecia

Background:

Androgenetic alopecia (AGA) is an androgen-related condition that develops in genetically predisposed individuals. The condition is characterized by the progressive loss of terminal hairs on the scalp in a characteristic distribution. Trichoscopy represents the dermoscopy imaging of the scalp and hair. Structures which may be visualized by trichoscopy include hair shafts, hair follicle openings, perifollicular epidermis and cutaneous microvessels.

Objective:

The aim of this prospective study was to identify the trichoscopic features of androgenetic alopecia.

Methods:

Hundred-four patients with AGA and 80 healthy subjects were enrolled in this study. Data on age, gender, personal and family history, clinical type and duration of disease were collected and analyzed. Control group consisted of 80 generally healthy subjects. Trichoscopic examination was performed using either videodermatoscope or handheld dermatoskope. Trichoscopy results were obtained in frontal, occipital and both temporal areas of the scalp, including number of yellow dots and vellus hairs, number of hairs in one pilosebaceous unit and percentage of follicular ostia with perifollicular hyperpigmentation. The data were statistically evaluated.

Results:

The number of yellow dots, pilosebaceous units with only one hair and with perifollicular hyperpigmentation was significantly increased in androgenetic alopecia (p<0.05). The percentage of thin hairs (<0.03 mm) in AGA was significantly higher than in healthy controls (p<0.05).

Conclusion:

Our study has shown the significances of trichoscopy of patients with AGA. Regular clinical and trichoscopical follow-ups are very important to monitor disease activity and treatment tolerance.

Follicular Map: A Novel Approach to Quantitative Trichoscopy

Background

Trichoscopy (hair and scalp dermoscopy) is gaining importance as an easy-to-use diagnostic and monitoring tool in various hair and scalp conditions.

Objective

The demand for a method to identify exactly the same site on scalp skin for subsequent examinations is growing constantly.

Methods

In total, 40,000 trichoscopic images of 70-fold magnification were analyzed. Graphical pattern recognition was used to identify hair shafts in trichoscopy images and to derive the coordinates of all follicular orifices. Determination of the relative positions of hair follicle orifices formed the Follicular Map (FMap). Processing and matching of FMaps involves conceptually simple but computationally complex numerical algorithms.

Results

FMaps were shown to be unique for specific locations on the scalp in each human individual. The follicular patterns were not affected by natural hair cycling processes and remained unchanged over the course of time. It has been tentatively verified that FMaps remain unaffected by noncicatricial alopecia.

Conclusions

The concept of FMap presents a novel approach to qualitative trichoscopy, allowing precise evaluation of treatment efficiency, clinical trial quality control, validation of diagnostic tools, and potentially other applications still to be discovered. The FMap enables the location of hair follicles to be precisely measured and recorded.

Applicability of Trichoscopy in Scalp Seborrheic Dermatitis

Introduction:

Seborrheic dermatitis (SD) is a chronic-recidive inflammatory skin disorder with predilection in areas rich of sebaceous gland. The most common clinical manifestations are pruritus and scales. Although SD can be diagnosed without special tools, other examinations may be needed to determine additional specific therapy. Trichoscopy is one of the noninvasive tools which can help to diagnose SD as it can provide the microstructure view of the scalp.

Materials and Methods:

This descriptive study was conducted to explore the trichoscopic features of SD and its characteristics. There were 96 SD patients enrolled in this study. The scalp was divided into four areas, and each area was scored based on Seborrheic Area Severity Index, comprising erythema, desquamation, number of papules, and percentage of lesion area. The most severe area was examined with a trichoscopy to observe the characteristics of hair and scalp. The association between trichoscopic findings and SD severity was analyzed with Fisher's exact test.

Results:

Overall, the participants were 36% males and 64% females with the mean age of 30 (13–70) years old. Based on the trichoscopic examination, the most common findings were thick hair shafts (72%), white scales (69%), arborizing thin vessels (38%), yellowish area (36%), and structureless red area (19%). These findings were not significantly different between mild and moderate SD (P > 0.05).

Conclusion:

Considering the merits and demerits of trichoscopic examination, it can be helpful to aid the diagnosis of SD. Further studies in Asian population with greater sample size are needed to demonstrate more significant result.

Feature characterization of scarring and non-scarring types of alopecia by multiphoton microscopy

OBJECTIVES

Non-invasive visualization of hair follicles is important for proper diagnosis and management of alopecia; however, histological assessment remains the gold standard. Laser imaging technologies have made possible noninvasive in vivo evaluation of skin and hair follicle. The aim of this study was to evaluate the ability of multiphoton microscopy (MPM) to non-invasively identify morphological features that can distinguish scarring from non-scarring alopecia.

METHODS

MPM images were obtained from areas on the scalp affected by alopecia. Investigators blinded to the diagnosis analyzed hair follicle and shaft sizes. Patients were recruited and imaged at the UC Irvine Health Medical Center and the University of California, Irvine Beckman Laser Institute. Patients with androgenetic alopecia (AGA) and alopecia areata (AA), and scarring alopecia, in particular frontal fibrosing alopecia (FFA) were recruited and imaged from July 2016 to July 2017.

RESULTS

We imaged 5 normal scalp subjects and 12 patients affected by non-scarring (7 subjects) and scarring (5 subjects) alopecia. In normal and non-scarring alopecia patients, MPM identified presence of sebaceous glands associated with hair follicles. MPM images of scarring alopecia were characterized by the presence of inflammatory cells surrounding hair follicles. Measurements of hair follicle diameter sizes were found to be significantly smaller in scarring alopecia patients compared to normal (P < 0.001) and compared to non-scarring alopecia patients (P = 0.046); non-scarring hair follicles were also significantly smaller than normal hair follicles (P = 0.043).

CONCLUSIONS

This study shows that MPM imaging can non-invasively identify morphological features that distinguish scarring from non-scarring alopecia. Further studies are needed to validate this technique and evaluate its potential to be used as an aid for guiding treatment. Lasers Surg. Med. 51:95-103, 2019. © 2018 Wiley Periodicals, Inc.

Alopecia Areata on Vertex as a Potential Pitfall for Misdiagnosis of Central Centrifugal Cicatricial Alopecia in African-American Women

Trichoscopy is a noninvasive visualization tool used to more accurately diagnose hair and scalp disorders. Alopecia areata (AA) in the patient of African descent can mimic the early signs of central centrifugal cicatricial alopecia (CCCA), especially if the initial presentation of hair loss occurs on the central scalp. Two African-American women presented with singular round-ovoid patches of decreased hair loss on the central scalp. Given the clinical presentation, CCCA was the working diagnosis. However, using dermoscopy, the patients were found to have exclamation hairs and short broken hairs on a background of honeycomb-like pigmented network and regular pinpoint white dots consistent with AA. The diagnosis was confirmed on biopsy. We demonstrate the role of dermoscopy for diagnosing AA in the patient of African descent.

Skin Manifestations of Insulin Resistance: From a Biochemical Stance to a Clinical Diagnosis and Management

Worldwide, more than 1.9 billion adults are overweight, and around 600 million people suffer from obesity. Similarly, ~382 million individuals live with diabetes, and 40–50% of the global population is labeled at “high risk” (i.e., prediabetes). The impact of these two chronic conditions relies not only on the burden of illnesses per se (i.e., associated increased morbidity and mortality), but also on their increased cost, burden of treatment, and decreased health-related quality of life. For this review a comprehensive search in several databases including PubMed (MEDLINE), Ovid EMBASE, Web of Science, and Scopus was conducted. In both diabetes and obesity, genetic, epigenetic, and environmental factors overlap and are inclusive rather than exclusive. De facto, 70–80% of the patients with obesity and virtually every patient with type 2 diabetes have insulin resistance. Insulin resistance is a well-known pathophysiologic factor in the development of type 2 diabetes, characteristically appearing years before its diagnosis. The gold standard for insulin resistance diagnosis (the euglycemic insulin clamp) is a complex, invasive, costly, and hence unfeasible test to implement in clinical practice. Likewise, laboratory measures and derived indexes [e.g., homeostasis model assessment of insulin resistance (HOMA-IR-)] are indirect, imprecise, and not highly accurate and reproducible tests. However, skin manifestations of insulin resistance (e.g., acrochordons, acanthosis nigricans, androgenetic alopecia, acne, hirsutism) offer a reliable, straightforward, and real-time way to detect insulin resistance. The objective of this review is to aid clinicians in recognizing skin manifestations of insulin resistance. Diagnosing these skin manifestations accurately may cascade positively in the patient’s health by triggering an adequate metabolic evaluation, a timely treatment or referral with the ultimate objective of decreasing diabetes and obesity burden, and improving the health and the quality of care for these patients.

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.

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.

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 Management of the Hair Loss Patient in the Primary Care Setting

Alopecias represent a heterogeneous group of disorders with different etiologies, presentations, and treatment options. The evaluation of the hair loss patient includes a comprehensive clinical history and physical examination; appropriate laboratory testing; and if indicated, a scalp biopsy. Treatment methods vary depending on the type of alopecia, and include watchful waiting, topical and systemic formulations, surgery, and treatment of any underlying or associated conditions. Referral to a dermatologist is helpful in diagnostically challenging and difficult to treat cases. Alopecia can cause emotional, mental, and social distress to patients. Early diagnosis and timely institution of appropriate treatment are helpful and comforting to those affected by this disease.

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.

Role of trichoscopy in children's scalp and hair disorders

Hair and scalp disorders in children may originate from the hair itself, scalp skin, or infectious causes and be congenital or acquired. The most common sign is alopecia, frequently brought on by tinea capitis, patchy alopecia areata, or trichotillomania. Sometimes less frequent and clinically more elusive conditions such as initial androgenetic alopecia, congenital triangular alopecia, or alopecia areata incognita may be responsible for hair loss. The noninvasive technique known as trichoscopy is being used more frequently, aiding in the prompt differential diagnosis and follow-up of many of these diseases, oftentimes providing further examination before a treatment decision is made. This review of trichoscopy of the main scalp and hair disorders afflicting children and adolescents discusses the most important dermoscopic criteria and the usefulness of this technique.

Clinical and histological challenge in the differential diagnosis of diffuse alopecia: female androgenetic alopecia, telogen effluvium and alopecia areata--part II

Diffuse alopecia is mainly caused by telogen effluvium, diffuse androgenetic alopecia (female-pattern hair loss) and diffuse alopecia areata. Differential diagnosis between the three disorders may be difficult in several occasions. In this second part of our study, chronic telogen effluvium and diffuse alopecia areata are discussed in detail, including clinical, dermoscopic and histological aspects. A flowchart presents a practical and objective differential diagnostic approach to diffuse alopecia.

Clinical and histological challenge in the differential diagnosis of diffuse alopecia: female androgenetic alopecia, telogen effluvium and alopecia areata - part I

Diffuse androgenetic alopecia (female pattern hair loss), telogen effluvium, and diffuse alopecia areata may have similar clinical manifestations. Subtle details on physical examination and dermoscopy of the scalp may help to identify those disorders. The authors present a practical discussion on how to approach the patient with diffuse alopecia, considering clinical history, physical examination, and dermoscopic findings. If the diagnosis remains unclear after a careful analysis of the clinical signs, a scalp biopsy may help to distinguish between the three diseases. In this first part of our study, an objective review of female androgenetic alopecia is presented and the most important histological changes are discussed.

Value of trichoscopy versus trichogram for diagnosis of female androgenetic alopecia

Background:

Female androgenetic alopecia (FAGA) is a frequent cause of hair loss in women. Standard diagnostic methods are clinical inspection, pull test, and trichogram. It has been suggested that scalp dermoscopy (trichoscopy) revealing diversity of hair shaft diameter >20% is diagnostic of FAGA.

Objective:

To evaluate the value of trichoscopy as compared to the trichogram for the diagnosis of FAGA.

Patients and Methods:

Retrospective case study of 162 women with the complaint of hair loss who underwent trichoscopic examination and trichograms.

Results:

Of all women diagnosed FAGA (55%), 62% were diagnosed by trichogram, 72% by trichoscopy with a cut-off point of 20%, and 100% irrespective of the degree of diversity of hair shaft diameter.

Conclusions:

Trichoscopy is a valuable and superior method to the trichogram for diagnosis of FAGA, especially in early cases, with the highest yield irrespective of the suggested cut-off of 20% diversity of hair shaft.

Dermoscopy guided scalp biopsy in cicatricial alopecia

BACKGROUND

Scalp biopsies are crucial for the diagnosis of cicatricial alopecia. However, the pathologic interpretation may not be diagnostic if biopsy is not obtained from the correct site. This is particularly relevant for cicatricial alopecia as the disease may be focal and disease activity difficult to appreciate by the naked eye.

OBJECTIVE

To report a new simple technique to select the optimal biopsy site in cicatricial alopecia.

METHODS

In the last 2 years we performed dermoscopy guided scalp biopsies using handled dermatoscopes in 80 patients with different forms of cicatricial alopecia. Biopsy site was selected based on presence of the following dermatoscopic features: perifollicular concentric white scales in lichen planopilaris, frontal fibrosing alopecia (FFA) and discoid lupus erythematosus (DLE); hair tufts in folliculitis decalvans, hairs surrounded by a peripilar grey-white halo in central centrifugal cicatricial alopecia and follicular red dots or keratotic plugs in DLE.

RESULTS

The dermoscopy guided biopsies yielded a definitive pathological diagnosis in 95% of the cases.

COMMENT

The advantage of this method is that it is a fast, precise way to identify even individually affected follicles in early or focal cicatricial alopecia. It also allows for the morphologic characterization of particular follicular structures.

Alopecia: evaluation and treatment

Hair loss is a very common complaint. Patients may describe increased shedding and diffuse or localized alopecia. The differential diagnosis of hair loss includes a number of disorders causing cicatricial or noncicatricial alopecias. This paper describes the clinical approaches and diagnostic tests that are useful in the evaluation of patients presenting with alopecia. It also reviews treatments for noncicatricial alopecias, including androgenetic alopecia, alopecia areata, and telogen effluvium, as well as cicatricial alopecias, including lichen planopilaris, its clinical variant frontal fibrosing alopecia, and discoid lupus erythematosus.