Divergent progression pathways in male androgenetic alopecia and female pattern hair loss: Trichoscopic perspectives

BACKGROUND

Despite similarities in progressive miniaturization of hair follicles and transition of terminal hairs to vellus hairs, insufficient trichoscopic comparisons between male androgenetic alopecia (MAGA) and female pattern hair loss (FPHL) hinder our ability to select effective treatments.

AIM

Our study aimed to explore gender-specific trichoscopic characteristics of MAGA and FPHL, while formulating hypotheses regarding the progression of these conditions across clinical stages.

METHODS

We classified 126 male MAGA subjects using Hamilton-Norwood Classification and 57 FPHL subjects using adopted Sinclair Scale. Subsequently, we analyzed nine trichoscopic factors divided into three categories: hair-diameter related, hair-number per follicular unit related, and hair density related factors.

RESULTS

Of the nine quantitative trichoscopic factors, hair-diameter and hair-number per follicular unit showed strong correlations with clinical stages in both genders. Hair density, a common trichoscopic factor for hair loss evaluation, weakly correlated with clinical stages in FPHL, but not at all in MAGA. In addition, MAGA was characterized by a progressive reduction in hair-diameter, followed by a reduction in hair-number per follicular unit. FPHL, on the contrary, showed the opposite progression.

CONCLUSIONS

Trichoscopic factors vary with disease severity in a gender-specific manner. Our research highlights that MAGA and FPHL involve two distinct streams: hair-diameter decreasing by hair follicle miniaturization (Stream 1), and hair-number per follicular unit decreasing by hair follicle tri-lineage niche dysfunction (Stream 2). MAGA typically starts from Stream 1 to Stream 2, while FPHL starts from Stream 2. These diverse progression pathways underscore the importance of personalized treatment approaches.

Trichoscopic Features of Scalp Discoid Lupus Erythematosus versus Lichen Planopilaris: A Systematic Review

Introduction

Lichen planopilaris (LPP) and discoid lupus erythematosus (DLE) are primary scarring alopecias that pose diagnostic challenges clinically, where trichoscopy features may provide benefit in delineating these two cicatricial alopecia, and also helps in assessing the evolution and therapeutic response. To date, there are few reviews on dermoscopic findings in differentiating these two alopecias.

Methods

A systematic literature review was conducted using the PubMed and Google Scholar databases. The search terms included for scalp DLE were 'lupus' OR 'discoid lupus' OR "scalp lupus" and for scalp LPP were "lichen planopilaris" OR "scalp follicular lichen planus" OR "lichen planus follicularis" and were combined with "dermoscopy" OR "dermatoscopy" OR "videodermoscopy" OR "video dermatoscopy" OR "trichoscopy". The differences in the prevalence of dermoscopic features in scalp DLE and LPP were calculated using the Chi-square test.

Results

Of 52 articles, 36 (17 LPP, 19 DLE) were eligible for quantitative analysis. We found predominant peripilar tubular casts and perifollicular erythema with the presence of arborizing vessels in the vicinity of these changes, indicating early LPP. In contrast, follicular red dots, speckled brown pigmentation, and hair diameter variability indicated active DLE. Shiny white areas were common in both the groups in late stages. The target pattern of distribution of blue-grey dots, milky red areas, and irregular white fibrotic dots were seen in LPP, and pink-white background, follicular plugs, perifollicular and interfollicular scale, rosettes, chrysalides, and red spider on yellow dots were detected in DLE. Features such as yellow dots and blue-grey structureless areas were nonspecific and did not have a major role in differentiating DLE from LPP.

Conclusion

This article provides a comprehensive review of the literature and delineates the trichoscopic differences and peculiarities of scalp DLE and LPP, including the correlation of dermoscopic features with histopathological findings.

Clinical Characterization and Treatment Response of Folliculitis Decalvans Lichen Planopilaris Phenotypic Spectrum: A Unicentre Retrospective Series of 31 Patients

Folliculitis decalvans and lichen planopilaris phenotypic spectrum has been described as a form of cicatricial alopecia. The aim of this study is to describe the clinical and trichoscopic features and therapeutic management of this condition in a series of patients. A retrospective observational unicentre study was designed including patients with folliculitis decalvans and lichen planopilaris phenotypic spectrum confirmed with biopsy. A total of 31 patients (20 females) were included. The most common presentation was an isolated plaque of alopecia (61.3%) in the vertex. Trichoscopy revealed hair tufting with perifollicular white scaling in all cases. The duration of the condition was the only factor associated with large plaques (grade III) of alopecia (p = 0.026). The mean time to transition from the classic presentation of folliculitis decalvans to folliculitis decalvans and lichen planopilaris phenotypic spectrum was 5.2 years. The most frequently used treatments were topical steroids (80.6%), intralesional steroids (64.5%) and topical antibiotics (32.3%). Nine clinical relapses were detected after a mean time of 18 months (range 12-23 months). Folliculitis decalvans and lichen planopilaris phenotypic spectrum is an infrequent, but probably underdiagnosed, cicatricial alopecia. Treatment with anti-inflammatory drugs used for lichen planopilaris may be an adequate approach.

Clinicopathologic and trichoscopic features of keratosis follicularis spinulosa decalvans: A case series study

Keratosis follicularis spinulosa decalvans (KFSD) is a rare X-linked hereditary disorder characterized by the triad of follicular hyperkeratosis-photophobia-alopecia. The clinical heterogeneity makes the diagnosis difficult. To investigate the clinicopathologic and trichoscopic features of KFSD and to further clarify the essential requisites for the diagnosis, we conducted a retrospective study of patients with KFSD. The clinical information, histologic features, and trichoscopic findings were evaluated. Eight patients were from seven separate families. Two females were mother and daughter from the same family and the other six patients were male and represented sporadic cases. The average age of onset of alopecia was 21.25 years. Involvement of the scalp hairs leading to progressive scarring alopecia on the midline of the scalp with variable degrees of inflammation was the pathognomonic feature. It typically began after puberty. Vellus hair-associated follicular hyperkeratosis affected all of the patients. However, photophobia was not a constant feature. Histopathologic examination revealed disorders of the hair follicle with an acute-chronic inflammatory response. Follicular changes including fused infundibulum, the protrusion of the outer root sheath into the follicular canal, and a dilatation of the follicles at the isthmus level caused by the occlusion of keratin were observed. The trichoscopic features included perifollicular scaling, tufted hairs, and loss of follicular openings. In conclusion, terminal hair involvement, either scalp hairs, eyebrows, or eyelashes, and the hyperkeratosis of the follicle of vellus hairs is the diagnostic basis of KFSD. We hypothesize that follicular changes in histopathology are the primary event that trigger variable inflammation and further follicular destruction.

Peripilar Sign in Androgenetic Alopecia: Does It Really Indicate Peripilar Infiltrate?

INTRODUCTION

Peripilar sign (PPS) is a trichoscopic sign that was first described in androgenetic alopecia (AGA) and is thought to reflect the presence of perifollicular infiltrate (PFI) in histopathology.

OBJECTIVES

To study PPS in a cohort of patients with AGA and to assess its validity as a sign indicative of PFI.

METHODS

One hundred patients with AGA (confirmed by trichoscopic examination) were recruited in this cross-sectional study. From those patients, frontal scalp biopsy was done for two subgroups, 22 patients with PPS and 23 patients without PPS. Both groups were compared as regards the presence of PFI.

RESULTS

Peripilar sign was present in 50% of the 100 studied cases. No significant difference existed between those with and those without PPS as regards PFI. Peripilar sign was significantly more encountered in patients with skin type III (p=0.001). Its absence was significantly associated with lower interpretability of yellow dots (p<0.001) and their scores were significantly positively correlated (r=0.498, p<0.001). Peripilar sign was significantly associated with absent melanophages histopathologically (p=0.011).

CONCLUSION

Peripilar sign as a trichoscopic sign in AGA does not reflect PFI. It represents a dark color more encountered in patients with lighter skin types. This can be explained by the increased contrast between the dark PPS and the lighter surrounding skin in lighter skin types. Further studies using melanocyte markers and Masson Fontana's stain are needed to further verify the cause of this peri-follicular dark color.

Evaluating the Effect of the Demographic, Trichoscopic and Laboratory Characteristics on The Recurrence of Alopecia Areata

INTRODUCTION

Alopecia areata (AA) has diverse disease characteristics and multiple factors may interfere with the prognosis of the disease.

OBJECTIVES

In this study, the factors affecting the AA recurrence were evaluated.

METHODS

A total of a hundred patients diagnosed with AA between June 2022 and March 2023 were included in this retrospective, cross-sectional study. The patients were divided into two groups according to the presence of outbreaks. Both groups were compared in terms of age, gender, disease duration, number of outbreaks, family history of AA, previous medical treatment history for AA, clinical type, disease severity, presence of accompanying nail findings, and trichoscopic and laboratory characteristics.

RESULTS

Among 100 patients, male dominance was found (N = 69). Most of the patients had patchy disease (90/100), mild disease severity (88/100), and a solitary outbreak (65/100). Male gender, longer disease duration, family history, presence of S2 severity of alopecia tool score, trachyonychia, short vellus hairs in trichoscopic examination, hypothyroidism, and folic acid deficiency were factors for AA outbreaks. Male gender and the presence of a family member with AA in the family were defined as the independent prognostic factors for disease recurrence.

CONCLUSIONS

While demographic, laboratory, and clinical findings are factors for AA outbreaks in the follow-up, male gender and family history should be considered independent predictors.

Post Herpetic Itch Leading to Frictional Alopecia of Eyebrow and Scalp-A Hitherto Undescribed Phenomenon

Post herpetic itch (PHI) is a less commonly reported sequela of herpes zoster. It can begin upon the resolution of the lesions or several weeks later. PHI is neuropathic in nature and is said to be caused by neural injury in the form of demyelination of itch-transmitting nerve fibers in the skin. The majority of PHI resolves over weeks to months with symptomatic treatment. We report a case of PHI resulting in frictional alopecia of eyebrows and scalp due to frequent rubbing of the skin and hairs secondary to bothersome neuropathic itch.

Pressure alopecias: A review

Pressure-induced alopecias (PAs) are an infrequent group of scarring and nonscarring alopecias that occur after ischemic obstruction of capillaries that leads to circumscribed areas of hair loss. Initially described after prolonged surgeries or immobilization, type 1 PA occurs after sustained external pressure to the skin, mainly the scalp prominences. Alopecia induced by cosmetic procedures, referred in this review as type 2 PA, is reported with increased frequency in literature and predominantly emerges from pressure exerted by the volume of injectables. It is important to differentiate type 2 PA from vascular occlusion-induced alopecia because they represent distinct entities. Clinically, PA may present with erythema, swelling, and tenderness; however, alopecia might be the sole manifestation. Crusts and ulceration are associated with a worse outcome and a higher risk of scarring alopecia. Prompt diagnosis is paramount to prevent complications. Trichoscopy, although considered nonspecific, may provide relevant clues for an accurate diagnosis. Hair regrows in most cases, but prognosis depends on ischemia severity and timely treatment with reperfusion therapies or mobilization. Treatment of hair loss is usually not necessary because the disease in most cases is self-limited and reversible. The role of topical minoxidil and corticosteroids remains unknown.

Unilateral eyelid itching with eyelash loss after travelling

Tinea blepharitis is a rare dermatophyte infection. The characteristic broken eyelash is an important diagnostic clue by trichoscopy or slit-lamp examination. Other clinical clues suggesting dermatophytosis include pruritic scaly annular erythema and a history of recent contact with pets.

Erosive pustular dermatosis of the scalp secondary to Erlotinib: A rare occurrence with trichoscopic perspective

Epidermal growth factor receptor inhibitors are anti-tumour agents that are frequently used for the treatment of neoplastic disorders. In addition to their cutaneous adverse effects, these drugs can rarely lead to erosive pustular dermatosis of the scalp. We report a case of a 67-year-old female who developed erosive pustular dermatosis of the scalp after being started on erlotinib from a trichoscopic perspective, which has been described in literature only once till now.

Trichoscopic evaluation of dental pulp stem cell conditioned media for androgenic alopecia

BACKGROUND

Conditioned media (CM) derived from mesenchymal stem cells (MSC) is known to induce hair regrowth in androgenic alopecia.

OBJECTIVES

The objectives of the study were to assess the efficacy and safety of one type of MSC-CM, the CM derived from dental pulp stem cells obtained from human exfoliated deciduous teeth (SHED-CM) and to compare the efficacy of SHED-CM with and without dihydrotestosterone synthesis inhibitor (DHT-inhibitor).

METHODS

Eighty-eight male androgenic alopecia subjects with Hamilton-Norwood Classification (H-N C) I-VII were evaluated by trichoscopy to explore which trichoscopic factors statistically correlated with H-N C. After being screened, 33 subjects received six SHED-CM treatments at 1-month intervals. Clinical severity was assessed through global and trichoscopic images from baseline to 9th month.

RESULTS

SHED-CM was effective for 75% of subjects regardless of disease severity, concomitant DHT-inhibitor use, and age. Adverse effects including pain and small hemorrhages were transient and mild. We also found that clinical hair status evaluated by absolute values of three quantitative trichoscopic factors (maximum hair diameter, vellus hair rate, and multi-hair follicular unit rate) showed a good correlation with H-N C stages, and what is more-a scoring system of these three factors can be a possible predictor of SHED-CM efficacy.

CONCLUSIONS

We have shown that SHED-CM provides global and trichoscopic image improvement for androgenic alopecia, regardless of concomitant DHT-inhibitor use.

A Cross-Sectional Study on Post-Coronavirus Disease (COVID-19) Hair Loss at a Tertiary Care Hospital

INTRODUCTION

Severe acute respiratory virus syndrome coronavirus 2 (SARS-CoV-2) was responsible for coronavirus disease (COVID-19) pandemic. As patients recovered from COVID-19 infection, hair loss was increasingly observed as a distressing symptom.

METHODS

This was a cross-sectional study of patients with post COVID-19 hair loss between July to December 2021 at a tertiary care center. Detailed history, clinical examination, trichoscopy and biochemical tests were performed and recorded. COVID-19 disease severity was assessed based on duration of COVID-19 infection and place of management.

RESULTS

The study included 120 patients with a mean age of 39.6 years. The majority of the patients were females treated at home and had COVID-19 infection for >2 weeks. The mean visual analog scale (VAS) score for stress was 5.25. Vitamin D deficiency was present in 56.7% and low ferritin in 30% of cases. The mean time of onset of hair loss post COVID-19 was 49 days. Patients mainly presented with diffuse hair loss. Trichodynia was present in 15.8% of cases. The degree of hair loss was severe in 55.8% of the subjects. Positive hair pull test was seen in 65% of patients. Most common trichoscopic features included single hair follicles (81.7%) and vellus hair >10% (60%).

CONCLUSIONS

The mean time of onset of hair loss post COVID-19 infection was less than 2 months. Majority patients had diffuse pattern and severe degree of hair loss. Trichoscopy can aid in unmasking co-existing patterned hair loss in patients presenting clinically with diffuse hair loss.

Favorable effect of herbal extract on androgenic alopecia: A case report

RATIONALE

Androgenic alopecia (AGA) is a prevalent condition with progressive miniaturization of hair follicles. Currently, reliable treatments have remained limited, and complementary medications for AGA are still being investigated. Traditional Chinese medicine formulas have conspicuous advantages in the treatment of AGA with good development prospects. Zimmer aqueous spray (ZAS) is a water spray containing Zimmer herbal extract powder (ZMWP), which consists of Ligustri lucidi Fructus, Ecliptae Herba, Fallopia multiflora (Thunb.) Harald. and Polygonatum sibiricum Delar. ex Redoute, etc. ZMWP is an active ingredient in the prevention of hair loss. Our aim is to provide evidence for the effectiveness of ZAS in the treatment of AGA.

PATIENT CONCERNS

A 41-year-old man had suffered from hair loss for 8 years.

INTERVENTIONS

The patient with moderate AGA received 3 to 4 mL ZAS daily or every other day for 3 months.

OUTCOMES

The hair density obviously increased after 3 months of therapy. The improvement of hair diameter, vellus hair rate, and 1 hair pilosebaceous unit rate were observed with a trichoscopy and quantitatively analyzed. Besides, honeycomb pigment pattern mitigated and arborized red lines.

LESSONS

The results suggested that ZMWP might have the capability of improving hair growth and attenuating AGA, which can be a promising alternative treatment of AGA.

Trichoscopic Features of Syphilitic Alopecia and Alopecia Areata: A Comparative Study

Background

Syphilitic alopecia (SA) and alopecia areata (AA) are two distinct conditions that frequently present diagnostic difficulties, especially when differentiating between them due to their similar clinical presentations. Trichoscopy may help in differential diagnosis, but a comparison between trichoscopic features of SA and AA is yet to be researched.

Objective

To compare trichoscopic features between SA and AA and determine their discriminative values.

Methods

Electronic medical records and trichoscopic images of patients diagnosed with SA or AA between January 2000 and February 2022 were retrieved. Trichoscopic features were statistically compared, and their discriminative values were demonstrated as sensitivity, specificity, predictive value, likelihood ratio, and area under the receiver operating characteristic curve (AUC).

Results

A total of 69 patients were included: 23 SA and 46 AA cases were matched with a 1:2 ratio. Black dots, broken hairs, pigtail hairs, exclamation mark hairs, tapered hairs, angulated hairs, and non-pigmented regrowing hairs were significantly more prevalent in AA than in SA (all P<0.05), whereas erythematous background was more prevalent in SA than in AA patients (P=0.008). Among the aforementioned trichoscopic features, exclamation mark hairs and non-pigmented regrowing hairs had a high positive likelihood ratio for AA (16.17 and 8.34, respectively); however, only exclamation mark hairs revealed high AUC (AUC=0.816).

Conclusion

Despite the presence of several similar trichoscopic features between SA and AA, trichoscopy can aid in distinguishing between the two diseases. Exclamation mark hairs are the only trichoscopic feature that can be used to differentiate patients with clinically suspicious SA from those with AA.

Congenital Cutis Verticis Gyrata in a Newborn with Turner Syndrome: A Rare Clinical Manifestation of This Chromosomal Disease with Trichoscopic Evaluation

Cutis verticis gyrata (CVG) is a rare disorder of the scalp that entails the development of ridges and furrows, which mimic the anatomical conformation of the brain. This skin condition has been classified in primary essential, primary non-essential, and secondary CVG, depending on the presence or absence of other associated disorders. We present the case report of a one-month-old female newborn affected by congenital CVG (CCVG), who also received a diagnosis of Turner syndrome (TS). Skin folding was present at birth and located at the left frontal region of the scalp in the sagittal plane. Our purpose was to make this pathology clinically and tricoscopically better known, since it can be related to different genetic, inflammatory, and neoplastic conditions, etc. Non-invasive investigations, such as ultrasonography (U/S) of the brain and scalp and trichoscopy, were also used to obtain the important clues necessary to help in the CVG classification. The clinical diagnosis and trichoscopical investigation of CVG may also be useful for those patients who may have a genetic disease that is not screened for during prenatal examinations.

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.

Therapeutic effects of topical cetirizine in the treatment of female pattern hair loss: a randomized controlled noninferiority trial

BACKGROUND

Female pattern hair loss (FPHL) is the most prevalent form of hair loss in women. It was aimed to evaluate the therapeutic effects of topical cetirizine 1%, versus topical minoxidil 2% in patients with FPHL.

RESEARCH DESIGN AND METHODS

Through a triple-blind randomized clinical trial, 60 women with FPHL were randomly divided into two groups of treatment with topical cetirizine 1% or topical minoxidil 2%. The endpoint was changing in hair loss severity as well as terminal hair density and diameter, according to trichoscopic evaluation. Intention-to-treat analysis was also performed for those who accomplished 3 months of treatment.

RESULTS

Both groups showed improvement in hair diameter and density after 6 months; however, the outcome was significant only in the minoxidil group. According to per-protocol analysis, minoxidil was significantly superior to cetirizine in hair density, but not in hair diameter. According to the hair loss severity scales, FPHL was significantly improved in both the cetirizine and minoxidil groups after 6 months of therapy. The dropout rate due to adverse effects was 10.0% and 6.6% in the cetirizine and minoxidil groups, respectively.

CONCLUSION

Although inferior to topical minoxidil, topical cetirizine can provide favorable therapeutic effects for FPHL, specifically when patient incompatibility with Minoxidil is observed.

TRIAL REGISTRATION

The study is registered in the Iranian Registry of Clinical Trials (IRCT) with the registration code IRCT20200521047536N1.

A Machine Learning Algorithm Applied to Trichoscopy for Androgenic Alopecia Staging and Severity Assessment

INTRODUCTION

Androgenic alopecia (AGA) staging is still based on macroscopic scales, yet the introduction of trichoscopy is gradually bringing an important change, even though it remains an eye-based method. However, recently developed artificial intelligence-assisted programs can execute automated count of trichoscopic patterns. Nevertheless, to interpret data elaborated by these programs can be complex. Machine learning algorithms might represent an innovative solution. Among them, support vector machine (SVM) models are among the best methods for classification.

OBJECTIVES

Our aim was to develop a SVM algorithm, based on three trichoscopic patterns, able to classify AGA patients and to calculate a severity index.

METHODS

We retrospectively analyzed trichoscopic images from 200 AGA patients using Trichoscale Pro® software, calculating the number of vellus hair, empty follicles and single hair follicular units. Then, we elaborated a SVM model, based on these three patterns and on sex, able to classify patients as affected by mild AGA or moderate-severe AGA, and able to calculate the probability of the classification being correct, expressed as percentage (from 50% to 100%). This probability estimate is higher in patients with more AGA trichoscopic patterns and, thus, it might serve as a severity index.

RESULTS

For training and test datasets, accuracy was 94.3% and 90.0% respectively, while the Area Under the Curve was 0.99 and 0.95 respectively.

CONCLUSIONS

We believe our SVM model could be of great support for dermatologists in the management of AGA, especially in better assessing disease severity and, thus, in prescribing a more appropriate therapy.

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.

Recent Advances in Understanding of the Etiopathogenesis, Diagnosis, and Management of Hair Loss Diseases

Hair-loss diseases comprise heterogenous conditions with respective pathophysiology and clinicopathological characteristics. Major breakthroughs in hair follicle biology and immunology have led to the elucidation of etiopathogenesis of non-scarring alopecia (e.g., alopecia areata, AA) and cicatricial alopecia (e.g., lichen planopilaris, LPP). High-throughput genetic analyses revealed molecular mechanism underlying the disease susceptibility of hair loss conditions, such as androgenetic alopecia (AGA) and female pattern hair loss (FPHL). Hair loss attracted public interest during the COVID-19 pandemic. The knowledge of hair loss diseases is robustly expanding and thus requires timely updates. In this review, the diagnostic and measurement methodologies applied to hair loss diseases are updated. Of note, novel criteria and classification/scoring systems published in the last decade are reviewed, highlighting their advantages over conventional ones. Emerging diagnostic techniques are itemized with clinical pearls enabling efficient utilization. Recent advances in understanding the etiopathogenesis and management for representative hair diseases, namely AGA, FPHL, AA, and major primary cicatricial alopecia, including LPP, are comprehensively summarized, focusing on causative factors, genetic predisposition, new disease entity, and novel therapeutic options. Lastly, the association between COVID-19 and hair loss is discussed to delineate telogen effluvium as the predominating pathomechanism accounting for this sequela.

A Comment on Mercantilism in the Trichological Sciences

A quasi-scientific interest in hair loss and hair care originated in a London barbershop, and became known as trichology, with the Institute of Trichologists being founded. Other corporations successively followed, offering paid courses by home-study for training of initiates who desire more knowledge about hair. Trichologists are not medically qualified but are taught the practice of care and treatment of the hair and scalp in health and disease within their restricted but specialized role. With the advent of opportunities in the social media, and of epiluminiscence microscopy, a procedure practiced by the guild of trichologists long before its nominal introduction as trichoscopy into dermatologic practice, representatives of the medical profession are following the example of the trichologists in offering online courses, though with a better understanding of clinical-pathological correlations based on their academic learning. Despite the enthusiasm emerging with its establishment as a dermatologic tool in the diagnosis of hair and scalp disorders, caution is warranted not to elevate trichoscopy to something like a fetish status. As a diagnostic procedure, trichoscopy is to be understood as representing an integral part of a comprehensive dermatological examination. The Hippocratic Oath is one of the oldest binding documents in history, allegedly still held sacred by physicians: to treat the ill to the best of one's ability, to preserve a patient's privacy, and to teach the secrets of medicine to the next generation without fee. And yet, as in no other field of medicine, paid online courses on trichoscopy are flourishing and with a primary commercial aim. However, dermato-trichology, or trichiatry require the same due diligence as any other medical discipline, with respect to its practice and its ethics. Medical artistry is neither reducible to a single hand-held diagnostic technique nor is it negotiable.

A review of bubble hair deformity

Bubble hair deformity is an acquired abnormality characterized by air-filled cavity formations within the hair shaft, usually because of heat damage. Traditionally, bubble hair is diagnosed by visualization of characteristic bubbles under light microscopy. The increased utilization of trichoscopy (scalp dermoscopy) has led to its adoption in the diagnosis of many hair and scalp conditions, including bubble hair deformity. We sought to review clinical reports evaluating the patient profile, use of diagnostic imaging, and treatment options for bubble hair deformity. A systematic search of PubMed was performed in February 2021 using various keywords. Titles and abstracts were screened, leading to the selection of 11 case reports or series. The majority of patients were middle-aged Caucasian women who had used a heated tool to dry or style wet hair. Treatment consisted of cessation of heated tool usage. Light microscopy visualization of characteristic hair shaft cavities was used for diagnosis of bubble hair deformity in reports published prior to 2012. Diagnosis by trichoscopy was used in more recent reports. Our findings support the use of trichoscopy as a convenient and noninvasive method of diagnosing bubble hair deformity. More clinical studies are needed to evaluate the development of bubble hair deformity in ethnic hair.

Griscelli Syndrome in Skin of Color: A Trichoscopic Perspective

Introduction

Griscelli syndrome (GS) is a very rare autosomal recessive disorder, belongs to group of "silvery hair syndromes" which includes Chediak-Higashi syndrome (CHS) and Elejalde syndrome. Hair light microscopy helps in the differentiation of GS and CHS, as both manifest with clinical features. Trichoscopy is useful in the diagnosis of many hair shaft disorders. Here, authors describe the trichoscopic features of GS in skin of color.

Materials and Methods

This was an observational study conducted in a private dermatology clinic and in a tertiary care hospital. A total of 5 cases of suspected GS were referred by pediatrician. Consent was obtained. The demographic data in terms of age, gender, consanguinity, and clinical history was documented. Trichoscopic examination was performed with FotoFinder videodermoscope with 20× magnification, the clinical images were captured with Medicam 1000. Trichoscopy showed large and irregular pigment clumps in 4 cases. One case demonstrated hypopigmentation of hair without pigment clumps [Figure 3a].

Results

Trichoscopy showed large and irregular pigment clumps in 4 cases. One case demonstrated hypopigmentation of hair without pigment clumps.

Conclusion

Trichoscopy shows characteristic features GS. It is a useful method when facility for light or polarized microscope is unavailable.

Trichoscopy in Alopecia Areata and Trichotillomania in Skin of Colour: A Comparative Study

Alopecia areata (AA) and trichotillomania (TTM) are the two common causes of localised non scarring alopecia. While AA is an autoimmune disorder, TTM is an impulse control disorder which makes the treatment of the two entities completely different. Trichoscopy is a non-invasive tool used to diagnose hair disorders, which not only is extremely helpful in diagnosing AA and TTM but also differentiates them from other hair disorders as well. The aim of our study is to describe the various trichoscopic features of AA and TTM and to compare the frequency of each trichoscopic feature in order to establish diagnostic clues for differentiating AA and TTM. Trichoscopy was performed on clinically diagnosed cases of AA and TTM with DL4 dermoscope and the images were analysed by 2 dermatologists independently. The frequency of trichoscopic features in AA and TTM was compared using chi square test. Twenty-four patients of TTM and 50 patients of AA were included in the study with mean age of AA being 30 years and mean age of TTM being 23.4 years. Exclamation mark hair, tapered hair, coudability hair, pigtail hair, clustered vellous hair, clustered regrowing hair and white hair were significantly more in alopecia areata. Conversely broken hair of different length, trichoptilosis, flame hair, mace hair, coiled hair, hair powder, fractured hair, v sign and burnt matchstick sign were the common features in TTM. To conclude, even though there is an overlap of trichoscopic features in AA and TTM, it is possible to distinguish the two if an assemblage of specific features are present.

Efficacy of Low-Level Laser Therapy in Androgenetic Alopecia - A Randomized Controlled Trial

Background

Androgenetic alopecia (AGA) is caused by the susceptibility of hair follicles to androgenic miniaturization, which leads to hair loss. The most common modalities for the treatment of AGA include the use of topical minoxidil and oral finasteride. Low-level laser therapy (LLLT) is a newer modality of treatment for AGA. We tried to evaluate the added benefit of LLLT in AGA compared with topical minoxidil 5% alone.

Aim

The aim of this study was to compare the efficacy of LLLT combined with topical 5% minoxidil in AGA versus topical 5% minoxidil used alone.

Materials and Methods

After ethics committee approval, 54 patients of AGA were randomly divided into two groups. Group A participants received LLLT therapy twice a week plus topical 5% minoxidil and Group B participants received only minoxidil 5% solution. Both the groups were followed up for 16 weeks and evaluated with gross photographs, TrichoScan analysis, and dermoscopy to look for any improvement in hair density.

Results

After 16 weeks, improvement in hair density of 14.78% ± 10.93% in Group A was recorded compared to 11.43% ± 6.43% in Group B. However, while comparing both means, P value was 0.45 which was not significant. The physician global assessment and patient satisfaction score revealed no significant difference between both the groups.

Conclusion

Although LLLT appears to be safe and effective in the treatment of male pattern hair loss, we did not observe any significant difference in terms of improvement in hair density between both the groups.

IADVL SIG Pediatric Dermatology (Academy) Recommendations on Childhood Alopecia Areata

Alopecia areata (AA) is a chronic inflammatory disease characterized by nonscarring alopecia. In contrast to adult onset AA, the epidemiology, clinical characteristics, and therapy of childhood AA are less explored. This study aims at providing recommendations for the management of childhood AA. The special interest group (SIG) in pediatric dermatology under the Indian Association of Dermatology, Venereology and Leprosy (IADVL) conducted online meetings from February 2021 to September 2021, intending to identify the critical aspects in the diagnosis and treatment of AA. The classification, diagnosis, and tools for assessment of disease activity of childhood AA have been described in this study, along with recommendations for topical and systemic therapy, including newer therapeutic options.

Conradi-Hünermann-Happle syndrome: Clinical and trichoscopic findings

Conradi-Hünermann-Happle syndrome (CHHS) is a rare genodermatosis resulting from mutations in the EBP (emopamil binding protein) gene. Dermatologic manifestations may include cicatricial alopecia, ichthyosis, follicular atrophoderma, pigmentary abnormalities, and nail dystrophy. In addition to genetic testing and clinical findings, trichoscopic findings may aid in the diagnosis. In this case report, we discuss the trichoscopic findings in a 3-year-old girl with CHHS and how these findings help us understand the pathophysiology of this disease.

Eponyms in Trichoscopy

Trichoscopy is a non-invasive scalp and hair dermoscopy. In our daily dermatology practice, many eponyms are used. The present article highlights various eponyms in trichoscopy described in dermatology.

Comparison Between Trichoscopic and Histopathological Evaluations of Hair Parameters

Background

Collecting data on hair counts helps dermatologists diagnose hair diseases more accurately. Quantitative trichoscopy analysis and pathologic examination are two common ways to evaluate hair parameters.

Purpose

The study aims to compare the effect of quantitative trichoscopy analysis and pathologic examination in hair counting and quantify the hair density of average Chinese people.

Methods

Trichoscopy was performed in four scalp regions with a total of twenty-three volunteers without alopecia: frontal, vertex, occipital, and parietal. Hair density parameters were recorded. A 4-mm punch biopsy was performed in the occipital area, and all specimens were transversely sectioned serially and observed to calculate the hair densities.

Results

The average hair density, hairs per follicle unit, and vellus hair ratio from quantitative trichoscopy analysis in the occipital region were 163.07±28.17/cm², 1.87±0.25 and 6.60±3.95%, lower than those from biopsy significantly (214.97±48.73/cm², 2.24±0.30 and 10.48±6.43%). The hair shaft diameter measured by quantitative trichoscopy analysis was 74.52±8.02μm, higher than that by histopathologic examination (68.65±8.00μm) (p<0.05).

Conclusion

Quantitative trichoscopy is a noninvasive, quick, and convenient way to evaluate hair density. Histopathologic examination is an invasive way but provides more accurate data. The data obtained from trichoscopy and pathological examination are different to some extent, which cannot be substituted entirely for each other. This study established the reference for hair density in the adult Chinese population.

Evaluation of the safety and efficacy of platelet-rich plasma in the treatment of female patients with chronic telogen effluvium: A randomised, controlled, double-blind, pilot clinical trial

BACKGROUND

Chronic telogen effluvium is characterised by diffuse loss of hair of the scalp. One of the emerging lines of treatment is platelet-rich plasma. However, not much of published data exist.

AIMS

A pilot study was conducted on chronic telogen effluvium patients to evaluate the efficacy and safety of platelet-rich plasma, and to compare two different methods of platelet-rich plasma preparation.

METHODS

The study included 30 female patients with chronic telogen effluvium. Patients were randomised into three groups: Group (1): Special platelet-rich plasma tubes centrifuged at 3500 rpm; Group (2): Ordinary laboratory tubes centrifuged at 1000 rpm; Group (3): Normal saline as a placebo. Patients' evaluation was done with visual analog scale, hair pull test, trichoscopy, photos, satisfaction questionnaire, and safety. All patients received four monthly sessions. Patients were evaluated one month and three months after the last session.

RESULTS

The hair pull test,visual analogue scale, and patient satisfaction results showed a statistically significant difference between group 1 vs. group 3 and group 2 vs.group 3 at one and three months after the sessions, while there was no difference between group1 vs. group 2. Trichoscopy results (baseline, one and three months after treatment) showed a significant increase in hair density and thickness in the frontal area, temporal area, and the vertex in groups 1 and 2 only. There was no statistically significant difference between the three groups with regards to side effects.

LIMITATIONS

The sample size was small with ten patients in each group. Furthermore, the follow-up of patients was for only three months.

CONCLUSIONS

Platelet-rich plasma could be considered as a promising therapy for patients with chronic telogen effluvium with an excellent safety profile. The ordinary laboratory low-cost tubes might be a reliable alternative to the expensive special platelet-rich plasma kits tubes. The trial registry number is PACTR202006539654415.

Evaluation of dermatoscopic findings of alopecia areata and tinea capitis in pediatric patients

OBJECTIVE

Pediatric patients often reveal localized alopecic foci on the scalp. The essential point upon approaching a child with localized alopecia is distinguishing the two most common causes, alopecia areata and tinea capitis, as their treatments are entirely different. Although potassium hydroxide examination is the preferred method for their clear distinction, dermatoscopy is also emerging as a rapid diagnostic tool. This study aimed to assess and compare the dermatoscopic findings of alopecia areata and tinea capitis.

MATERIALS AND METHODS

Enrolled in this study were 34 children with tinea capitis and 21 children with alopecia areata admitting to a single-center outpatient clinic between 2017-2021. The authors confirmed all children's diagnoses by an integrative evaluation of clinical features, potassium hydroxide examination results, and treatment response patterns. Clinical features and the variables of interest (dermatoscopic findings) were investigated through the medical records and the baseline dermatoscopic images.

RESULTS

The most common dermatoscopic finding within the tinea capitis cohort was comma hairs, detected in 33 (97.1%) of the patients. Other findings of the tinea capitis group included squamation (n=31, 91.2%), broken and dystrophic hairs (n=30, 88.2%), corkscrew hairs (n=24, 70.6%), zigzag hairs (n=18, 52.9%), and pigtail hairs (n=9, 26.5%). The most common dermatoscopic finding within the alopecia areata cohort was exclamation mark hairs (n=13, 61.9%), that was followed by black dots (n=9, 42.9%), yellow dots (n=8, 38.1%), vellus hairs (n=6, 28.6%), and broken and dystrophic hairs (n=5, 23.8%).

CONCLUSION

Among the detailed evaluation of dermatoscopic findings of tinea capitis and alopecia areata patients, the only overlapping feature was dystrophic and broken hairs that could be present in both diseases; but were more common within the TC group than within the AA group (88.2% vs. 23.8%).

Dermoscopy and Trichoscopy in Dermatomyositis-A Cross-Sectional Study

BACKGROUND

(Video)dermoscopy is a non-invasive diagnostic technique that has a well-established role in dermatooncology. In recent years, this method has also been increasingly used in the assessment of inflammatory dermatoses. So far, little is known about the (video)dermoscopic features of dermatomyositis (DM).

METHODS

Consecutive patients with DM were included in the study and videodermoscopic assessments of the nailfolds, scalp, and active skin lesions were performed.

RESULTS

Fifteen patients with DM (10 women and 5 men) were included. Capillaroscopy showed elongated capillaries (90.9%), avascular areas (81.8%), disorganized vessel architecture (81.8%), tortuous capillaries (72.7%), dilated capillaries (72.7%), and hemorrhages (72.7%). The trichoscopic findings included linear branched vessels (80.0%), linear vessels (60.0%), linear curved vessels (53.3%), perifollicular pigmentation (40.0%), perifollicular erythema (33.3%), scaling (20.0%), white (20.0%) or yellow (20%) interfollicular scales, and white (20.0%) or pinkish (13.3%) structureless areas. Polymorphic vessels of an unspecific distribution and white or pink structureless areas were frequently observed under dermoscopy in cutaneous manifestations of DM, including Gottron's papules and Gottron's sign.

CONCLUSIONS

Dermoscopy of the nailfolds (capillaroscopy), scalp (tricoscopy), and active cutaneous lesions may be of value in the preliminary diagnosis of DM.

Tufted hairs: A bouquet of flowers in different hair diseases

Tufted hairs, an unusual hair follicle dysplasia, are characterized by several hair shafts grouped together, emerging from a single hair follicle-like "doll's hair". This clinical picture is considered characteristic of folliculitis decalvans (FD). However, the emergence of grouped hair shafts from a single follicle can also be observed in other hair disorders, even if not as a distinctive diagnostic sign. This paper aims to collect and analyze all clinical and trichoscopic features of different hair diseases with tufted hairs to find distinctive features, helping the clinician with the diagnosis.

Role of Trichoscopy in Evaluation of Alopecia Areata: A Study in a Tertiary Care Referral Centre in the Eastern India

Background

Alopecia areata is an autoimmune disorder affecting the hair-bearing sites of the body. Trichoscopy has recently been practiced in the diagnosis of alopecia areata.

Aim

To elicit trichoscopy patterns in alopecia areata and to find out any correlation of trichoscopic findings with disease severity.

Methods

Trichoscopy was done on clinically diagnosed cases of alopecia areata and on age and sex-matched controls without hair disorders by using a DL1 dermoscope (magnification: ×10). Observed dermoscopic findings were analyzed to find the correlation with disease severity.

Results

In total, 87 cases and 60 controls were included in the study with the mean age for cases being 25.47 ± 14.07 years. There was male predominance of cases (51; 58.62%). Alopecia in multiple patches was the most common type (42; 48.27%), and scalp was the most common site of involvement (79; 90.8%). Yellow dots (YD), black dots (BD), broken hairs (BH), circle hair (CH), and tapering hairs (TH) or exclamation hair (EH) were found to be statistically significant findings in alopecia areata as compared to controls. Circle hair was significantly associated with total severity of alopecia areata (P = 0.041). Yellow dots had a positive correlation with the number of episodes of alopecia areata (Spearman's rho = 0.273, P = 0.0106) and mean severity of alopecia tool (SALT) score (P = 0.0130). No significant association was noted between trichoscopic findings and disease activity, family history, disease associations, or nail involvement.

Conclusion

A constellation of trichoscopic findings helps in establishing the diagnosis of alopecia areata obviating the need for biopsy.

A Clinico-trichological Study of Female Androgenetic Alopecia

Background

Female Androgenetic Alopecia (FAGA) is one of the most common cause of diffuse scalp hair loss in women. FAGA is insidious in onset, gradually progressive, non scarring alopecia. Trichoscopy is a newly developed non invasive, objective, bed side analytical method of hair imaging based on video dermoscopy of scalp. The objective of this study is to study the clinical features of female androgenetic alopecia, to study the trichoscopic features in patients of female androgenetic alopecia and to correlate the trichoscopic features according to clinical grade of female androgenetic alopecia.

Methods

Study enrolled 50 females with FAGA and 50 normal females. FAGA cases were divided into subgroups according to sinclair scale. Laboratory investigations including hemoglobin level, triiodothyronine (T3), thyroxine (T4) thyroid stimulating hormone (TSH) and serum ferritin level were carried out in both cases and controls. After clinical diagnosis, trichoscopic examination was done and categorised using Diagnostic Criteria set by Rakowska A. et al and trichoscopic findings were coorelated with clinical grades.

Results

>4 yellow dots in frontal area , >2:1 ratio of single hair units (frontal: occiput) & >3:1 ratio of hair with perifollicular discoloration (frontal: occiput) are mainly seen in late stages of FAGA i.e. grade 4 & 5 and >1.5:1 ratio of vellus hairs (frontal :occiput) in early stages i.e. grade 2 & 3 while lower mean hair thickness in frontal area & > 10% thin hairs in frontal area are seen in all stages of FAGA Conclusion: Trichoscopy not only confirms the diagnosis by assessing the trichoscopic features of FAGA but also coorelates them with clinical severity. And as the age increases, grade of clinical severity increases. Not necessarily hemoglobin, thyroid and serum ferritin levels will be dearranged in FAGA cases.

Limitation

The study is done on few number of patients. Further studies needs to be done to validate results.

Trichoscopic Findings in Pressure Alopecia: Report of Two Cases and Review of the Literature

Pressure alopecia (PA) is an uncommon type of hair loss due to ischemic changes of the scalp, as a result of prolonged immobilization. Clinically, it often appears within the 1^st month of the trigger and tends to resolve spontaneously within 4 months. If the duration of the immobilization is longer, irreversible alopecia can be developed. Trichoscopy is usually nonspecific, being black dots, broken, and dystrophic hairs the most frequent findings. However, yellow dots and thin hairs have also been reported. We herein present two patients with PA, one with a recent development and another one with a long-lasting alopecia. Both of them showed keratotic follicular plugs and thin hairs as the main trichoscopic findings.

Trichoscopic features of hair and scalp in noncomplaining individuals: A descriptive study

BACKGROUND

Trichoscopy is a simple noninvasive tool that is used in calculating different hair parameters and the diagnosis of different hair/scalp diseases at variable magnifications.

OBJECTIVE

The aim of this work is to describe the features and parameters of hair and scalp in a healthy sample of Egyptian population using videodermoscopy. This may help to provide standard range of measurements of normal hair in both males and females.

METHODS

A nonrandomized, observational study for features and parameters of hair structure, performed on 368 healthy Egyptian subjects with no hair/scalp complaint.

RESULTS

Each scalp area has its own vascular pattern. Male subjects showed different values regarding their hair parameters from the female subjects. No significant difference was seen after application of hair dye, except for few values. In both genders, there was a change in hair parameters with age. Smoking had a negative influence on hair parameters.

CONCLUSION

Hair features and parameters observed in our population are different from those reported by other populations. Smoking affects hair thickness and density. Dyed hair has greater thickness mostly due to the protective effect of hair conditioners.