[Translated article] Trichoscopy in Alopecia Areata

Alopecia areata is an autoimmune disease that affects the hair follicle and can present as bald patches on the scalp and hair loss in other parts of the body. Diagnosis is clinical but can be aided by trichoscopy, a simple, rapid technique that reduces the need for invasive procedures and can also help with monitoring treatment response. We review the usefulness of trichoscopy in alopecia areata. The most common trichoscopic findings are yellow dots, black dots, exclamation mark hairs, short vellus hairs, and coudability hairs. Other, less common, findings can also help establish a diagnosis. Good response to treatment is indicated by the disappearance of black dots, broken hairs, and exclamation mark hairs. The observation of yellow dots, by contrast, indicates chronic disease and poor response to treatment.     

Tricoscopia en la alopecia areata

Alopecia areata is an autoimmune disease that affects the hair follicle and can present as bald patches on the scalp and hair loss in other parts of the body. Diagnosis is clinical but can be aided by trichoscopy, a simple, rapid technique that reduces the need for invasive procedures and can also help with monitoring treatment response. We review the usefulness of trichoscopy in alopecia areata. The most common trichoscopic findings are yellow dots, black dots, exclamation mark hairs, short vellus hairs, and coudability hairs. Other, less common, findings can also help establish a diagnosis. Good response to treatment is indicated by the disappearance of black dots, broken hairs, and exclamation mark hairs. The observation of yellow dots, by contrast, indicates chronic disease and poor response to treatment.     

Trichoscopy for common hair loss diseases: algorithmic method for diagnosis

In recent years, the usefulness of trichoscopy (scalp dermoscopy) has been reported for hair loss diseases. Here, characteristic trichoscopic features of common hair loss diseases are described using a DermLite II pro or Epilight eight. Characteristic trichoscopic features of alopecia areata are black dots, tapering hairs (exclamation mark hairs), broken hairs, yellow dots and short vellus hairs. In androgenetic alopecia (AGA), hair diameter diversity (HDD), perifollicular pigmentation/peripilar sign and yellow dots are trichoscopically observed. In all cases of AGA and female AGA, HDD more than 20%, which corresponds to vellus transformation, can be seen. In cicatricial alopecia (CA), the loss of orifices, a hallmark of CA, and the associated changes including perifollicular erythema or scale and hair tufting were observed. Finally, an algorithmic method for trichoscopic diagnosing is proposed.     

斑秃的皮肤镜表现及对治疗的反应

目的 探讨斑秃患者皮肤镜征象表现及其在不同治疗方法治疗后消失的情况.方法 回顾性分析80例初诊或复发后初诊斑秃患者的初始皮肤镜征象以及在不同治疗方法治疗后消失的顺序,并分析其原因.结果 斑秃发病男女比例相近,平均发病年龄为26.5岁,平均病程为32.6个月,临床类型以斑片型多见;斑秃患者皮肤镜征象出现率由高到低依次为黄点（87.5％）、黑点（82.5％）、断发（77.5％）、短毳毛（76.25％）、感叹号发（45.0％）,黄点、断发、短毳毛与斑秃病程呈负相关,感叹号发与轻拉发实验呈正相关,黑点、断发、感叹号发两两之间亦呈显著正相关.二苯环丙烯酮（DPCP）组患者随访期间内均未见明显新生毛发,而另外3组有1种或以上皮肤镜征象消失的患者均伴有新生毛发增多.复方甘草酸苷组、复方倍他米松组、口服激素组中4种征象（黄点、黑点、断发、感叹号发）均有.患者治疗后征象最先消失比例最高的为感叹号发,平均时间为治疗后7.3周,第二消失比例最高的为黑点,平均时间为7.6周,第三消失比例较高的为断发,平均时间为8.2周,最后消失的为黄点,平均时间为8.4周,组间差异无统计学意义.结论 感叹号发与病情活动度呈正相关,DPCP组患者病程长,病情活动度少,以重型及难治型患者占大多数,治疗起效慢.治疗后皮肤镜征象的消失与治疗方法无关,与治疗起效时间有关,开始起效时间约在7.3周左右.超过随访时间所有征象均未消失的患者,说明病情活动未得到控制,需调整治疗方案.治疗起效后毛囊重新进入生长期,引起感叹号发首先消失,随之黑点、断发亦消失。     

Clinical significance of dermoscopy in alopecia areata: analysis of 300 cases

Objective To determine dermoscopic findings of alopecia areata (AA) from a large‐scale study that can be used as clinical indicators of disease. Methods Dermoscopic examination of areas of hair loss on the scalp of 300 Asian patients with AA was performed using a DermLite® II pro, which can block light reflection from the skin surface without immersion gels. Using the Spearman rank‐order correlation coefficient by rank test, correlations between the incidence of each dermoscopic finding and the severity of disease and disease activity were examined. The sensitivity and specificity of the findings as diagnostic clues for AA were evaluated. Results Characteristic dermoscopic findings of AA included black dots, tapering hairs, broken hairs, yellow dots, and clustered short vellus hairs (shorter than 10 mm) in the areas of hair loss. Black dots, yellow dots, and short vellus hairs correlated with the severity of disease, and black dots, tapering hairs, broken hairs, and short vellus hairs correlated with disease activity. For diagnosis, yellow dots and short vellus hairs were the most sensitive markers, and black dots, tapering hairs, and broken hairs were the most specific markers. Conclusion Dermoscopic characteristics, such as black dots, tapering hairs, broken hairs, yellow dots, and clustered short vellus hairs, are useful clinical indicators for AA.     

斑秃皮损的皮肤镜影像及其与临床病理的关系

目的 探讨皮肤镜下斑秃皮损的微细改变及其与临床、病理相关性。方法 使用皮肤镜观察62例斑秃患者和44例其他类型脱发患者的皮损,收集患者临床及实验室资料,并对其中15例斑秃患者进行皮损部位组织病理活检,以了解皮肤镜的组织形态学基础。结果 皮肤镜下斑秃影像为黄点征、黑点征、断发、毳毛、新生短发和感叹号样毛发。黄点征发生率最高（83.9%）,而诊断斑秃的特异性指标为感叹号样毛发、黑点和断发,且后三者发生率与斑秃的活动性及轻拉发试验阳性率呈显著正相关关系。甲状腺过氧化物酶抗体升高发生率与轻拉发实验阳性率及断发发生率呈显著正相关。黄点征发生率和病理下毛囊口角栓阳性率之间呈显著正相关关系,新生短发发生率和毛囊周围肥大细胞浸润发生率以及黑点发生率则与生长期与退行期毛囊之间比例减少均呈显著负相关关系。结论 可以用黄点征作为斑秃诊断的初筛指标,而感叹号样毛发、黑点和断发对于确诊斑秃的特异性较高,且提示患者病情仍处于活动期。斑秃患者皮肤镜影像与病理有一定相关性,可用于判断病情并指导治疗。     

Trichoscopy of alopecia areata: An update

The diagnosis of alopecia areata is usually based on clinical manifestations. However, there are several hair and scalp disorders that share similar clinical features with alopecia areata, such as tinea capitis, trichotillomania or traction alopecia. Trichoscopy as a fast, non‐invasive and easy‐to‐perform technique may help to identify subtle details and establish the correct diagnosis. The aim of this review is to present the spectrum of trichoscopic findings in alopecia areata. A systematic review of the published work was performed by searching the PubMed, Scopus and EBSCO databases, complemented by a thorough hand search of reference lists. Of 427 articles retrieved, 30 studies were eligible for quantitative analysis. The reported features of alopecia areata were: yellow dots (6–100% patients), short vellus hairs (34–100%), black dots (0–84%), broken hairs (0–71%) and exclamation mark hairs (12–71%). Tapered hairs (5–81%) were reported in few studies, but a relatively high frequency of this finding in alopecia areata may indicate their important role in the differential diagnosis of hair loss. Rarely reported features, which include upright regrowing hairs (11–96%), pigtail (circle) hairs (4–61%) and Pohl‐Pinkus constrictions (2–10%), may also be helpful in the diagnosis of alopecia areata. There is no pathognomonic trichoscopic marker for alopecia areata and the most common trichoscopic features are not the most specific. Therefore, the diagnosis should be based on the coexistence of several trichoscopic findings, not on the presence of a single feature.     

Interferon‐gamma serum level and immunohistochemical expression of CD8 cells in tissue biopsies in patients with alopecia areata in correlation with trichoscopic findings

Alopecia areata (AA) is an autoimmune form of nonscarring hair loss. The aim of the study was to assess the serum concentration of interferon gamma (IFN‐γ) and CD8 cell expression in lesional skin biopsies in correlation with the disease severity, activity, duration, and trichoscopic findings in patients with AA. The study included 30 patients with AA and 15 age‐ and sex‐matched healthy controls. Trichoscopy was performed and photographs were captured for the alopecic areas, and the enzyme‐linked immunosorbent assay technique was used for serum level of IFN‐γ assessment and immunohistochemistry for CD8 cells. The results obtained indicate that IFN‐γ serum level in patients was significantly higher than that of control subjects, and significantly correlated with the activity status and the duration of the disease. CD8+ T cells infiltrate intensity significantly correlated with severity. Yellow dots (YDs), vellus hair, black dot, and exclamation marks were the most common trichoscopic findings. The presence of black dots significantly correlated to the disease activity, duration, serum IFN‐γ, and CD8+ infiltrate intensity. The presence of YDs significantly correlated with the mean serum IFN‐γ level. Exclamation marks significantly correlated with the disease activity and the degree of CD8+ infiltrate. In conclusion, trichoscopy could be a reliable indicator of the IFN‐γ serum level and CD8+ T cell infiltrate intensity in AA patient.     

母女同患重症斑秃二例

患者1,女,7岁。头发全部脱落6个月余。患者2,女,33岁,系患者1之母,弥漫性脱发2个月余。两例患者毛发镜下可见断发、感叹号样发、黑点征、短毳毛。患者1给予白芍总苷胶囊、复方甘草酸苷片、沙棘颗粒、六味地黄颗粒口服,米诺地尔酊、哈西奈德溶液、卤米松乳膏外用等治疗16个月后病情好转。患者2给予白芍总苷胶囊、活力苏口服液、甲泼尼龙片口服,生发酊、哈西奈德溶液、卤米松乳膏外用等治疗9个月后病情好转。     

Use of trichoscopy for the diagnosis of alopecia areata coexisting with primary scarring alopecia in a female hair loss patient

Despite patchy hair loss being typically observed in alopecia areata (AA), similar lesions can be seen in other forms of alopecia and the diagnosis is sometimes challenging. Of note, patchy primary scarring alopecia (SA) needs to be clearly distinguished from AA as SA can leave permanent hair loss. Herein, we report a previously unreported case of AA coexisting with SA successfully diagnosed by detailed trichoscopic investigation. A 42‐year‐old woman visited us with patchy hair loss lesions on the scalp. On physical examination, alopecic lesions sized up to 2 cm in diameter were observed in the right temporal and parietal regions. A gentle hair pull test collected dystrophic anagen hairs from some patches. Trichoscopy detected tapering hairs and black dots. The diagnosis of AA was made. However, some reddish patches were totally hair pull test negative, urging us to further evaluate the remaining lesions. Additional trichoscopic investigation revealed the disappearance of follicular ostia and the presence of a white and milky‐red area and peripilar scales, suggestive of SA. In histology, the clinically AA lesion showed peribulbar cell infiltration, while the potentially SA lesion demonstrated inflammatory cell infiltration around the isthmus and the decrease in hair follicles, some of which were replaced by fibrotic tissue. The final diagnosis of AA coexisting with SA was made. Intralesional corticosteroid injection improved AA but not SA. These findings emphasize the need for thorough trichoscopic examination for accurate diagnoses of rare hair loss conditions.     

Trichoscopy features of trichotillomania

Trichotillomania is a form of traction alopecia resulting from repetitive and compulsive hair pulling and plucking. Trichotillomania and patchy alopecia areata may have similar clinical and dermoscopic features in some cases. On trichoscopic examination, the presence of black dots, coiled or hook hair, shafts of varying lengths with fraying or split ends (trichoptilosis), and an absence of exclamation mark hairs and yellow dots are suggestive of trichotillomania.     

Isolated hair loss on the eyebrow: five cases with trichoscopic features

Alopecia areta (AA) and trichotillomania (TTM) are common causes for hair loss on the eyebrows. Yellow dots, vellus hairs, anisotrichosis, empty follicular openings, and black dots were observed in the present study’s patients with AA. Split hairs, question mark hairs, broken hairs, flame hairs, black dots, hairs with different lengths, and hemorrhagic areas were found in the patients with TTM. Trichoscopy is a very useful and helpful technic in distinguishing AA and TTM on the eyebrows.     

Evaluation of Clinical Significance of Dermoscopy in Alopecia Areata

Background:Alopecia areata (AA) is a common, chronic inflammatory disease characterized by nonscarring hair loss on the scalp or any hair-bearing area of the body. Recently, dermoscopy, a noninvasive diagnostic procedure, has been employed for the diagnosis of AA.Aim:To evaluate various dermoscopic patterns in AA and correlate these patterns with the disease activity and severity.Results:A total of fifty patients of AA were recruited in the study. Female outnumbered males with the ratio being 1.173:1. Mean age of the patients was 25.06 years. Mean duration of disease was 14 months. The most common site involved was scalp (80%) and type noted was patchy (84%). Various dermoscopic patterns noted were yellow dots (YD) (88%), short vellus hair (66%), black dots (BD) (58%), broken hairs (BHs) (56%), tapering hair (TH) (26%), Coudability hairs (14%), pigtail hair (14%), and Pohl-Pinkus constrictions (2%). Statistically significant correlation was observed between BD, BHs, THs, and disease activity. No significant correlation was found between severity and any of the dermoscopic features.Conclusion:The most common dermoscopic pattern in our study was YD. Presence of BDs, BHs, and THs indicate active disease. Dermoscopic patterns were not affected by severity of the disease.     

Alopecia areata: Clinical presentation, diagnosis, and unusual cases

Alopecia areata (AA) is a nonscarring hair loss disorder with a 2% lifetime risk. Most patients are below 30 years old. Clinical types include patchy AA, AA reticularis, diffuse AA, AA ophiasis, AA sisiapho, and perinevoid AA. Besides scalp and body hair, the eyebrows, eyelashes, and nails can be affected. The disorder may be circumscribed, total (scalp hair loss), and universal (loss of all hairs). Atopy, autoimmune thyroid disease, and vitiligo are more commonly associated. The course of the disease is unpredictable. However, early, long‐lasting, and severe cases have a less favorable prognosis. The clinical diagnosis is made by the aspect of hairless patches with a normal skin and preserved follicular ostia. Exclamations mark hairs and a positive pull test signal activity. Dermoscopy may reveal yellow dots. White hairs may be spared; initial regrowth may also be nonpigmented. The differential diagnosis includes trichotillomania, scarring alopecia, and other nonscarring hair loss disorders such as tinea capitis and syphilis.     

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.     

Elucidation of demographic,clinical and trichoscopic features for early diagnosis of self-healing acute diffuse and total alopecia

The term “acute diffuse and total alopecia” (ADTA) has been often used as a synonym for self-regressing severe alopecia areata (AA). However, ADTA is originally defined as a rapidly-progressive subtype of AA (RP-AA) with short recovery time and favorable prognosis irrespective of interventions. Indeed, a subpopulation of ADTA recovers spontaneously. We focused on this unique subset of AA, which we coined as “self-healing ADTA” (sADTA). Prompt and accurate differentiation of sADTA from other RP-AA is important to avoid unnecessary treatments, which is still challenging due to the lack of predictive diagnostic hallmarks. In this study, 18 sADTA patients were retrospectively analyzed to delineate their demographics and clinical features, including gentle hair pull test and trichoscopic findings, followed by statistical comparison with those of RP-AA. All sADTA cases were female and the average age was 38.1 ± 15.9 years. The progression of hair loss areas peaked at 3.6 ± 1.5 months, and complete hair regrowth was achieved in 7.9 ± 1.7 months. The identified factors supporting the diagnosis of sADTA included being female; the absence of scalp pain and itch; the absence of extra-scalp hair loss; club hair predominance in hair pull test; predominant short vellus hairs; and increase in vacant follicular ostia on trichoscopy. Subsequently, a scoring system for early diagnosis of sADTA was developed by counting the number of six identified factors present in a tested case. When analyzed by the developed system, all sADTA cases, including an additional four cases, had scores of 4 or above, while all RP-AA cases had scores below 3 except one case. Therefore, the system successfully differentiated sADTA from RP-AA (P < 0.01). Despite some technical limitations, the current study suggested that sADTA is a distinctive entity with unique pathophysiology and that early diagnosis before intervention is feasible based on the characteristics.     

先天性三角形脱发10例临床分析

【摘要】 目的 观察先天性三角形脱发的临床特点。方法 收集厦门市儿童医院2020年8月至2021年6月诊治的10例先天性三角形脱发患儿的临床资料,分析其临床及皮肤镜特征。结果 10例患儿均为男性,年龄2个月至6岁4个月。6例患儿出生时或者出生后1月内发现脱发,4例为4个月至6岁。脱发情况：5例位于左侧额颞部,3例位于右侧额颞部,2例位于头顶部。患儿脱发区均可见毳毛样毛发,拉发试验均阴性,其中1例毳毛样毛发区散在正常毛发。皮肤镜检查：脱发区边界较清,可见大量毳毛样毛发,周围为正常毛发,未见黄点征、黑点征及感叹号状发。7例曾因脱发就诊于皮肤科,其中5例被诊断为斑秃,2例被诊断为皮脂腺痣。结论 先天性三角形脱发常见于儿童,好发部位为左侧额颞部。脱发区正常毛发被细的毳毛样毛发代替是该病的特点,皮肤镜有助于诊断和鉴别诊断。     

Dry dermoscopy in clinical treatment of alopecia areata

Although dermoscopy is conventionally utilized with immersion gel for diagnosis of pigmented tumor, we utilized dry dermoscopy, which is dermoscopy without immersion gel, for clinical treatment of alopecia areata (AA). The scalp skin and hair of a 38-year-old Japanese male, and 23-, 22- and 47-year-old Japanese females with AA, whose normal hair color was black, were examined by dry dermoscopy. Exclamation mark hairs, short hairs, fractured hairs and black dots, all characteristic of AA, were detected by dry dermoscopy of the scalp of the 23-year-old female with ophiasis type AA. In the case of the 47-year-old female with round hair loss on the occipital scalp and diffuse hair loss over the fronto-vertical region, dry dermoscopy was useful for diagnosis of AA based on hair characteristic of AA. After she received corticosteroid pulse therapy with 500 mg of i.v. methylprednisolone on 3 successive days, her hair showed apparent regrowth and disappearance of the abnormal hairs characteristic of AA, evidenced by dry dermoscopy 1 month later. In a case of long-lasting AA in the 23-year-old female, we found a follicular plaque-like appearance at the opened hair follicle pores by dry dermoscopy. Histopathologically, the incompletely differentiated remnant hair shaft was packed in the follicular infundibulum. In addition, regrowing vellus hairs, which were difficult to clinically recognize, were detected by dry dermoscopy. Dry dermoscopy is therefore useful for both diagnosis and follow up of AA.