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.     

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.     

Coudability hairs: a revisited sign of alopecia areata assessed by trichoscopy

Background. We have previously reported several trichoscopic (dermatoscopic) characteristics, such as black dots, ‘exclamation‐mark’ hairs, broken hairs, yellow dots and clustered short vellus hairs as being useful clinical indicators for alopecia areata (AA). ‘Coudability hairs’, which are normal‐looking hairs tapered at the proximal end, have been previously reported as another sign of AA. Aims. To use trichoscopy to evaluate coudability hairs as a clinical indicator for the disease activity of AA and a substitute‐marker for the hair‐pull test. Methods. Trichoscopic examinations of hair loss and perilesional areas on the scalps of 100 East Asian patients with AA were performed using a dermatoscope. Using Spearman’s rank‐order correlation coefficient by rank test, we examined the correlations of scores between coudability and AA disease activity, severity or duration and other trichoscopic features, and then evaluated the coudability score as a surrogate‐marker for the hair‐pull test. Results. Coudability scores correlated positively with AA disease activity, hair‐pull tests, short duration, black dots and exclamation‐mark hairs, and correlated negatively with short vellus hairs. Conclusions. Coudability hairs, more closely perceived by trichoscopy, are useful‐markers for disease activity in AA and provide a surrogate‐marker for the hair‐pull test.     

Scalp dermoscopy of androgenetic alopecia in Asian people

Although dermoscopy is used mainly for diagnosing pigmented skin lesions, this device has been reported to be useful in observing alopecia areata and frontal fibrosing alopecia. Herein, we investigated the dermoscopic features and their incidence of androgenetic alopecia (AGA; n  = 50 men) and female AGA (FAGA; n  = 10 women) in Asian people. More than 20% hair diameter diversity (HDD), which reportedly is an early sign of AGA and corresponds to hair follicle miniaturization, was observed in the affected area of all AGA and FAGA cases, suggesting that HDD is an essential feature to diagnose AGA and FAGA. Peripilar signs, corresponding to perifollicular pigmentation, were seen in 66% (33/50) of AGA and 20% (2/10) of FAGA women. This incidence in the present study was lower than previously reported in white subjects possibly because the Asian skin color conceals slight peripilar pigmentation. Yellow dots were observed in 26% (13/50) of AGA and 10% (1/10) of FAGA cases and the number of yellow dots in AGA and FAGA was limited to 10 on the overall hair loss area. Yellow dots possibly indicate the coincidence of AGA and enlargement of the sebaceous glands caused by common end-organ hypersensitivity to androgen. In conclusion, dermoscopy is useful to diagnose AGA and FAGA and provides insights into the pathogenesis of AGA.     

'Black dots' seen under trichoscopy are not specific for alopecia areata

Background. ‘Black dots’ are macrocomedo‐like round structures localized to the follicular ostium, and are considered a specific trichoscopic feature of alopecia areata (AA). Aim. To characterize specific features of ‘black dots’, and assess their possible presence in common hair and scalp disorders. Methods. In total, 107 patients with hair loss [30 with alopecia areata (AA), 37 with androgenetic alopecia (AGA), 17 with chronic telogen effluvium (TE), 23 with other hair and scalp diseases] and 93 healthy controls were examined, using a videodermoscope with 20–70 times magnification. Results. There was a correlation between the black dots and the early acute phase of the various alopecia types with the presence of the black dots. Black dots were found in 11% (22/107) of patients with hair loss, including 53.3% (16/30) with AA; in 40% (2/5) of patients with severe chemotherapy‐induced alopecia, and in 100% of patients with dissecting cellulitis of the scalp (n = 2), hypotrichosis simplex (n = 1), and congenital aplasia cutis (n = 1). No black dots were seen in patients with AGA or TE. Conclusions. Black dots are not specific for AA, and may be present in other hair and scalp diseases.     

雄秃样纤维性秃发一例

【摘要】 报道1例雄秃样纤维性秃发（FAPD）及其临床病理、皮肤镜和TrichoScan特征,以提高对FAPD的认识。患者男,23岁,前额及头顶部进行性脱发10年,伴局部头发变细、软,偶有头皮瘙痒。皮肤科检查：前额至头顶部头发弥漫性稀疏,前额发际线后移,局部发质细软,脱发区可见部分毛囊角化性丘疹、毛囊周围红斑,未见明显鳞屑。TrichoScan检查：毛发密度明显降低,毳毛比例增加。皮肤镜检查：部分毛囊开口消失,融合性白点征。头皮组织病理检查：毛囊漏斗部、峡部淋巴细胞苔藓样浸润,毛囊周围同心层状纤维化,毛囊结构破坏,毛囊性微瘢痕形成,残留毛囊直径变异度明显增加,可见部分毳毛。诊断：FAPD。FAPD临床易误诊为雄激素性秃发,需及早诊断并治疗。     

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.     

[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.     

Patients with profuse hair shedding may reveal anagen hair dystrophy: a diagnostic clue of alopecia areata incognita

Background Several patients, especially women, seek advice because of hair loss. They may be diagnosed clinically as having telogen effluvium (TE) or androgenetic alopecia (AGA), but histopathology may reveal that a proportion of them have in fact alopecia areata incognita (AAI). Objectives To detect dystrophic anagen hairs in such patients. Methods We studied 1932 patients with hair loss and no signs of classical alopecia areata. They were submitted to the modified wash test (which counts the total number of telogen hairs lost and the percentage of vellus hairs) and divided into patients having pure TE (403), patients with AGA + TE (1235) and patients with pure AGA (294). Dystrophic hairs were detected with a low magnification microscope. Results Dystrophic hairs were observed in 13 patients with TE (3.2%), in 54 with AGA + TE (4.4%) and in none with AGA. In addition, 7 patients with TE and 32 with AGA + TE developed small patches of alopecia areata in 6 to 9 weeks. No patches developed in patients with AGA. Conclusions The presence of dystrophic hairs and the development of patches of alopecia areata (and their absence in pure AGA) provide a first evidence of the possibility that within the heterogenous condition named TE some patients have in fact AAI.     

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.     

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。     

Videodermatoscopy Enhances Diagnostic Capability in Some Forms of Hair Loss

Background: Videodermatoscopy is a non-invasive technique that allows in vivo skin observation at high magnifications. Objective: The goal of this study was to determine if videodermatoscopy enhances diagnostic capability beyond standard clinical observation in three series of patients: one group of patients with overt alopecia areata (AA), one with overt androgenetic alopecia (AGA), and one with hair loss with no apparent diagnostic features. Methods: The first group consisted of 200 patients affected by acute (140 patients) and chronic (60 patients) AA, and the second group of 100 patients affected by AGA. In both groups, the clinical diagnosis was confirmed by pull tests and trichograms. The third group consisted of 50 patients with clinically undifferentiated hair loss. In all groups, videodermatoscopy was performed at magnifications ranging from 20× to 600×. Results: In acute AA (n = 140), three videodermatoscopy patterns were identified, characterized by: (i) ‘exclamation point’ and/or ‘cadaveric’ hairs (n = 62); (ii) ‘vellus’ hairs, in some cases with increased proximal shaft thickness and pigmentation (n = 38); and (iii) coexistence of all the features from (i) and (ii) [n = 40]. In chronic AA (n = 60), in those cases who were recently converted to chronic form from acute AA (n = 35), videodermatoscopy showed a scalp skin that appeared smooth and thin, with evident follicular openings. In cases of long-standing chronic AA (n = 25), hair follicle openings appeared to be obstructed by keratotic plugs. However, whether the two follicular patterns were related to disease duration or to some unknown factors is unclear. In some patients with chronic AA, videodermatoscopy also revealed hair regrowth, which appeared either as homogeneous, indicating early disease remission (upright ‘vellus’ hairs), or as sparse, thin, and twisted vellus hairs that were usually lost in a few weeks time. In AGA patients, videodermatoscopy observation allowed an accurate assessment of the ratios of miniaturized to normal hairs, a finding that was interpreted as a prognostic feature. Interestingly, videodermatoscopy clearly demonstrated the hair abnormalities corresponding to both diseases in those patients with concomitant causes of hair loss, as we observed in five patients simultaneously affected by AA and AGA. In the third group, videodermatoscopy allowed identification of early or minimal forms of AA (n = 20), AGA with mild hair loss of the centro-parietal area of the scalp (n = 20), and scarring alopecia (n = 10). Conclusion: The results indicate that videodermatoscopy represents a very useful tool in the evaluation of hair loss, both for differential diagnosis (especially in early, transitional and mild forms) and for prognostic evaluation. It allows rapid, detailed, and non-invasive observation of the scalp skin and hair, and it provides high-resolution quality imaging.     

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.     

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。     

Kenogen in female androgenetic alopecia. A longitudinal study

BACKGROUND: Kenogen indicates the physiological interval of the hair cycle in which the hair follicle remains empty after the telogen hair has been extruded and before a new anagen hair emerges. Kenogen frequency and duration are greater in men and women with androgenetic alopecia (AGA). OBJECTIVE: To study the relationship of kenogen with female AGA. METHODS: A woman with AGA, studied 14 years before, was re-examined for 2 years by the phototrichogram technique. Kenogen was identified when telogen lasted 3 months and shedding left the follicle empty. RESULTS: Kenogen lasted 1-5 months, the longest duration affecting cycles of vellus hairs, and involved more hair follicles (16 vs. 8%) than in the first observation. Cycles of vellus hairs increased in number from 4 to 13%, and cycles with a normal succession of phases decreased from 60 to 32%. CONCLUSIONS: The number of kenogen phases increased in parallel with vellus hairs and the diminished number of normal hair cycles, features that mark AGA aggravation. Kenogen seems to be related also to the progression of female AGA.     

Female-patterned alopecia in teenage brothers with unusual histologic features

BACKGROUND: Patterned hair loss, follicular miniaturization, and increased telogen hair counts characterize androgenic alopecia (AGA). Follicular inflammation in AGA has been associated with treatment resistance and progressive hair loss. CASE REPORT: Brothers, 15 and 18 years old, presented with frontal and mid-scalp hair loss with an intact frontal hairline noted over a 1-year period. The elder reported past use of androgenic steroids. Laboratory assessment for metabolic and hormonal abnormalities was unrevealing, and hair pull test was negative. Scalp biopsies revealed decreased terminal hairs, marked diameter variation of anagen hairs, decreased terminal to vellus hair ratios (3.7:1/3.4:1, older/younger), and increased telogen counts (23%/21%). Infrabulbar and peri-isthmic (follicular bulge region) lymphocytic infiltrates were present. Hair loss has progressed, unabated by daily topical 0.5% clobetasol (for 6 months), daily 5% minoxidil (1 year), and latter, daily oral finasteride (2 years - older brother only). DISCUSSION: Based on patterned hair loss and miniaturized hairs, these brothers have AGA. The female pattern of hair loss (diffuse hair loss affecting the central scalp with preservation of frontal hair line) coupled with follicular isthmic lymphocytic inflammation represents an unusual presentation, possibly a treatment resistant, inflammatory variant of AGA. The differential diagnosis includes exogenous androgen-mediated hair loss, cicatricial pattern hair loss, or the superimposition of alopecia areata.     

Androgenetic alopecia in males: a histopathological and ultrastructural study

Background  Androgenetic alopecia is a common cosmetic hair disorder, resulting from interplay of genetic, endocrine, and aging factors leading to a patterned follicular miniaturization. Microinflammation seems to be a potential active player in this process.
Aims  To study the histopathological and ultrastructural changes occurring in male androgenetic alopecia (AGA).
Patients/methods  Fifty-five subjects were included in this study (40 with AGA and 15 as normal age-matched controls). Skin biopsies from frontal bald area and occipital hairy area were subjected to histopathological examination, immunohistochemical staining for collagen I and ultrastructural study.
Results  The frontal bald area of patients showed highly significant increase in telogen hairs and decrease in anagen/telogen ratio and terminal/vellus hair ratio ( P  <   0.001). Perifollicular inflammation was almost a constant feature in early cases and showed a significant inverse correlation with perifollicular fibrosis ( P  =   0.048), which was more marked with thickening of the follicular sheath in advanced cases.
Conclusion  Follicular microinflammation plays an integral role in the pathogenesis of AGA in early cases. Over time, thickening of perifollicular sheath takes place due to increased deposition of collagen, resulting in marked perifollicular fibrosis, and sometimes ends by complete destruction of the affected follicles in advanced cases.     

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.