Trichoscopy: a new frontier for the diagnosis of hair diseases

Abstract

Trichoscopy is hair and scalp dermoscopy using a handheld dermoscope or polarized light video microscope. This article shows the revised trichoscopic algorithm for common hair loss diseases. For the algorithm for cicatricial alopecia, loss of orifices, micropustules and/or hair tufting with six or more hairs should be carefully observed. When loss of hair orifices cannot be seen in the hair loss area, diagnosis as noncicatricial alopecia is established. Among noncicatricial alopecia, alopecia areata is most commonly encountered and should be mainly considered for differential diagnosis. Therefore, the first check point is yellow dots, black dots or broken hairs. The hallmark of androgenetic alopecia and tinea capitis is hair diameter diversity (≥20%) and comma hairs, respectively. Hair shaft abnormalities can be diagnosed from the characteristics of trichoscopy reported until now.

Keywords::

• algorithm
• alopecia
• dermoscopy
• hair shaft
• trichoscopy
• video microscope

Figure 1. Revised algorithm for trichoscopic diagnosis of hair loss diseases.

Figure 2. Trichoscopic images of characteristic features in various kinds of hair loss.

(A) loss of orifices in linear scleroderma (sclerodermie en coup de sabre), (B) broken hairs, (C) black dots, (D) tapering hairs (exclamation mark hairs), (E) yellow dots and (F) short vellus hairs in alopecia areata, (G) micropustules and (H) hair tufting with six or more hairs in folliculitis decalvans/tufted folliculitis, (I) comma hairs in tinea capitis, and (J) short vellus hairs in androgenetic alopecia.

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Release date: 15 November 2012; Expiration date: 15 November 2013

Learning objectives

• Upon completion of this activity, participants will be able to:

• • Distinguish an effective algorithm for generating a diagnosis from trichoscopy

• • Assess the appearance of different hair diseases on trichoscopy

• • Analyze findings of temporal triangular alopecia

• • Evaluate trichoscopy findings in determining the prognosis of alopecia areata

Financial & competing interests disclosure

EDITOR

Elisa Manzotti

Publisher, Future Science Group, London, UK

Disclosure: Elisa Manzotti has disclosed no relevant financial relationships.

CME AUTHOR

Charles P Vega, MD

Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine

Disclosure: Charles P. Vega, MD, has disclosed no relevant financial relationships.

AUTHORS AND CREDENTIALS

Shigeki Inui, MD, PhD

Department of Regenerative Dermatology, Osaka University Graduate School of Medicine, Osaka, Japan

Disclosure: Shigeki Inui, MD, PhD, has disclosed no relevant financial relationships.

Trichoscopy

Trichoscopy is hair and scalp dermoscopy using a handheld dermoscope or polarized light video microscope [1,2]. Historically, in 1993, Kossard and Zagarella described spotted white dots in cicatricial alopecia in dark skin as the first dermoscopic finding in hair loss diseases [3]. While some reports later showed the usefulness of dermoscopy for hair diseases [4–9], this technique was still not so popular. However, after Ross et al. [10] reported the usefulness of various dermoscopic features in common hair loss diseases and Rakowska et al. [11] showed availability of the dermoscope in observing hair shaft abnormality, dermoscopy for hair diseases has become a hot topic and has been studied by many groups. Dermoscopy was originally used for observing and diagnosing pigmented skin lesions, such as melanocytic nevus and melanoma, and it was claimed that dermoscopy, especially without immersion gel, for hair diseases is a different methodology from the orthodox dermoscopy (personal communication). This technique was then termed as trichoscopy [2]. Because of noninvasiveness and easy accessibility to the hair or scalp, it is very useful in the clinical practice. By trichoscopy, alopecic and hair shaft disorders can be observed and diagnosed, avoiding skin biopsy that is otherwise necessary to precisely diagnose. Indeed, yellow dots, a typical trichoscopic feature in alopecia areata (AA), are perceptible only by trichoscopy [10,12,13]. The algorithmic method for trichoscopic diagnosis of hair loss disease was previously proposed [14] and in this article the revised version is shown and discussed. Additionally, trichoscopy for hair shaft abnormalities is summarized based on the recent findings using trichoscopy.

Algorithmic method for diagnosis of hair loss diseases by trichoscopy: cicatricial or noncicatricial?

The revised trichoscopic algorithm is shown in Figure 1. At the first step, whether the loss of orifices (Figure 2A) exists or not should be observed. The loss of orifices corresponds to permanent destruction of hair follicles, resulting in fibrosis, and is therefore of great importance for predicting prognosis because it determines if the hair loss is irreversible cicatricial or reversible noncicatricial. However, it may be very difficult to define it in some cases. Indeed, ophiasis type AA shows similar appearance to the loss of orifices without other typical signs of AA on hair loss areas, mimicking frontal fibrosing alopecia (FFA) [15]. These two entities are ‘look-alike’ also in clinical appearance because they show recalcitrant hairline hair loss and therefore can be a diagnostic dilemma [16]. Characteristic trichoscopic images in FFA are loss of orifices, perifollicular scale and feeble perifollicular erythema [17,18], while those of AA are broken hairs, black dots, tapering hairs (exclamation mark hairs), yellow dots and short vellus hairs (Figure 2B–2F) [13]. As for pathologic process, tapering hairs correspond to rapid catagen transition from anagen, broken hairs and black dots to the resultant hair fragility [19], and yellow dots to distention of the affected follicular infundibulum with keratinous material and sebum [10]. Among the signs for AA, yellow dots appear during application of topical corticosteroid [15], indicating that careful long-term follow-up and observation are important to precisely carry out differential diagnosis. Furthermore, cicatricial marginal alopecia (CMA) was described as a new distinctive pattern of alopecia [20]. Trichoscopic features of this entity are low hair density with loss of follicular ostia, reduced diameter of the remaining hairs and absence of perifollicular hyperkeratosis or abnormal scalp vessels [21]. CMA must be considered in the differential diagnosis of FFA and ophiasis type AA.

Cicatricial alopecia: neutrophilic or lymphocytic?

After cicatricial alopecia is indicated from the loss of orifices, the existence of micropustules (Figure 2G) and/or hair tufting with six or more hairs (Figure 2H) [22] should be carefully observed. Either finding indicates neutrophil- or mixed cell-mediated cicatricial alopecia such as folliculitis decalvans/tufted folliculitis, acne keloidalis and dissecting cellulitis of the scalp according to the recently proposed classification of primary cicatricial alopecia [23]. In the long-lasting folliculitis decalvans/tufted folliculitis, white and milky-red (strawberry ice cream color) areas without hair follicular opening predominate [24]. For further distinct diagnosis among these, the clinical appearance must be taken into consideration. If there are no findings such as micropustules and hair tufting, lymphocytic cicatricial alopecia is highly suggested. However, when neutrophilic or mixed cell alopecia is not so active or well controlled, no pustules are detected and the number of tufting hairs is four or five, suggesting that neutrophilic or mixed cell cicatricial alopecia may not be completely excluded from the above-mentioned points. Because two or three hair shafts emerge from one hair follicle unit in normal subjects, hair tufting is defined as positive when the number is four or more. Regarding the pathomechanism of hair tufting, inflammation around the isthmus and infundibulum damages infundibular epithelium of several follicular units, followed by coalescence of follicular units due to perifollicular fibrosis [25]. At the further step, follicular red dots are specific for discoid lupus erythematosus [26] and hair tufting indicates lichen planopilaris [27]. The red dots correspond pathologically to dilated infundibula containing keratotic material. Additionally, reduction in number and size of sebaceous glands and the presence of dilated vessels and red blood cell extravasation in perifollicular distribution around the isthmus make the color reddish [26]. After the inflammatory stage of lichen planopilaris, violaceous-blue interfollicular area, corresponding to pigment incontinence, can be seen by trichoscopy [24]. Moreover, in the fibrotic stage, large irregular white dots merge into milky-red (strawberry ice cream color) or white areas [3,28]. Without these features, the diagnosis must be determined based on clinical appearance and/or histopathological findings. Although it is possible to histopathologically discriminate between neutrophilic/mixed cell and lymphocytic cicatricial alopecia, there are rarely significant histopathological differences among the diseases of each category [29], indicating that clinical morphology is more stressed for this diagnostic step. White dots were originally described in a black patient of lichen planopilaris as a focal decrease in epidermal melanin pigment overlying the site of fibrous tracts [3], but the recent report showed that eccrine pores are also detected as white dots on the scalp of people with pigmented skin [30]. Therefore, white dots should be carefully observed whether they are fibrous spots or simply eccrine pores.

Noncicatricial alopecia: do yellow dots, black dots or broken hairs exist or not?

When loss of hair orifices cannot be seen in the hair loss area, diagnosis as noncicatricial alopecia is established. Among noncicatricial alopecia, AA is most commonly encountered in the clinical practice and should be mainly considered for differential diagnosis. The first check point is subsequently whether yellow dots, black dots or broken hairs are seen or not. When numerous yellow dots are observed, the diagnosis of AA is confirmed. However, the limited number of yellow dots are seen in other type of alopecia including androgenetic alopecia (AGA) [10,31], hypotrichosis congenita and tinea capitis [14]. When hair diameter diversity (≥20%) [9], corresponding to hair follicle miniaturization, is seen, the diagnosis should be AGA. Moreover, comma hairs [32] (Figure 2I), corkscrew hairs [33], zigzag hairs and interrupted (Morse code-like) hairs [24] are characteristic for tinea capitis. When these are not detected, further clinical and/or histopathological investigation is needed. As mentioned above, yellow dots are a sensitive marker for AA but are not specific because this sign is reportedly detected even in one of cicatricial alopecia discoid lupus erythematosus [24].

AA & trichotillomania

In noncicatricial alopecia, black dots and/or broken hairs strongly suggest AA but trichotillomania should be carefully ruled out for diagnosing AA. AA can be discriminated from trichotillomania based on the existence of tapering hairs [34] and/or clustered short vellus hairs (≤10 mm). The activity of AA can be monitored by the ratio of pathognomic hairs such as broken hairs, black dots and tapering hairs and short vellus hairs. However, AA often shows various trichoscopic conditions depending on the lesional sites, suggesting the importance of careful observation of the entire hair loss area. In trichotillomania, tapering hairs and clustered short vellus hairs are not observed because the premature catagen induction is unlikely to occur. The regrowing hairs in trichotillomania are in anagen phase, providing terminal hair shaft growth. Another point for differential diagnosis is coiled hairs formed by hair pulling in trichotillomania [34]. However, we should be careful about coexistence of AA and trichotillomania [35,36]. When tapering hairs exist, association with AA is indicated but if there are no signs such as tapering hairs, short vellus hairs or coiled hairs, either AA or trichotillomania and their association have to be considered. Collectively, it is worth noting that we have to be cautious for trichoscopic differential diagnosis for these two entities and need to obtain comprehensively clinical and/or histopathological data in ambiguous cases.

Seborrheic alopecia

When there are no yellow dots, black dots or broken hairs, perifollicular yellow scale, possibly mixed with sebum, are a clue to diagnose seborrheic alopecia [14]. Because psoriasis rarely causes hair loss [37], there may be a problem about differential diagnosis between these two diseases. The most significant findings in scalp psoriasis are red dots and globules, twisted red loops and glomerular vessels, corresponding to dilated capillaries in the dermal papillae, while those in seborrheic alopecia are arborizing vessels and atypical red vessels [38].

Remitting AA, androgenetic alopecia & temporal triangular alopecia

When only short vellus hairs are seen without any other findings, differential diagnosis becomes problematic. Typically, this sign is observed in remitting AA, showing the regrowth activity of hairs, but some diseases should be included in the differential diagnosis. This feature can be seen in the most advanced area of AGA [39] (Figure 2J) but the diagnosis of AGA is relatively easy by searching hair diameter diversity in the premature sites. Incomplete hair loss of the temporal scalp at childhood is sometimes difficult to specifically diagnose with two possibilities of remitting AA and temporal triangular alopecia (TTA). Although TTA is also referred as congenital triangular alopecia, the hair loss starts at birth only in 36.5% of patients and therefore the nomenclature of TTA is preferred [40]. Hair loss in TTA is persistent while single type AA showing only short vellus hairs without pathognomic hairs apparently remits within 6 months [41]. From this fact and the previous report of trichoscopy in TTA [42], the diagnostic criteria including trichoscopic findings for TTA was proposed as follows [41]:

• • Triangular or lancet-shaped patch of alopecia involving front-temporal scalp;

• • Trichoscopically normal follicular openings with vellus hairs surrounded by normal terminal hair area;

• • Trichoscopically no broken hairs, tapering hairs, black dots, yellow dots and orifice loss;

• • Persistent without significant hair regrowth for 6 months after clinically or trichoscopically confirming the existence of vellus hairs.

In addition, TTA can be discriminated from CMA by the absence of loss of hair orifices and low hair density. The differential diagnosis from aplasia cutis and nevus sebaceous is possible based on a complete lack of skin appendages and a translucent appearance in aplasia cutis and bright yellow dots not associated with hair follicles in nevus sebaceous [43].

Telogen effluvium

In telogen effluvium, one report showed that yellow dots and short vellus hairs are seen in some cases of telogen effluvium [39] and another indicated presence of upright regrowing hairs and predominance of hair follicle openings with only one emerging hair shaft as clues to diagnose telogen effluvium [24]. However, specific diagnostic findings are rarely observed and therefore basically the diagnosis of telogen effluvium is based on exclusion of AGA, diffuse-type AA and other types of alopecia.

Limitation of trichoscopy & algorithm

Taken together, trichoscopy is very powerful tool to diagnose hair loss diseases but it must be kept in mind that the final diagnosis should be carried out from comprehensive consideration of trichoscopic and clinical images. When there are unsolved discrepancies, careful follow-up and histopathological investigation are recommended. Moreover, the algorithm shown here covers only limited common hair loss diseases and therefore requires expansion to the wider range of diseases.

Trichoscopic clues for diagnosing other hair loss diseases

Another pathway for diagnosing hair loss diseases is trichoscopic clues by characteristic features. In lipedematous alopecia of the scalp, the linear area of teleangiectasia within the scalp creases, possibly caused by compression of the superficial blood capillaries, can be trichoscopically seen [44]. The orange spots seen by trichoscopy suggest scalp sarcoidosis and dystrophic hairs may indicate granulomatous activity [45]. The orange spots correspond to the round, well-formed granulomas in the superficial dermis. Hair casts are trichoscopically detected as white to brown cylindrical structures encircling the proximal hair shafts, providing a diagnostic clue for traction alopecia [46]. In the moth-eaten alopecia of secondary syphilis, the histopathology is similar to that of AA [47,48] and therefore the trichoscopy may be mimicking. However, so far there is no report of trichoscopy in syphilitic alopecia.

Trichoscopic findings as clinical markers in AA

Trichoscopy is useful for not only diagnosis but also management of AA [13,49]. In AA, the black dots, yellow dots and short vellus hairs correlated with the severity of disease. In addition the black dots, tapering hairs, and broken hairs correlate positively with disease activity but short vellus hairs correlate negatively [13]. The yellow dots or short vellus hairs in the hair loss area were detected by trichoscopy in 63.7 or 72.7% of the 300 Asian patients with AA, respectively, and either yellow dots or short vellus hairs in the hair loss areas seen in 94.0% of the patients, suggesting that this combination enhances the sensitivity of diagnosis of AA [13]. Additionally, because yellow dots predominate in long-lasting AA [24], disease duration of the enrolled patients may make a difference in the incidence of yellow dots. In the African–American patients with AA, a diffuse honeycomb-like pigmented network and white dots are observed by trichoscopy, suggesting that skin color affects trichoscopy images [50]. Moreover, normal-looking hairs with tapering toward the orifices are found in the perilesional hair-bearing scalp of AA patients [51]. Because similar features were previously described as ‘coudability’ by Shuster [52,53], this type of hair was designated as coudability hair. These were seen in 38% of AA patients and correlated with disease activity in a relatively early stage of AA [51]. During contact immunotherapy for AA, diffuse slate-colored pigmentations appear in 5.91% of patients (11 out of 186) [54]. Using trichoscopy, the reticular and granular pigmentations were observed, sparing the orifices and eccrine pores. Histopathology of the pigmentations showed lichenoid or vacuolar interface dermatitis with necrotic keratinocytes and dermal melanophages, consistent with pigmented contact dermatitis. Furthermore this sign represents a clinical indicator of poor responsiveness to treatment [54].

Trichoscopy in diffuse-type AA

There are some reports regarding trichoscopy in diffuse-type AA or mimicking cases. Diffuse-type AA on acute progression corresponds to acute diffuse and total alopecia of the female scalp (ADTAFS) characterized as AA showing rapid progression of diffuse alopecia of female scalp and preferable prognosis [55]. Previous trichoscopy study showed that black dots, tapering hairs and broken hairs are the specific diagnostic markers for ADTAFS to rule out female pattern hair loss (FPHL) and telogen effluvium. Additionally, some of these features were seen in 95% of cases, indicating them as a sensitive marker. Regarding the yellow dots, while numerous yellow dots were found in ADTAFS, a limited number of yellow dots were found on the hair loss scalp of the FPHL patients, suggesting that a differential diagnosis is possible from the number of yellow dots [56]. Conversely, in AA incognita (AAI), which is known as another type of diffuse-type AA, dystrophic hairs, exclamation point hairs (tapering hairs) and cadaverized hair were present in only 28.6% of patients while yellow dots and short vellus hairs were seen in all cases [57]. In this study of AAI, the histopathology showed increased vellus hairs and only subtle peribulbar lymphocytic infiltrate, suggesting that these AAI cases were at remitting phase, not active and inflammatory phase. Moreover, there is one expert opinion that AAI is not in the spectrum of AA and the trichoscopic description of AAI [57] fits with FPHL or acute telogen effluvium [58], indicating some overlap among these conditions.

Quantitative analysis using trichoscopy

Trichoscopy can be used for quantitative analysis for hair loss diseases. Rakowska et al. quantitatively evaluated trichoscopy images of normal female subjects and patients of FPHL and telogen effluvium [59] and found that FPHL may be differentiated from chronic telogen effluvium based on trichoscopy criteria as follows. Major criteria are:

• • Ratio of more than four yellow dots in four images (70-fold magnification) in the frontal area

• • Lower than average hair thickness in the frontal area compared to the occiput

• • More than 10% of thin hairs (below 0.03 mm) in the frontal area

Minor criteria encompass increased frontal to occipital ratio of:

• • Single-hair pilosebaceous units

• • Vellus hairs

• Perifollicular discoloration

Fulfillment of two major criteria or one major and two minor criteria allows to diagnose FPHL with a 98% specificity.

Hair shaft abnormalities

Hair shaft abnormalities can be diagnosed from the characteristics of trichoscopy summarized in Table 1 [11,60–62]. In the case of woolly hair syndrome, differential diagnosis from curly hairs of normal subjects is easy using trichoscopy because they do not differ significantly from straight hairs [60]. However, there are some limitations; the characteristic sign of ‘tiger tail’ in trichothiodystrophy can not be observed by trichoscopy and light microscopy is more useful [62]. In addition, when pediculosis capitis can be suspected, trichoscopy should not be performed because direct touch to hair shafts may cause contagions.

Expert commentary & five-year view

Because of increasing trichoscopic findings in hair diseases, trichoscopy has become a very important technique and allowed us to avoid scalp biopsy for difficult cases. In the next 5 years, more observations will be reported and subsequently how we understand the accumulated discoveries should be pivotal. Here, one strategy for this purpose based on an algorithmic method was proposed but there could be other approaches, which are expected to improve our knowledge about hair diseases. Furthermore, trichoscopy can be used for quantitative analysis as mentioned above and additional criteria for other diseases will be developed in the future. However, summarizing and standardizing trichoscopic nomenclature will be needed as various terminologies were and will be introduced. Moreover, recently UV-enhanced trichoscopy has been introduced by Rudnicka et al. [24], and by using this new equipment, tinea capitis, pityrosporum folliculitis and porphyria are more precisely and easily diagnosed because the UV light covers the spectrum of a Wood’s lamp. Furthermore, sophisticated methods for trichoscopy are expected to be developed in the future. As a new technique, reflectance confocal laser scanning microscopy has been reported to be helpful for observing hair follicle structures in hair loss diseases [63–65] and is expected to be investigated in more detail.

Table 1. Characteristic trichoscopic features of hair shaft abnormalities.

Study (year)	Disease	Trichoscopic feature	Ref.
Rakowska et al. (2007) Wallace et al. (2009)	Monilethrix	Regularly bended ribbon sign	[11]
Wallace et al. (2009)	Chemically dyed	Hair color change, sharply demarcated	[62]
Wallace et al. (2009) Rakowska et al. (2008)	Netherton syndrome	Nodules on hair shaft Golf tee-like end	[62] [60,61]
Wallace et al, (2009)	Bubble hair	Dysmorphia of distal hair shaft	[62]
Wallace et al. (2009) Rakowska et al. (2008)	Pili annulati	Subtle spangly, shimmering appearance with alternating light and black areas Regular width, white bands with misty appearance	[60,62]
Wallace et al. (2009)	Pili torti	Twists in hair shafts	[62]
Rakowska et al. (2008)	Woolly hair syndrome	Crawling snake appearance	[60]
Wallace et al. (2009)	Hair casts	Keratin casts adhering to hair shafts	[62]

Key issues

• • The loss of orifices corresponds to permanent destruction of hair follicles, resulting in fibrosis, indicating the diagnosis of cicatricial alopecia.

• • The existence of micropustules and/or hair tufting with six or more hairs indicates neutrophil- or mixed cell-mediated cicatricial alopecia such as folliculitis decalvans/tufted folliculitis, acne keloidalis and dissecting cellulitis of the scalp.

• • The characteristic features of alopecia areata are broken hairs, black dots, tapering hairs (exclamation mark hairs), yellow dots and short vellus hairs.

• • The activity of alopecia areata can be monitored by the ratio of pathognomic hairs such as broken hairs, black dots and tapering hairs and short vellus hairs.

• • Among lymphocytic cicatricial alopecia, follicular red dots are specific for discoid lupus erythematosus and hair tufting indicates lichen planopilaris.

• • The hallmark of androgenetic alopecia and tinea capitis is hair diameter diversity (≥20%) and comma hairs, respectively.

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Trichoscopy: a new frontier for the diagnosis of hair diseases

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Activity Evaluation: Where 1 is strongly disagree and 5 is strongly agree

	1	2	3	4	5
1. The activity supported the learning objectives.
2. The material was organized clearly for learning to occur.
3. The content learned from this activity will impact my practice.
4. The activity was presented objectively and free of commercial bias.

1. You are seeing a 25-year-old woman for patchy hair loss on her scalp, and you decide to perform trichoscopy. According to the algorithm in the current review, what is the first question to be answered as you examine this patient?

• □ A Is the hair loss neutrophilic or lymphocytic?

• □ B Are yellow dots present?

• □ C Are black dots present?

• □ D Is the hair loss cicatricial or non-cicatricial?

2. Trichoscopy reveals broken hairs, black dots, yellow dots, and short vellus hairs. What is this patient's probable diagnosis?

• □ A Alopecia areata (AA)

• □ B Frontal fibrosing alopecia (FFA)

• □ C Cicatricial marginal alopecia

• □ D Tinea capitis

3. You suspect that this patient might have temporal triangular alopecia. Which of the following choices is characteristic of this condition?

• □ A Involvement of the temporal scalp only

• □ B Normal follicular openings with vellus hairs surrounded by normal terminal hair areas

• □ C Tapering hairs

• □ D Regrowth of hair within 6 months

4. The patient is ultimately diagnosed with AA. Which of the following findings on trichoscopy correlates with a good prognosis for AA?

• □ A Short vellus hairs

• □ B Black dots

• □ C Tapering hairs

• □ D Broken hairs