|Year : 2020 | Volume
| Issue : 3 | Page : 491-499
Trichoscopy of diseases leading to cicatricial alopecia
Abeer M Kamel, Radwa O.M Kamel, Amina A.F.A.M Amer
Department of Dermatology and Venereology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
|Date of Submission||03-Aug-2020|
|Date of Decision||12-Aug-2020|
|Date of Acceptance||16-Aug-2020|
|Date of Web Publication||2-Oct-2020|
MSc Amina A.F.A.M Amer
Department of Dermatology and Venereology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, 11865
Source of Support: None, Conflict of Interest: None
Background Scarring alopecias show loss of follicular ostia or atrophy. Clinical inflammation is frequently, but not always, present. Histologic inflammation may be present. Ultimately, histologic confirmation is the best method to confirm the presence of a fibrosing/scarring process with loss of hair follicles.
Objective The aim was to identify possible characteristic trichoscopic patterns of diseases leading to primary cicatricial alopecia.
Patients and methods Trichoscopy was carried out on 100 Egyptian patients clinically diagnosed to have cicatricial alopecia. Patients were randomly recruited from the Dermatology Outpatient Clinic, Al Zahraa University Hospital. Patients were categorized according to the cause of primary cicatricial alopecia into eight groups.
Results In this study, the authors had 100 patients. The authors reached the final diagnosis by clinical examination in 83 patients, and 17 patients had a differential diagnosis by clinical examination. When the authors applied the trichoscope on 100 patients, the authors reached the final diagnosis in 98 of them, and two patients still had a differential diagnosis by trichoscopy, so the authors did biopsy for those two patients, and histopathological examination resulted in the final diagnosis.
Conclusion This study confirms that a handheld trichoscope is a very efficient and simple diagnostic tool of cicatricial alopecia.
Keywords: cicatricial alopecia, histopathology, trichoscopy
|How to cite this article:|
Kamel AM, Kamel RO, Amer AA. Trichoscopy of diseases leading to cicatricial alopecia. Sci J Al-Azhar Med Fac Girls 2020;4:491-9
| Introduction|| |
Cicatricial alopecia results from follicular damage that is sufficient to cause the destruction and replacement of pilosebaceous structures by scar tissue. Primary scarring alopecias represent a group of disorders that primarily affect the hair follicles, as opposed to secondary scarring alopecias, which affect the dermis and secondarily cause follicular destruction. Inflammation may predominantly involve lymphocytes or neutrophils .
Cicatricial alopecias that mainly involve lymphocytic inflammation include discoid lupus erythematosus (DLE), lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), central centrifugal alopecia, and pseudopelade (Brocq). Cicatricial alopecias that are due to predominantly neutrophilic inflammation include folliculitis decalvans and dissecting cellulitis (DC). Folliculitis keloidalis is a cicatricial alopecia with a mixed inflammatory infiltrate .
Early diagnosis of primary cicatricial alopecia (PCA) is imperative, and it should be treated aggressively to reduce permanent scarring. Dermoscopy may assist in selecting the optimal site of biopsy for pathological diagnosis .
Dermoscopy is a noninvasive diagnostic technique that permits a magnified view of the components of the epidermis and superficial dermis .
Trichoscopy is a method of hair and scalp evaluation and is used for diagnosing hair and scalp diseases .
In trichoscopy, hair and scalp structures may be visualized at many-fold magnification. Magnifications ranging from 10-fold to 70-fold are most popular in research and clinical practice .
Several previous studies have described some dermatoscopic features of diseases leading to PCA such as scattered dark-brown discoloration of the skin, large yellow dots and thick arborizing vessels in cutaneous (discoid) lupus erythematosus, tubular perifollicular scaling and elongated blood vessels in LPP, minor perifollicular scaling in FFA, tufted hair strands with starburst pattern perifollicular hyperplasia in folliculitis decalvans, and large, ‘3D’ yellow dots imposed over dystrophic hair in DC .
| Aim|| |
The aim is to identify possible characteristic trichoscopy patterns of diseases leading to PCA.
| Patients and methods|| |
The current study is carried on 100 Egyptian patients clinically diagnosed to have cicatricial alopecia. Patients were all randomly recruited from the Dermatology Outpatient Clinics, Al Zahraa University Hospital.
The following were the inclusion criteria:
- All ages and both sexes have been included in the study.
- Patients clinically diagnosed to have cicatricial alopecia.
All patients were subjected to the following:
- Informed written consent was taken, and the study was approved by the Research Ethical Committee of Al-Azhar University and fulfilled all the ethical aspects required in human research.
- Full history, taking including the following items:
- Personal history, including name, age, sex, marital status, occupation, sun exposure habits, and special habits of medical importance.
- Complaint and the associated symptoms or associated systemic symptoms.
- History of the present illness.
- Medical history of other skin or systemic diseases.
- Drug history including drugs for other medical conditions and previous medications for the current lesion.
- Full clinical examination:
- General medical examination.
- Cutaneous examination, including skin, hair, nail, mucous membranes, and draining lymph nodes.
- Examination of the lesion: site, skin changes, type of remaining hair, number, and dimensions.
- Digital photography of the lesion.
- Dermoscopic examination and photography: the dermoscope used in the current study was Dermlite DL4 (3Gen, San Juan Capistrano, USA). It provided 10-fold magnifications. Dermoscopic image capturing was performed by a single practitioner to avoid diversification during the procedure.
- The following dermoscopic structures were assessed in each case:
- Folliclular ostia.
- Perifollicular and interfollicular epidermis.
- Hair shafts.
- Vascular structures.
- Skin biopsy was done in some cases.
The collected data was revised, coded, tabulated, and introduced to a personal computer using Microsoft Excel (Microsoft Company American multinational technology company with headquarters in Redmond, Washington, USA). Data were presented, and suitable analysis was done according to the type of data obtained for each parameter.
Mean±SD and range were used for parametric numerical data and frequency and percentage for nonnumerical data.
| Results|| |
This study included 100 patients with PCA. Patients were categorized according to the cause of PCA into eight groups as shown in [Table 1].
Results of dermoscopic features among each group and their frequency
Acne Keloidalis Nuchae cases
They showed absent follicular ostia in a white structureless area in 93% of cases; broken hair in 79% of cases; erythematous area and scales in 64% of cases; perifollicular cast in 57% of cases; entrapped hair and tufted hair in 43% of cases; microulceration and yellow areas in 29% of cases; pustules in 21% of cases; yellowish scales in 14% of cases; and black dots, dystrophic hair, telangiectasia, and perifollicular scales in 7% of cases, as shown in [Figure 1].
|Figure 1 Frequency of dermoscopic features in patients with Acne Keloidalis Nuchae.|
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Dissecting cellulitis cases
They showed broken hair, black dots, dystrophic hair, pustules, absent follicular ostia in a white structureless area, and yellow dots in 100% of cases; erythematous area, microulceration, and 3D bubbles yellow dots in 75% of cases; and telangiectasia, yellow areas, cadavarized hair, and follicular plugging in 50% of cases, as shown in [Figure 2].
|Figure 2 Frequency of dermoscopic features in patients with dissecting cellulitis.|
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Discoid lupus erythematosus cases
They showed follicular plugging in 76% of cases; erythematous areas in 67% of cases; absent follicular ostia in a white structureless area and telangiectasia in 52% of cases; scales in 43% of cases; perifollicular scale in 24% of cases; red dots in 19% of cases; hyperpigmented rim and arborizing blood vessels in 14% of patients; black dots, microulceration, yellow dots, vellus hair, and small upright hair, each showed same frequency, which is 10% of cases; and interfollicular blue gray area, regrowing hair, pigtail hair, polymorphous blood vessels, and yellow crustations, each showed same frequency, which is 5% of cases, as shown in ‘[Figure 3]‘.
They showed tufted hair in 82% of cases, microulceration in 64% of cases, absent follicular ostia in a white structureless area in 55% of cases, scales in 45% of cases, perifollicular scale in 45% of cases, erythematous area and pustules in 36% of cases, violaceous areas in 27% of cases, brownish pigmentation in 18% of cases, and telangiectasia and yellowish crustations in 9% of cases, as shown in [Figure 4].
Frontal fibrosing alopecia cases
They showed absent vellus hair in the frontal hairline in 100% of cases, perifollicular scale in 95% of cases, perifollicular cast in 70% of cases, absent follicular ostia in a white structureless area in 60% of cases, scales in 50% of cases, erythematous area in 30% of cases, lonely hair strands in 20% of cases, and brownish pigmentation in 10% of cases, as shown in [Figure 5].
Lichen-DLE overlap cases
They showed absent follicular ostia in a white structureless area in 100% of cases, and erythematous area, scales, telangiectasia, perifollicular scales, interfollicular blue gray area, red dots, follicular plugging, and brownish pigmentation in 50% of cases, as shown in [Figure 6].
|Figure 6 Frequency of dermoscopic features in patients with Lichen-discoid lupus erythematosus overlap.|
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Lichen planopilaris cases
They showed absent follicular ostia in a white structureless area in 95% of cases, perifollicular scale in 95% of cases, perifollicular cast in 84% of cases, scales in 74% of cases, peripilar violaceous halo in 63% of cases, erythematous area in 53% of cases, brownish pigmentation in 21% of patients, absent vellus hair in the frontal hairline in 16% of cases, and telangiectasia in 5% of cases, as shown in [Figure 7].
|Figure 7 Frequency of dermoscopic features in patients with lichen planopilaris.|
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Pseudopelade of Brocq cases
They showed absent follicular ostia in a white structureless area in 80% of cases and erythematous area, pigtail hair, and brownish pigmentation in 20% of cases, as shown in [Figure 8].
|Figure 8 Frequency of dermoscopic features in patients with Pseudopelade of Brocq.|
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| Discussion|| |
The present study included 100 patients with PCA. Patients were categorized according to the cause of PCA into eight groups.
In DLE group, our results were comparable to Lallas et al.  who stated that follicular keratotic plugs, telangiectasias and perifollicular scale were the most common dermoscopic criteria and also with Rakowskaet al.  who stated that the most characteristic trichoscopic features of DLE were keratotic plugs, thick arborizing vessels, scattered dark-brown discoloration and blue gray dots.
We reported arborizing blood vessels in 14% of DLE cases and polymorphous blood vessels in 5% of DLE cases and not in any other groups, so we considered these signs were specific for DLE diagnosis. Miteva and Tosti  stated that tortuous branching vessels represented the most common finding in DLE.
Regarding LPP group, our results were in accordance with Rakowska et al.  who stated that the most characteristic trichoscopic features of LPP were perifollicular scaling, tubular perifollicular hyperkeratosis, perifollicular inflammation, and violaceous areas.
Regarding Acne Keloidalis Nuchae (AKN) group, our results coincided with Rudnicka et al. , who stated that tufted hair strands, crusting, and follicular pustules were the most frequent trichoscopic signs. Moreover, they were similar to Miteva and Tosti , who stated that trichoscopic features of AKN were broken hair strands with tufting, ingrown hair strands, and peripilar casts.
Our results showed presence of entrapped hair strands in 43% of AKN cases and not in any other groups of PCA, and according to our knowledge, we considered it a specific sign for AKN diagnosis.
Regarding FD group, our results coincided with Otberg et al. , who stated that the most characteristic trichoscopic feature of folliculitis decalvans was the presence of hair tufts that contain 5 to less than 20 hair shafts commonly surrounded by a band of yellowish scales and perifollicular epidermal hyperplasia arranged in a starburst pattern. However, the results were in contrast to Miteva and Tosti  who stated that tufted hair strands can be seen also in LPP, and in this condition, the tuft consists only of 2–3 hair strands. Moreover, the results were consistent with Rakowska et al.  who stated that tufted hair strands, perifollicular hyperplasia, yellowish tubular scaling and follicular pustules, and white and milky red areas lacking follicular openings were frequent signs of FD. Moreover, Rudnicka et al.  reported follicular pustules and yellow discharge in FD cases.
Additionally, we detected tubular scaling in our FD cases. This in accordance with Rudnicka et al.  who stated that tubular scales have been shown to occur characteristically in folliculitis decalvans and LPP.
In comparison between FD and AKN, we found tufted hair in 43% of AKN cases and 82% of FD cases. Rudnicka et al.  stated that the most characteristic trichoscopic feature of folliculitis decalvans was the presence of hair tufts that contain 5 to less than 20 hair shafts emerging from one single dilated follicular orifice (polytrichia). Our results showed its presence in AKN also.
Regarding FFA group, our results coincided with Toledo-Pastrana et al.  who stated that, in a population of 79 women, 100% showed no follicular opening, 72.1% follicular hyperkeratosis, 66.3% perifollicular erythema, and 44.8% follicular plugs. Thus, 100% of patients had at least one of the dermoscopic elements described as suggestive of FFA, 53% had two of them, 45% had three, and 27% had all those elements. Perifollicular erythema was present in 95% of cases in which the disease was active. In contrast to this study, we did not detect follicular plugging but we detected absent vellus hair in 100% of patients.
We found lonely hair sign in 20% of FFA cases and not in any other groups, so we considered it a specific sign for diagnosing FFA. We agreed with Tosti et al.  who stated that lonely hair strands surrounded by areas of fibrosis are a clue for diagnosing FFA. In contrast, Camacho  stated that they also present with any type of scarring alopecia.
Regarding Pseudopelade of Brocq (PPOB) group, our results showed dermoscopic features in the form of absent follicular ostia in a white structureless area (porcelain ‘ivory-white’ areas) in 80% of cases, and erythematous area, pigtail hair, and brownish pigmentation in 20% of cases. Our results coincided with Rudnicka et al.  who reported that loss of follicular ostia and ivory-white areas were signs of PPOB.
Regarding DC group, our results coincided with Rudnicka et al.  who stated that trichoscopy shows yellow structureless areas and 3D yellow dots imposed over dystrophic hair shafts. Black dots, pinpoint-like vessels, with a whitish halo occasionally were present. End-stage fibrotic lesions were characterized by confluent ivory-white or white areas lacking follicular openings.
Regarding DLE-lichen overlap group, we were the first to report absent follicular ostia in a white structureless area in 100% of cases, and erythematous area, scales, telangiectasia, perifollicular scales, interfollicular blue gray area, red dots, follicular plugging, and brownish pigmentation in 50% of cases. Up to our knowledge, there are no previous studies in literature about dermoscopic signs of this overlap.
In our study, we observed red dots in 19% cases of DLE and in 52% of patients with lichen-DLE overlap. Tosti et al.  were the first to report this dermoscopic criterion and stated that the follicular red dot pattern is a dermoscopic feature of active scalp DLE. They postulated that recognition of this distinctive dermoscopic pattern may help the clinician differentiate DLE from other diseases causing cicatricial alopecia. Later on, Karadağ Köse and Güleç  observed red dots in patients with PCA (66.7%), in patients with androgenetic alopecia (18.6%), in patients with alopecia areata (16.6%), and in patients with telogen effluvium (5.3%). They postulated that they could represent the counterpart of simple red loops and twisted red loops that are appreciated at 50-fold or higher magnifications by videodermatoscopy.
In comparison between DLE and DC, it was revealed that yellow dots were present in 100% of DC cases and 10% of DLE cases. In DC, it is a three-dimensional (3D) structure imposed over dystrophic hair shafts and called 3D yellow dots.
Our study showed that 3D yellow dots presented in 75% of DC cases and not presented in any other groups of PCA, so we considered it a specific sign for diagnosing DC, and this is consistent with Rakowska et al.  who stated that yellow dots, appearing as large ‘3D’ soap bubbles imposed over dark dystrophic hair strands are specific for DC.
The identification of cicatricial alopecia is primarily based on the absence of follicular openings, manifesting in trichoscopy as empty dots .
In our study, absent or reduced follicular openings in whitish structureless areas was present in 52% of DLE cases, 95% of LPP cases, 93% of AKN cases, 64% of kerion cases, 55% of FD cases, 60% of FFA cases, 80% of PPOB cases, and 100% of DC and lichen-DLE overlap cases. It was found in all groups, so we considered it a hallmark of PCA. Corresponding to our results, Karadağ Köse and Güleç  observed white structureless areas in 95.2% of patients with PCA.
| Conclusion|| |
The diagnosis of PCA is challenging because of overlapping features clinically and histopathologically. Trichoscopy may provide quick and reliable diagnosis and obviate the necessity of scalp biopsy in busy clinics.
Introduction of dermoscopy as a routine diagnostic tool in dermatological examination will be of a great aid for accurate diagnosis of cicatricial alopecia.
Supplementary prospective, blinded studies are needed over a larger scale of patients in each separate type of cicatricial alopecia to further quantify the predictive power of the dermoscopic patterns observed in this study.
Prospective studies should be done on cicatricial alopecia with long-term post-treatment follow-up to determine the effect of treatment on changing the dermoscopic features of the disease.
Financial support and sponsorship
Conflicts of interest
There is no conflicts of interest.
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