Vous êtes sur la page 1sur 5

doi: 10.1111/j.1346-8138.2010.01119.

x Journal of Dermatology 2011; 38: 71–75

INVITED ARTICLE

Trichoscopy for common hair loss diseases:


Algorithmic method for diagnosis
Shigeki INUI
Department of Regenerative Dermatology, Graduate School of Medicine, Osaka University, Osaka, Japan

ABSTRACT
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), peri-
follicular 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.
Key words: alopecia areata, androgenetic alopecia, cicatricial alopecia, trichoscopy, trichotillomania.

INTRODUCTION and severity4 but can be seen also in trichotillomania,


which should be noted for differential diagnosis of
In recent years, the usefulness of trichoscopy (scalp AA. In addition, as similar features, ‘‘comma hairs’’
dermoscopy)1 has been reported for hair loss dis- are observed in tinea capitis.5 The tapering hairs
eases. Here, characteristic trichoscopic features of (Fig. 1b), corresponding to rapid catagen induction in
common hair loss diseases are described using a AA, are seen in 31.7%,4 providing an indicator for dis-
DermLite II pro (3Gen, San Juan Capistrano, CA, ease activity. This category contains ‘‘coudability
USA) or Epilight eight (Ondeko, Tokyo, Japan) and an hairs’’ (Fig. 1c),6 normal-looking hairs tapered at the
algorithmic method for trichoscopic diagnosing is proximal aspect, which were previously reported as
proposed. another sign of AA.7 The broken hairs (Fig. 1d) are
encountered in 45.7% of the 300 case series and
positively correlated with disease activity4 while they
ALOPECIA AREATA
can be seen in trichotillomania. The yellow dots
Characteristic trichoscopic features of alopecia areata (Fig. 1e), first reported by Ross et al.,2 are considered
(AA) are black dots, tapering hairs (exclamation to be a mixture of immature hair shaft and sebum.3
mark hairs), broken hairs, yellow dots and short vel- The previous study suggested that they positively
lus hairs2–4 (Fig. 1). Among these, the black dots, correlate with AA severity and have a tendency of
tapering hairs and broken hairs are known as positive correlation with AA activity.4 As a diagnostic
pathognomonic hairs of AA. marker, the yellow dots are sensitive but not specific
The black dots (Fig. 1a), seen in 44.3% of the 300 because they can be seen in other hair loss disea-
case series, positively correlate with disease activity ses including androgenetic alopecia (AGA) (Fig. 3c),

Correspondence: Shigeki Inui, M.D., Ph.D., Department of Regenerative Dermatology, Graduate School of Medicine, Osaka University, 2-2 G2,
Yamada-oka, Suita-shi, Osaka 5650871, Japan. Email: inui@r-derma.med.osaka-u.ac.jp
Received 27 August 2010; accepted 27 August 2010.

 2011 Japanese Dermatological Association 71


S. Inui

(a) (b) (c)

(d) (e) (f)

Figure 1. Trichoscopic findings in alopecia areata: (a) black dots, (b) tapering hairs (exclamation mark hairs), (c) coudability
hairs, (d) broken hairs, (e) yellow dots, (f) short vellus hairs.

(a) (b)

Figure 2. Yellow dots in (a) hypotrichosis congenita and (b) kerion celsi.

hypotrichosis congenita (Fig. 2a) and kerion celsi ANDROGENETIC ALOPECIA


(Fig. 2b). The clustered short vellus hairs (Fig. 1f)
shorter than 10 mm, seen in 44.3% of the series of In AGA, hair diameter diversity (HDD), perifollicular
the 300 cases, negatively correlated with disease pigmentation ⁄ peripilar sign and yellow dots are
activity and severity.4 They can be observed on seem- trichoscopically observed. In all cases of AGA and
ingly complete hair loss areas, providing a sensitive female AGA (FAGA), HDD more than 20%, which cor-
diagnostic marker for AA. Indeed, either yellow dots responds to vellus transformation,8,9 can be seen
or short vellus hairs are seen in 94% of AA.4 (Fig. 3a), providing a useful hallmark to diagnose early

72  2011 Japanese Dermatological Association


Trichoscopy for common hair loss diseases

(a) (b)

(c)

Figure 3. Trichoscopic findings in androgenetic alopecia.


(a) Hair diameter diversity, (b) perifollicular pigmentation ⁄
peripilar sign, (c) yellow dots (arrowhead).

AGA. However, hereditary hypotrichosis simplex (a) (b)


(HHS), a rare autosomal dominant form of hair loss
characterized by hair follicle miniaturization, must be
considered10,11 in cases of young patients with HDD.
To rule out HHS, the recent finding of a mutation
(Leu9Arg) in the adenomatosis polyposis downregu-
lated 1 (APCDD1) gene in HHS is useful.11 The perifol-
licular pigmentation ⁄ peripilar sign (Fig. 3b) was first
described by Deloche et al.12 and in their report all
cases of AGA showed this sign in white but in Asian
patients only 66% (33 ⁄ 50) showed it, ascribing the
discrepancy to interference by skin color.9 Yellow
Figure 4. Trichoscopic findings in cicatricial alopecia. (a)
dots (Fig. 3c) are seen in 26% (13 ⁄ 50) of AGA patients Loss of orifices in frontal fibrosing alopecia, (b) hair tufting in
and their number was up to 10 on the whole scalp folliculitis decarvans.
while yellow dots in AA are more numerous.

ing perifollicular erythema or scale and hair tufting


CICATRICIAL ALOPECIA
(Fig. 4b) were observed.13,14 Hair tufting can be seen
In cicatricial alopecia (CA), the loss of orifices (Fig. 4a), in CA such as folliculitis decarvans ⁄ tufted folliculitis,
a hallmark of CA and the associated changes includ- acne keloidalis, dissecting cellulitis of the scalp, kerion

 2011 Japanese Dermatological Association 73


S. Inui

Hair tufting Folliculitis decarvans/tufted folliculitis, acne keloidalis, dissecting cellulitis


of the scalp, kerion celsi, lichen planopilaris

Cicatricial Red dots DLE


(+) alopecia

Neither Diagnosis from clinical appearance and/or histopathology


(consider all types of cicatricial alopecia)

Numerous Alopecia areata


Loss of Yellow dots Hair diameter diversity (≥20%) Androgenetic alopecia
orifices A few
Other alopecia: hypotrichosis congenita, Kerion celsietc

Tapering hairs Alopecia areata

Short vellus hairs Alopecia areata


(–) Non-cicatricial Black dots and/or (activity (BD + BH + TH)/SVH)*
alopecia broken hairs
Curled hairs Trichotillomania**
(sometimes associated with alopecia areata)
No findings Alopecia areata and/or trichotillomania

Perifollicular scale/sebum Seborrheic alopecia***

Short vellus hairs, many Alopecia areata, remitting


Neither
Hair diameter diversity (≥20%) Androgenetic alopecia

No findings Telogen effluvium

Figure 5. Algorithmic method for trichoscopic diagnosis of common hair loss diseases. *The activity of alopecia areata is
estimated by the ratio of pathognomonic hairs ⁄ short vellus hairs. **In trichotillomania, curled hairs, caused by strong pulls, are
often seen. ***Seborrheic alopecia can be diagnosed by the perifollicular scale and sebum in hair follicles more than 10 in annular
zones with approximate 2.5-cm diameters. BD, black dots; BH, broken hairs; DLE, discoid lupus erythematosus; SVH, short
vellus hairs; TH, tapering hairs.

celsi and lichen planopilaris.15 Further, Tosti et al.16 REFERENCES


have recently reported that the follicular red dot
pattern is a specific feature of active lupus erythe- 1 Rudnicka L, Olszewska M, Rakowska A et al. Tricho-
scopy: a new method for diagnosing hair loss. J Drugs
matosus of the scalp.
Dermatol 2008; 7: 651–654.
2 Ross EK, Vincenzi C, Tosti A. Videodermoscopy in the
ALGORITHMIC METHOD FOR evaluation of hair and scalp disorders. J Am Acad
Dermatol 2006; 55: 799–806.
TRICHOSCOPIC DIAGNOSIS OF COMMON 3 Inui S, Nakajima T, Itami S. Dry dermoscopy in clinical
HAIR LOSS DISEASES treatment of alopecia areata. J Dermatol 2007; 34: 635–
639.
Based on previous reports and observations, herein, 4 Inui S, Nakajima T, Nakagawa K et al. Clinical signifi-
an algorithmic method for trichoscopic diagnosis of cance of dermoscopy in alopecia areata: analysis of 300
common hair loss diseases is proposed (Fig. 5). In the cases. Int J Dermatol 2008; 47: 688–693.
clinical practice, diagnosis should be comprehen- 5 Slowinska M, Rudnicka L, Schwartz RA et al. Comma
sively made from clinical appearance and trichos- hairs: a dermatoscopic marker for tinea capitis: a rapid
diagnostic method. J Am Acad Dermatol 2008; 59:
copy. When these findings are not consistent, biopsy
S77–S79.
should be considered. Because this scheme deals 6 Inui S, Nakajima T, Itami S. Coudability hairs: a revisited
with typical cases of a limited range of hair loss dis- sign of alopecia areata assessed by trichoscopy. Clin
eases, it will be revised hereafter. Exp Dermatol 2010; 35: 361–365.

74  2011 Japanese Dermatological Association


Trichoscopy for common hair loss diseases

7 Shuster S. ‘Coudability’: a new physical sign of alopecia genetic alopecia. Arch Dermatol Res 2004; 295: 422–
areata. Br J Dermatol 1984; 111: 629. 428.
8 Tosti A, Iorizzo M, Piraccini BM. Androgenetic alopecia 13 Inui S, Nakajima T, Shono F et al. Dermoscopic findings
in children: report of 20 cases. Br J Dermatol 2005; 152: in frontal fibrosing alopecia: report of four cases. Int J
556–559. Dermatol 2008; 47: 796–799.
9 Inui S, Nakajima T, Itami S. Scalp dermoscopy of andro- 14 Harries MJ, Trueb RM, Tosti A et al. How not to get
genetic alopecia in Asian people. J Dermatol 2009; 36: scar(r)ed: pointers to the correct diagnosis in patients
82–85. with suspected primary cicatricial alopecia. Br J Derma-
10 Toribio J, Quinones PA. Hereditary hypotrichosis sim- tol 2009; 160: 482–501.
plex of the scalp. Evidence for autosomal dominant 15 Annessi G. Tufted folliculitis of the scalp: a distinctive
inheritance. Br J Dermatol 1974; 91: 687–696. clinicohistological variant of folliculitis decalvans. Br J
11 Shimomura Y, Agalliu D, Vonica A et al. APCDD1 is a Dermatol 1998; 138: 799–805.
novel Wnt inhibitor mutated in hereditary hypotrichosis 16 Tosti A, Torres F, Misciali C et al. Follicular red dots: a
simplex. Nature 2010; 464: 1043–1047. novel dermoscopic pattern observed in scalp discoid
12 Deloche C, de Lacharriere O, Misciali C et al. Histolog- lupus erythematosus. Arch Dermatol 2009; 145: 1406–
ical features of peripilar signs associated with andro- 1409.

 2011 Japanese Dermatological Association 75