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Trichoscopy (or dermoscopy of hair and scalp) is an easy in-office technique that may be performed with a handheld dermoscope or a digital videodermoscopy system. This method is gaining increasing popularity, because it may be applied in differential diagnosis of multiple hair and scalp diseases. The focus of this article is application of trichoscopy in differential diagnosis of the most frequent hair and scalp diseases in dermatologic practice. Trichoscopy of genetic hair shaft abnormalities are briefly addressed. A new classification of perifollicular and interfollicular skin surface abnormalities is proposed.

Key Points

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Trichoscopy (hair and scalp dermoscopy) may be performed with any handheld or digital dermoscope.
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This method may be used as a diagnostic aid in differential diagnosis of hair loss and scalp diseases and in monitoring therapy.
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Trichoscopy diagnosis is based on evaluation of hair shafts, follicular openings, and perifollicular epidermis.
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Characteristic trichoscopy features of several hair and scalp diseases are known. These diseases include alopecia areata, androgenetic alopecia, discoid lupus erythematosus, folliculitis decalvans, genetic hair shaft abnormalities, lichen planopilaris, scalp psoriasis, tinea capitis, and trichotillomania.

Trichoscopy is based on analysis of structures that may be visualized with a dermoscope. These basic structures may be divided into 4 groups: (1) hair shafts, (2) hair follicle openings (dots), (3) perifollicular epidermis, and (4) blood vessels.

Basic structures

Evaluation of Hair Shafts

The authors have recently suggested a classification of hair shaft abnormalities that may be visualized by trichoscopy. This classification distinguishes the following groups of hair shaft abnormalities: (1) hair shafts with fractures, (2) hair narrowings, (3) hairs with node-like structures, (4) curls and twists, (5) bands, and (4) short hairs. Only selected types of abnormalities are discussed in this article.

Many types of short hairs appear crucial for differential diagnosis of the most frequent types of hair loss in clinical practice. These are hairs that are less than 5 mm long. They include, among others, bent and hypopigmented vellus hairs, which are most characteristic of androgenetic alopecia. Vellus hairs may be also present in long-lasting, severe alopecia areata. Another type of short hairs is comma and corckscrew hairs, which are characteristic for tinea capitis. Short flame-like hairs are observed in trichotillomania.

Micro–exclamation mark hairs are hairs with narrowings at the proximal end. This type of abnormality is observed in alopecia areata and in trichotillomania.

Evaluation of Hair Follicle Openings (Dots)

With trichoscopy, whether hair follicle openings are normal, empty, fibrotic, or contain biologic material, such as hyperkeratotic plugs or hair residues, may be distinguished. Dots is a common term for hair follicle openings seen by trichoscopy.

Black dots (formerly called cadaverized hairs) represent pigmented hairs broken or destroyed at scalp level. They are observed in alopecia areata, dissecting cellulitis, tinea capitis, and trichotillomania.

Yellow dots are hair follicle openings that contain keratosebaceous material. They may be observed in alopecia areata, discoid lupus ertythematosus, and female androgenic alopecia. Rarely, yellow dots may be observed in telogen effluvium and trichotillomania. Yellow dots, appearing as large 3-D soap bubbles imposed over dark dystrophic hairs, are specific for dissecting cellulitis.

There are 2 types of white dots: classic, big, irregular white dots and pinpoint white dots. Classic white dots represent areas of perifollicular fibrosis and are observed most commonly in lichen planopilaris. Pinpoint white dots correspond to hair follicle openings and eccrine gland openings, observed within pigmented background. They are present in patients with dark skin phototypes, regardless of hair loss.

Red dots are described in discoid lupus erythematosus and are considered a good prognostic finding, indicating possible hair regrowth.

Regularly distributed gray or brown-gray dots are a characteristic finding in the eyebrow area of patients with frontal fibrosing alopecia.

Evaluation of Perifollicular Epidermis

Abnormalities of scalp skin color or structure that may be visualized by trichoscopy include scaling, changes in color, abnormalities in skin surface structure, and presence of discharge. A new classification of these abnormalities is presented in Box 1 , which indicates the clinical significance of individual abnormalities.

BOX 1

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Scaling
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  Diffuse
  - ▪
    White (psoriasis, discoid lupus erythematosus, allergic dermatitis, dry skin)
  - ▪
    Yellowish (seborrheic dermatitis, discoid lupus erythematosus, ichthyosis)
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  Perifollicular
  - ▪
    Color of scales
    - •
      White (lichen planopilaris)
    - •
      Yellowish (folliculitis decalvans)
  - ▪
    Shape of scale arrangement
    - •
      Tubular (lichen planopilaris)
    - •
      Tubular with collar formation (folliculitis decalvans)
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Color
- ○
  Brown areas
  - ▪
    Honeycomb hyperpigmentation (common)
  - ▪
    Perifollicular; peripilar sign (female and male androgenetic alopecia, telogen effluvium, healthy individuals)
  - ▪
    Scattered (discoid lupus erythematosus, actinic keratosis)
- ○
  White areas (cicatricial alopecia, detached epidermis, edema)
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  Pink, strawberry ice cream–color areas (early fibrosis in cicatricial alopecia)
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  Yellow areas (dissecting cellulitis, follicular pustules, bacterial infection)
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  Red (inflammation, extravasation, erosion, vascular abnormalities)
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  Violaceous blue (lichen planopilaris, discoid lupus erythematosus)
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Discharge
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  Yellow and yellow-red (folliculitis decalvans, bacterial infections, dissecting cellulitis, tinea capitis)
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  White follicular spicules (monoclonal gammopathy)
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Surface structure
- ○
  Starburst pattern hyperplasia (folliculitis decalvans)

Classification of perifollicular and interfollicular skin surface abnormalities in trichoscopy (most common or characteristic occurrences shown in parentheses)

Data from Rudnicka L, Olszewska M, Rakowska A, editors. Trichoscopy: dermoscopy of hair and scalp. Springer-Verlag; 2012.

Evaluation of Blood Vessels

Appearance of cutaneous microvessels in trichoscopy may vary in type, arrangement, and number, depending on disease. Analysis of blood vessel arrangement is of special importance in differential diagnosis of inflammatory scalp diseases, such as scalp psoriasis, seborrheic dermatitis, or discoid lupus erythematosus.

Differential diagnosis of nonscarring alopecia

Telogen Effluvium

The term, telogen effluvium , refers to a wide range of clinical situations with the common feature of abrupt, generalized shedding of telogen hairs. It is considered the most common type of hair loss, but only limited evidence-based knowledge is available.

Trichoscopy findings in telogen effluvium include presence of empty hair follicles, predominance of follicular units with only 1 hair, perifollicular discoloration (peripilar sign), and upright regrowing hairs ( Fig. 1 , Table 1 ). Trichoscopy results do not differ depending on the factor that induced telogen hair loss.

Table 1

Trichoscopy features of telogen effluvium and androgenetic alopecia

	Telogen Effluvium	Androgenetic Alopecia
Follicular units with only 1 hair	+	++
Upright regrowing hairs	++	±
Perifollicular discoloration (peripilar sign)	+	++
Vellus hairs	−	+
Hair shaft thickness heterogeneity	−	+
Predominance of abnormalities in the frontal region	−	+

+, Increased; ++, significantly increased.

Adapted from Rudnicka L, Olszewska M, Rakowska A, editors. Trichoscopy: dermoscopy of hair and scalp. Springer-Verlag; 2012.

Androgenetic Alopecia

Male androgenetic alopecia and female androgenetic alopecia share similar trichoscopy features. Hair shaft thickness heterogeneity, with simultaneous presence of thin, intermediate, and thick hairs, is the most characteristic feature of androgenetic alopecia. It has been shown that hair diameter diversity reflects follicle miniaturization in androgenetic alopecia. Hair thickness may be estimated when performing trichoscopy with a handheld dermoscope. With this method, hair shafts may classified as thin, intermediate, or thick. Some digital videodermoscopes possess software that allows detailed evaluation of hair shaft thickness in micrometers. Detailed evaluation of hair shaft thickness is not necessary for diagnosis and differential diagnosis in clinical practice but may be useful for monitoring treatment efficacy and is indispensable for clinical trials.

Another trichoscopy feature of androgenetic alopecia is increased proportion of vellus hairs. The proportion of vellus hairs in the frontal scalp area of patients with female androgenetic alopecia is 20.9% ± 12%. This is significantly more than the 6.15% ± 4.6% in healthy volunteers. Multiple vellus hairs may be also present in severe alopecia areata. Thus, sole presence of vellus hairs should not be mistaken for androgenetic alopecia.

The number of hairs in 1 follicular unit is decreased in androgenetic alopecia. Follicular units with only 1 hair predominate in these patients, especially in a late phase of disease. In the frontal area of patients with female androgenetic alopecia, average percentage of follicular units with only 1 hair is 65.2% ± 19.9%. The corresponding number in healthy individuals is 27.3% ± 13%. The percentage of follicular units with only 1 hair is also increased in telogen effluvium (39.0% ± 13.4%) and in various forms of anagen hair loss.

The authors' experience and study results of show presence of yellow dots a constant finding in androgenetic alopecia, but literature data are inconsistent.

In different studies, yellow dots were observed in 66%, 30.5%, 10% to 26%, and 7% of patients with androgenetic alopecia. The authors find an explanation for this discrepancy in that in androgenetic alopecia some yellow dots have only sebaceous content and not keratosebaceous material, as in other diseases. These sebaceous yellow dots may be washed away by a vigorous hair wash. Accordingly, when patients come for a trichoscopy examination directly after washing their hair, these yellow dots may not be detectable. In the authors' practice, in patients with noncicatricial alopecia, trichoscopy is always performed together with a trichogram. For this reason, patients are asked to not wash their hair for 3 days before examination. The small, sebaceous yellow dots may develop during these 3 days. This hypothesis is partly confirmed by the authors' unpublished observations, showing that the number of sebaceous yellow dots in androgenetic alopecia is higher before than after hair washing. No other trichoscopy features depend on hair washing.

Brown perifollicular discoloration (peripilar sign) is observed in 20% to 66% of patients with androgenetic alopecia. A proportion of 32.4% ± 4.7% hair follicle openings are affected. This feature may be also observed in some patients with telogen effluvium and in healthy individuals with the difference that in androgenetic alopecia the proportion of affected hair follicle openings is higher in the frontal compared with the occipital area. In healthy individuals and in patients with telogen effluvium, the proportion of affected hair follicle openings is significantly lower and the distribution is proportional in all scalp areas. Table 1summarizes the major differences between androgenetic alopecia and telogen effluvium. Fig. 2 presents major trichoscopy features of androgenetic alopecia.

Trichoscopy of senescent (senile, involutionary) alopecia shares with androgenetic alopecia predominance of follicular units with only 1 hair, decreased hair shaft density with honeycomb pattern pigmentation, and slight tendency to form brown perifollicular discoloration (peripilar sign).

Alopecia Areata

In most cases, alopecia areata is diagnosed based on clinical appearance. Trichoscopy may be useful, however, for differential diagnosis of difficult cases, in particular in diffuse alopecia areata or in patients with total hair loss.

The hallmark trichoscopy features of alopecia areata are regularly distributed yellow dots, micro–exclamation mark hairs, tapered hairs, black dots, broken hairs, and regrowing hairs. Trichoscopy of alopecia areata may differ depending on diseases activity, severity, and duration. These differences were evaluated in multiple studies in recent years.

Lacarrubba and colleagues investigated 200 patients with alopecia areata, subdivided into acute and chronic disease. This study identified 3 features of acute alopecia areata: micro–exclamation marks, black dots, and vellus hairs. Inui and colleagues identified similar markers of disease activity (black dots, tapering hairs, and broken hairs) based on trichoscopy performed in 300 patients with alopecia areata. In this study, vellus hairs were found to be a marker of long-lasting, inactive disease. Ross and colleagues divided 58 patients with alopecia areata into the following subgroups: patchy, ophiasis, diffuse, and alopecia totalis/universalis. Trichoscopy features were similarly expressed in all investigated subgroups. The authors' experience shows that black dots are a most constant marker of disease activity in alopecia areata. A recent study from Turkey performed with a handheld dermoscope confirmed earlier data obtained by digital videodermoscopy.

Some patients with active alopecia areata of long duration show monilethrix-like hairs with characteristic Pohl-Pinkus constrictions. In a study by Mane and colleagues, this type of abnormality was observed in 2 of 66 (3%) investigated patients with alopecia areata. Presence of hairs with Pohl-Pinkus constrictions may lead to misdiagnosis of monilethrix.

Features of hair regrowth include pigmented short upright regrowing hairs and regularly coiled pigtail hairs. The authors used the term, pigtail hairs , in a publication to describe hairs that form regular circular or oval structures as they grow. They have to be distinguished from irregularly coiled hairs of trichotillomania.

Trichotillomania is a common and the most difficult differential diagnosis of alopecia areata. Trichoscopy features of alopecia areata are presented in Fig. 3 .

Trichotillomania

Trichoscopy of trichotillomania shows decreased hair density, hairs broken at different lengths, short hairs with trichoptilosis (split ends), irregular coiled hairs, upright regrowing hairs, and black dots. Yellow dots are generally not observed in trichotillomania. Inui and colleagues observed yellow dots in 1 patient with trichotillomania. These dots differed from yellow dots in other diseases by containing a black dot in their central part. The authors' retrospective analysis of trichoscopy images confirms the presence of characteristic yellow dots with fine black peppering inside as a rare but highly characteristic trichoscopy feature of trichotillomania. This finding has to be differentiated from yellow dots in dissecting folliculitis, which are bigger, bulging, and contain a single black hair shaft residue.

In a recent study, the authors identified further characteristic trichoscopy features of trichotillomania. These are hair shaft residues, which appear in trichoscopy as flame hairs, tulip hairs, V-sign, and structureless hair residues ( Table 2 ).

Table 2

Trichoscopy differential diagnosis of trichotillomania

	Trichotillomania	Alopecia Areata
Broken hairs	++	+
Irregular coiled hairs/hook hairs	+	−
Short hairs with trichoptilosis (split ends)	+	−
Micro–exclamation mark hairs	+	++
Tapered hairs	+	++
Flame hairs	+	−
Tulip hairs	++	+
V-sign	++	±
Structureless hair residues	+	±
Black dots	+	++
Yellow dots	±	++
Yellow dots with black peppering	+	−
Regrowing pigtail hairs (circular or oval)	−	+
Hypopigmented vellus hairs	−	+

Adapted from Rudnicka L, Olszewska M, Rakowska A, editors. Trichoscopy: dermoscopy of hair and scalp. Springer-Verlag; 2012.

Micro–exclamation mark hairs are rare in trichotillomania, but they may be a diagnostic pitfall and cause misdiagnosis of alopecia areata. The authors' experience shows that micro–exclamation mark hairs in trichotillomania tend to have a pigmented proximal end and a flat distal end, whereas most micro–exclamation mark hairs in alopecia areata have a hypopigmented proximal end and a pointed distal end.

Alopecia areata may be the initial trigger for trichotillomania and the 2 conditions may coexist, which makes trichoscopic differential diagnosis even more challenging. Table 2 summarizes main differences in trichoscopy between trichotillomania and alopecia areata. Trichoscopy features of trichotillomania are presented in Fig. 4 .

Differential diagnosis of cicatricial alopecia

Cicatricial alopecia is less frequent in clinical practice compared with noncicatricial alopecia and differential diagnosis is rarely difficult. Trichoscopy may be helpful, however, in establishing correct diagnosis in doubtful cases. The most characteristic trichoscopy features of cicatricial alopecia are presented in Table 3 . The table includes the most common types of primary cicatricial alopecia: discoid lupus erythematosus, classic lichen planopilaris, frontal fibrosing alopecia, dissecting cellulitis, and folliculitis decalvans.

Table 3

Trichoscopy features of cicatricial alopecia

		Discoid Lupus Erythematosus	Classic Lichen Planopilaris	Frontal Fibrosing Alopecia	Dissecting Cellulitis	Folliculitis Decalvans
Vessels	Thick arborizing vessels	++	+	−	−	−
	Elongated vessels	+	++	−	−
	Pinpoint-like vessels with whitish halo	−	−	−	++	+
Color	White and milky-red homogenous areas	+	++	++	−	++
	Dark-brown scattered discoloration	+	−	−	−	−
	Violaceous blue discoloration	+	++	−	−	−
	Structure-less yellow areas	−	−	−	+	−
Dots	3-D yellow dots (soap bubbles) with hairs residues	−	−	−	+	−
	Large yellow dots	+	−	−	−	−
	White dots	+	++	+	−	+
	Red dots	+	−	++	−	−
	Gray dots (eyebrows)	−	−	+	−	−
Scaling	Perifollicular scaling	−	++	+	−	+
Hyperplasia	Perifollicular hyperplasia with starburst pattern	−	−	−	−	+

++, Very common; +, common.

Adapted from Rakowska A, Slowinska M, Kowalska-Oledzka E, et al. Trichoscopy in cicatricial alopecia. J Drugs Dermatol 2012;11(6):753–8.

Discoid Lupus Erythematosus

The most characteristic trichoscopy features of discoid lupus erythematosus of the scalp are thick arborizing vessels and large yellow dots. Scattered brown discoloration of the skin may be observed in some patients. Yellow dots with radial, thin arborizing vessels emerging from the dot are considered characteristic for discoid lupus erythematosus. This feature is sometimes referred to as “red spider in yellow dot.” Red dots, described by Tosti and colleagues, are considered a good prognostic factor for of hair regrowth. Long-lasting, inactive lesions differ from active lesions by presence of structureless milky-red areas, and lack of follicular openings ( Fig. 5 ).

Classic Lichen Planopilaris

The most characteristic trichoscopy feature of classic lichen planopilaris is white perifollicular scaling with scales entangling hair shafts up to 2 mm to 3 mm above scalp surface. The authors call this phenomenon, tubular scaling .

Other findings include perifollicular inflammation, elongated blood vessels, and violaceous blue interfollicular areas.

In the fibrotic stage of lichen planopilaris, the predominating features are big, irregular (classic) white dots, which merge into white and/or milky-red areas. The color and appearance of the milky-red areas, which correspond to fibrosis of recent onset, are described by some investigators as strawberry ice cream color ( Fig. 6 ).

Frontal Fibrosing Alopecia

Trichoscopy findings in active frontal fibrosing alopecia include minor perifollicular scaling and predominance of follicular openings with only 1 hair ( Fig. 7 ). Arborizing vessels were described in 1 study but not confirmed by other investigators.

Dissecting Cellulitis

In dissecting cellulitis (dissecting folliculitis, perifolliculitis capitis abscedens et suffodiens) trichoscopy shows yellow, structureless areas. A characteristic finding is yellow dots with 3-D structure imposed over a thick, black, hair shaft residue. The authors consider the term, soap bubbles , used by Dr Sami Abdennader during a conference lecture, adequate to describe this feature ( Fig. 8 ). Pinpoint-like vessels with a whitish halo were described in patients with dissecting folliculitis, but they are not uncommon in other scalp diseases. End-stage disease with scarring lesions is characterized by confluent ivory-white areas lacking follicular openings.

Folliculitis Decalvans

Folliculitis decalvans is characterized by presence of multiple hairs in 1 follicular unit. These follicular tufts usually consist of 5 to 20 hairs. This feature may be observed both clinically and by trichoscopy ( Fig. 9 ). Additional trichoscopy findings include perifollicular hyperplasia arranged in a starburst pattern and follicular pustules. Tubular scaling is observed in 66% of patients with folliculitis decalvans. It differs from tubular scaling in patients with lichen planopilaris by a yellowish color and by a tendency to fold away from the hair shafts and form collar-like structures.

In long-lasting lesions, white or milky-red (strawberry ice cream color) areas lacking follicular openings predominate. White dots are rare. There seems to be no characteristic vascular pattern, although Baroni and Romano observed increased numbers of twisted red loops.

Pseudopelade Brocq

Trichoscopy features of classic pseudopelade of Brocq are nonspecific. These are white areas with no follicular openings. Solitary dystrophic hairs at the periphery of the lesion may be found. Thus, Brocq pseudopelade is a diagnosis of exclusion both clinically and by trichoscopy.

Differential diagnosis of hair shaft abnormalities

Trichoscopy is a perfect tool for noninvasive evaluation of most genetic hair shaft abnormalities. It has been documented that trichoscopy allows detecting characteristic structure abnormalities of monilethrix ( Fig. 10), trichorrhexis invaginata, trichorrhexis nodosa, pili torti, and pili annulati. The first studies were performed with a digital videodermoscopy system, but Silverberg and colleagues showed that trichoscopy with a handheld dermoscope also may be applied as an in-office technique to diagnose genetic diseases of the hair.

Other applications of trichoscopy

Kim and colleagues performed a large study that documented that trichoscopy may be used for differential diagnosis of inflammatory scalp diseases, such as scalp psoriasis and seborrheic dermatitis, based predominantly on structure and arrangement of blood vessels.

Slowinska and colleagues described comma hairs as a characteristic feature of tinea capitis ( Fig. 11 ). Later, Hughes and colleagues identified corckscrew hairs as another characteristic finding in patches of tinea capitis. Recent findings show also zigzag hairs and interrupted (Morse code–like) hairs are observed in these patients.

Accumulating casuistic data indicate that trichoscopy may develop into a method of diagnosis beyond dermatology. Possible application of trichoscopy in identifying follicular spicules in multiple myeloma, follicular mucinosis in lymphoproliferative disorders, or scalp lesions in Langerhans cell histiocytosis is feasible, but requires adequate, evidence-based confirmation.

UV-enhanced trichoscopy

UV-enhanced trichoscopy is a method of hair and scalp evaluation, first described by the authors' group in 2011. This method differs from classic trichoscopy by replacing regular or polarized light with UV light, at a wavelength covering the spectrum of a Wood lamp. This method may enhance the diagnostic potential of trichoscopy in tinea capitis and Malassezia furfur (Pityrosporum ovale) infections ( Fig. 12 ).

Authors have no conflict of interest.

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Hari's Random Thoughts by Hariharan Ramamurthy