Trichoscopy - a useful tool in the preliminary differential diagnosis of autoimmune bullous diseases

Trichoscopy of Pemphigus Vulgaris and Foliaceus on Black Scalp

Introduction

Pemphigus foliaceus (PF) and pemphigus vulgaris (PV) are bullous diseases characterized by loss of keratinocyte adhesion, easily ruptured blisters, and erosions. The scalp is involved in up to 60% of patients due to the high concentration of antigens in hair follicles. Trichoscopy has been studied in bullous diseases. However, research on pemphigus trichoscopy remains scarce. This study aimed to analyze the main trichoscopic features of pemphigus on the black scalp, a topic poorly appraised thus far.

Methods

Ten male and 8 female patients were enrolled, evenly distributed between PV (aged 16-59) and PF (aged 20-72), with Fitzpatrick phototypes equal to or greater than IV. Scalp evaluations were conducted using digital dermoscopy, with 20-to-70-fold magnification. Our results were compared with original research on Caucasian scalp pemphigus.

Results

Our study identified the previously published and also novel trichoscopic features. Our patients exhibited higher percentages (p < 0.05) of eight classic structures, considering both PF and PV; PF only; PV only. Aside from yellow dots (p = 0.002), our sample showed no statistically significant differences between the PV and PF groups in black patients.

Conclusion

Peculiarities of black scalp trichoscopy did not interfere in the diagnosis of pemphigus. Trichoscopy should be a routine diagnostic tool in patients with bullous scalp diseases, especially in the early stages, and to guide biopsy. To our knowledge, this is the first study focused on trichoscopy of pemphigus affecting black scalp. It indicates that, among other findings, yellow dots may be a relevant hallmark of scalp PV.

Dermatitis Herpetiformis: An Update on Diagnosis, Disease Monitoring, and Management

Dermatitis herpetiformis (DH), Duhring disease, is caused by gluten sensitivity and affects 11.2 to 75.3 per 100,000 people in the United States and Europe with an incidence of 0.4 to 3.5 per 100,000 people per year. DH is characterized by a symmetrical blistering rash on the extensor surfaces with severe pruritus. The diagnosis continues to be made primarily by pathognomonic findings on histopathology, especially direct immunofluorescence (DIF). Recently, anti-epidermal transglutaminase (TG3) antibodies have shown to be a primary diagnostic serology, while anti-tissue transglutaminase (TG2) and other autoantibodies may be used to support the diagnosis and for disease monitoring. Newly diagnosed patients with DH should be screened and assessed for associated diseases and complications. A gluten-free diet (GFD) and dapsone are still mainstays of treatment, but other medications may be necessary for recalcitrant cases. Well-controlled DH patients, managed by a dermatologist, a gastroenterologist, and a dietician, have an excellent prognosis. Our review comprehensively details the current diagnostic methods, as well as methods used to monitor its disease course. We also describe both the traditional and novel management options reported in the literature.

Trichoscopy may enhance differential diagnosis of erythroderma

There is a paucity of data concerning the usability of trichoscopy in erythrodermic patients. The objective of the study was to compare trichoscopic features in erythroderma of various etiologies. Forty-nine patients with the determined cause of erythroderma (including atopic dermatitis, mycosis fungoides, allergic contact eczema, psoriasis, Sézary syndrome, drug reactions, pityriasis rubra pilaris, dermatomyositis, actinic reticuloid, crusted scabies and pemphigus foliaceus) were included in the study. Dotted vessels were present in patients with atopic dermatitis, pityriasis rubra pilaris, mycosis fungoides, Sézary syndrome and psoriasis and absent in dermatomyositis, crusted scabies, and pemphigus foliaceus (chi-square test, p=0.016). Spermatozoon-like vessels were observed only in mycosis fungoides and Sézary syndrome (p=0.001). Whitish-pinkish structureless areas were described in all patients with mycosis fungoides, pemphigus foliaceus, actinic reticuloid, and crusted scabies (p=0.028). The type of vessels and the presence of whitish-pinkish structureless areas under trichoscopy may indicate the cause of erythroderma.

Diagnostic Accuracy of Trichoscopy in Inflammatory Scalp Diseases: A Systematic Review

BACKGROUND

The common inflammatory scalp diseases, such as psoriasis, seborrheic dermatitis, lichen planopilaris, discoid lupus erythematosus, contact dermatitis, or pemphigus may share similar clinical features.

OBJECTIVE

To identify and systematically review the available evidence on the accuracy of trichoscopy in inflammatory scalp disorders.

METHODS

A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 58 articles were included in the analysis.

RESULTS

The following trichoscopy features were found to show the highest specificity for the respective diseases: in psoriasis: diffuse scaling, simple and twisted red loops, red dots and globules, and glomerular vessels; in seborrheic dermatitis: atypical vessels, thin arborizing vessels, and structureless red areas; in discoid lupus erythematosus: follicular plugs and erythema encircling follicles; in lichen planopilaris: milky red areas or fibrotic patches; in contact dermatitis: twisted red loops; in pemphigus foliaceus: white polygonal structures and serpentine vessels; in pemphigus vulgaris: red dots with whitish halo and lace-like vessels; and in dermatomyositis: lake-like vascular structures.

LIMITATIONS

Different nomenclature and variability in parameters, which were analyzed in different studies.

CONCLUSION

This systemic analysis indicates that trichoscopy may be used with high accuracy in the differential diagnosis of inflammatory scalp diseases.

Pemphigus scalp lesions: is trichoscopy helpful in clinical diagnosis?

BACKGROUND

Pemphigus is an autoimmune intraepidermal bullous disease which can affect skin and∕or mucous membranes. Trichoscopy is a non-invasive tool that can help in the clinical diagnosis especially if the patient is presented with only scalp lesions. We conducted this study to investigate the trichoscopic features of pemphigus scalp lesions.

METHODS

A total of 100 patients with confirmed diagnosis of pemphigus entered the study; Seventy-nine patients were diagnosed as pemphigus vulgaris (PV) and 21 as pemphigus foliaceus (PF). Trichoscopy of the scalp lesions was performed, and three dermatologists examined separately the trichoscopic images of each patient. The results were re-checked simultaneously by the examiners. Association between variables was analyzed by using different tests including: chi-square test or Fischer's exact test, independent T-Test or Mann-Whitney nonparametric test and logistic regression model when applicable.

RESULTS

Mean age of the patients was 45.41 ± 11.13 years, and 58% of cases were male. The most common trichoscopic features observed among all cases were diffuse scaling (71/100), presence of any types of vessels (67/100), and extravasation (63/100). Positive anagen pull test, extravasation, yellow hemorrhagic crust, and polymorphic vessels were more commonly seen in PV than PF cases (P value < 0.05), and by having data of these variables, we can differentiate between PV and PF scalp lesions with 74% sensitivity and 91% specificity.

CONCLUSION

Trichoscopy can help in clinical diagnosis of pemphigus scalp lesions but should be followed by other modalities such as biopsy and direct immunofluorescence for definite diagnosis.

Alopecia in Autoimmune Blistering Diseases: A Systematic Review of Pathogenesis and Clinical Features of Disease

Background

Autoimmune blistering diseases (AIBD) are characterised by the body's production of autoantibodies against structural proteins in the epidermis and/or the basement membrane on cutaneous and mucosal surfaces. Alopecia is a complication of AIBD that has generally been overlooked in patients with severe blistering diseases because it is regarded as a cosmetic issue. Yet recent research into quality of life tools has found that stigmatisation by appearance plays a significant role in blistering diseases.

Aim

To review the current literature detailing the pathogenesis and clinical presentations of alopecia in AIBD patients.

Method

We searched Medline, PubMed and EMBASE electronic databases up to September 2018, for empirical human and animal studies.

Results

Only 36 human studies including 223 patients (190 pemphigus, 25 pemphigoid, 5 epidermolysis bullosa acquisita, 2 dermatitis herpetiformis and 1 linear IgA disease) detailed demographic and clinical manifestations of alopecia. A range of hair evaluation methods was demonstrated to reach alopecia diagnosis. Furthermore, with no universal validated scoring system for alopecia severity, alopecia patterns have been summarised.

Conclusion

Previous randomised trials have not highlighted alopecia as an important outcome of AIBD, so epidemiological evaluation of the available literature has been helpful in summarising trends between existing studies and demonstrating inconsistencies.

Pathogenesis and clinical features of alopecia in epidermolysis bullosa: A systematic review

BACKGROUND

Epidermolysis bullosa (EB) is a group of rare genetic skin diseases characterized by the gene mutations encoding adhesion proteins within the skin. These adhesion proteins are also present in normal hair follicles. Anecdotally, there have been reports of scalp alopecia as a complication of EB and there are scattered cases in the literature, but alopecia has generally been overlooked in severe blistering diseases because it is regarded as a cosmetic issue. Therefore, there is no consensus about the natural history and clinical manifestations of alopecia in EB to allow potential intervention.

OBJECTIVES

To review the current literature detailing the pathogenesis and clinical presentations of alopecia in EB patients.

METHODS

Relevant human studies were searched in Medline, PubMed, and EMBASE electronic databases up to October 2018.

RESULTS

Only 15 reports detailed 29 EB patients with demographic and clinical manifestations of alopecia. Vertical biopsy sections were the most common method of alopecia diagnosis, and the most common pattern was patchy scalp alopecia (45%) followed by diffuse alopecia (41%). The most robust finding was nonspecific scarring alopecia in all dystrophic EB (DEB) patients and nonspecific nonscarring alopecia in most patients with EB simplex (EBS).

CONCLUSIONS

Hair abnormalities observed in EB are of variable severity despite there being no universal validated alopecia scoring system, with alopecia occurring secondary to blistering, or in areas prone to trauma.

Dermatitis Herpetiformis: Novel Perspectives

Dermatitis herpetiformis (DH) is an inflammatory disease of the skin, considered the specific cutaneous manifestation of celiac disease (CD). Both DH and CD occur in gluten-sensitive individuals, share the same Human Leukocyte Antigen (HLA) haplotypes (DQ2 and DQ8), and improve following the administration of a gluten-free diet. Moreover, almost all DH patients show typical CD alterations at the small bowel biopsy, ranging from villous atrophy to augmented presence of intraepithelial lymphocytes, as well as the generation of circulating autoantibodies against tissue transglutaminase (tTG). Clinically, DH presents with polymorphic lesions, including papules, vesicles, and small blisters, symmetrically distributed in typical anatomical sites including the extensor aspects of the limbs, the elbows, the sacral regions, and the buttocks. Intense pruritus is almost the rule. However, many atypical presentations of DH have also been reported. Moreover, recent evidence suggested that DH is changing. Firstly, some studies reported a reduced incidence of DH, probably due to early recognition of CD, so that there is not enough time for DH to develop. Moreover, data from Japanese literature highlighted the absence of intestinal involvement as well as of the typical serological markers of CD (i.e., anti-tTG antibodies) in Japanese patients with DH. Similar cases may also occur in Caucasian patients, complicating DH diagnosis. The latter relies on the combination of clinical, histopathologic, and immunopathologic findings. Detecting granular IgA deposits at the dermal-epidermal junction by direct immunofluorescence (DIF) from perilesional skin represents the most specific diagnostic tool. Further, assessing serum titers of autoantibodies against epidermal transglutaminase (eTG), the supposed autoantigen of DH, may also serve as a clue for the diagnosis. However, a study from our group has recently demonstrated that granular IgA deposits may also occur in celiac patients with non-DH inflammatory skin diseases, raising questions about the effective role of eTG IgA autoantibodies in DH and suggesting the need of revising diagnostic criteria, conceivably emphasizing clinical aspects of the disease along with DIF. DH usually responds to the gluten-free diet. Topical clobetasol ointment or dapsone may be also applied to favor rapid disease control. Our review will focus on novel pathogenic insights, controversies, and management aspects of DH.

The Significance of Scalp Involvement in Pemphigus: A Literature Review

Scalp is a unique location for pemphigus because of the abundance of desmogleins localized in hair follicles. Scalp involvement is observed in up to 60% of patients in the course of pemphigus. The lesions may occasionally lead to alopecia. Unforced removal of anagen hairs in a pull test is a sign of high disease activity. Direct immunofluorescence of plucked hair bulbs is considered a reliable diagnostic method in patients with pemphigus. Follicular acantholysis is a characteristic histopathological feature of pemphigus lesions localized on the scalp. Trichoscopy may serve as a supplementary method in the diagnosis of pemphigus. This review summarizes the most recent data concerning scalp involvement in pemphigus vulgaris and pemphigus foliaceus. A systematic literature search was conducted in three medical databases: PubMed, Embase, and Web of Science. The analysis included literature data about desmoglein distribution in hair follicles, as well as information about clinical manifestations, histopathology, immunopathology, and trichoscopy of scalp lesions in pemphigus and their response to treatment.