Trichoscopy in genetic hair shaft abnormalities

Netherton Syndrome with a Novel Likely Pathogenic Variant c.420del (p.Ser141ProfsTer5) in SPINK5 Gene: A Case Report

Introduction

Netherton syndrome (NS) is a rare autosomal recessive genodermatosis in the group of congenital ichthyosis. The clinical manifestations of the syndrome vary from a very mild clinical manifestation occurring with the picture of ichthyosis linearis circumflexa to exfoliative erythroderma. It can be fatal in the first days of a newborn's life due to dehydration, hypothermia, weight loss, respiratory infections, and sepsis. A specific anomaly of the hair trichorrexis invaginata is considered pathognomonic for the syndrome. Genetic testing of SPINK5 gene is key to confirming the diagnosis and starting early treatment.

Case Presentation

We present a case report of NS in a 6-year-old boy who suffered from generalized erythroderma and desquamation of the skin from birth. The patient has atopic diathesis, recurrent skin infections, increased levels of IgE, and delayed physical development. Two genetic variants in SPINK5 gene with clinical significance were identified. The first detected variant is a nonsense mutation, predicted to cause loss of normal protein function either by protein truncation or by nonsense-mediated mRNA decay. The second variant is a likely pathogenic frameshift mutation that truncates the protein in 5 amino acids. The child was treated with acitretin, without satisfactory effect.

Conclusion

The genetic variant we have described correlates with a severe clinical phenotype of NS. The second genetic variant of the SPINK5 gene, inherited from the father in our case, is novel and has never been published in the literature.

Dermoscopic Patterns of Genodermatoses: A Comprehensive Analysis

(1) Background: Genodermatoses are a clinically and genetically heterogenous group of inherited skin disorders. Diagnosing inherited skin diseases is a challenging task due to their rarity and diversity. Dermoscopy is a non-invasive, easily accessible, and rapid tool used in dermatology not only for diagnostic processes but also for monitoring therapeutic responses. Standardized terminologies have been published for its proper use, reproducibility, and comparability of dermoscopic terms. (2) Methods: Here, we aimed to investigate dermoscopic features in various genodermatoses by conducting a systematic review and comparing its results to our own findings, data of patients diagnosed with genodermatoses at the Department of Dermatology, Venereology and Dermatooncology, Semmelweis University. (3) Results: Our systematic search provided a total of 471 articles, of which 83 reported both descriptive and metaphoric dermoscopic terminologies of 14 genodermatoses. The literature data were then compared to the data of 119 patients with 14 genodermatoses diagnosed in our department. (4) Conclusion: Dermoscopy is a valuable tool in the diagnosis of genodermatoses, especially when symptoms are mild. To enable the use of dermoscopy as an auxiliary diagnostic method, existing standardized terminologies should be extended to more genodermatoses.

Hair shaft аbnormalities: a literature review

Hair shaft defects, which are the result of both congenital and acquired pathologies, are usually accompanied by a violation of their physical characteristics and a change in appearance. Hair becomes dull, dry, not elastic, poorly styled, broken. Determining the presence of hair fragility formed the basis for the classification of heterogeneous abnormalities of the hair shaft and their division into two groups. The similarity of clinical symptoms and the impossibility of visual verification of the diagnosis dictate the need for additional research methods (dermatoscopy, microscopy, histology), the results of which will help to correctly diagnose. Knowledge of the nuances of the clinical picture, the main dermatoscopic and microscopic markers, the distinctive features of the course of various anomalies of the hair rods expands the capabilities of practicing trichologists, cosmetologists, dermatovenerologists and doctors of other specialties in the field of diagnosis, therapy and prevention of structural hair changes. The literature review presents the main clinical, dermatoscopic, microscopic and histological signs of various disorders of hair shafts.

Dermatologic manifestations of thyroid disease: a literature review

Introduction

Thyroid hormone is considered one of the key regulatory hormones for skin homeostasis. Multiple organs are affected by the release of peripheral thyroid hormones (T4 and T3) further regulating various functions at a cellular level. Specifically, skin is considered an important target organ in which the thyroid hormone has a significant impact. Multiple skin diseases are associated with thyroid hormone dysregulation. However, other striking dermatologic manifestations are seen in nails and hair as well. Hypothyroidism, hyperthyroidism, and thyroid cancer can have an array of cutaneous manifestations, and we present the recent updates in this field.

Methods

A PubMed search was performed for updates in any new skin disease findings and treatments between 2010 and 2022. Research published in the past decade and previously known foundational skin findings associated with thyroid disease were presented in this review.

Conclusion

Cutaneous manifestations of thyroid disease is one of the first notable signs of thyroid hormone dysregulation. This article reviews the recent updates on the thyroid and skin interplay, and it further discusses overt visible findings and various available treatment modalities.

Griscelli Syndrome in Skin of Color: A Trichoscopic Perspective

Introduction

Griscelli syndrome (GS) is a very rare autosomal recessive disorder, belongs to group of "silvery hair syndromes" which includes Chediak-Higashi syndrome (CHS) and Elejalde syndrome. Hair light microscopy helps in the differentiation of GS and CHS, as both manifest with clinical features. Trichoscopy is useful in the diagnosis of many hair shaft disorders. Here, authors describe the trichoscopic features of GS in skin of color.

Materials and Methods

This was an observational study conducted in a private dermatology clinic and in a tertiary care hospital. A total of 5 cases of suspected GS were referred by pediatrician. Consent was obtained. The demographic data in terms of age, gender, consanguinity, and clinical history was documented. Trichoscopic examination was performed with FotoFinder videodermoscope with 20× magnification, the clinical images were captured with Medicam 1000. Trichoscopy showed large and irregular pigment clumps in 4 cases. One case demonstrated hypopigmentation of hair without pigment clumps [Figure 3a].

Results

Trichoscopy showed large and irregular pigment clumps in 4 cases. One case demonstrated hypopigmentation of hair without pigment clumps.

Conclusion

Trichoscopy shows characteristic features GS. It is a useful method when facility for light or polarized microscope is unavailable.

Trichoscopy in Healthy Adult Egyptian Females: Normal Values of Hair Measurable Parameters

Introduction

Documenting normal hair values through trichoscopy can provide a useful baseline when evaluating and treating hair loss in different populations. The aim of our study was to document normal values for measurable parameters of hair in adult Egyptian females.

Methods

This cross-sectional study involved 90 Egyptian females (age range 18-48 years), with no symptoms or signs of hair or scalp disease. Trichoscopy was performed in different scalp areas using FotoFinder Medicam 1000 videodermoscopy. Trichoscopy images were subjected to statistical processing using TrichoLAB system.

Results

The frontal area demonstrated the highest number of hairs (190 ± 29/cm2), greatest average hair shaft thickness (63 ± 8 μm), greatest percentage of thick hairs (71% ± 12), highest mean cumulative hair thickness (12 ± 2 mm/cm2), and highest mean number of follicular units (82 ± 8/cm2). The temporal area showed the highest percentage of thin hairs (9% ± 5) and single-hair pilosebaceous units (23% ± 7), lowest mean number of hairs (154 ± 25/cm2), least average hair shaft thickness (60 ± 9 μm), least mean cumulative hair thickness (9 ± 2 mm/cm2), and least mean number of follicular units (70 ± 8/cm2). The occipital area showed the greatest percentage of triple-hair follicles (43% ± 12). Based on trichoscopy, the norms for hair parameters were calculated.

Conclusion

Normal hair parameters in adult Egyptian females differ from those documented from other ethnicities. Evaluating and treating hair loss in clinical practice should be done in reference to documented normal values, which can be set through trichoscopy.

Usefulness of Trichoscopy over Hair Light Microscopy in Menkes Disease

Menkes disease (MD) is a rare X-linked recessive neurodegenerative disorder caused by mutations in the ATP7A gene, with a high mortality rate within the first 3 years of life. It typically affects males and is characterized by impaired copper distribution and malfunction of several copper-dependent enzymes. Patients develop progressive muscle hypotonia associated with neurological damage and hair shaft dysplasia - particularly pili torti. Pili torti is usually very subtle in the first 3 months of life and gradually increases during the first year. Light microscopy examination in search for pili torti requires the observation of more than 50 hair shafts. In contrast, trichoscopy with a hand-held dermatoscope allows to easily identify the hair shaft defect. We report a case of a Hispanic male infant with MD in whom we show that trichoscopy is superior to hair light microscopy in revealing pili torti.

Pili Torti: A Feature of Numerous Congenital and Acquired Conditions

Pili torti is a rare condition characterized by the presence of the hair shaft, which is flattened at irregular intervals and twisted 180° along its long axis. It is a form of hair shaft disorder with increased fragility. The condition is classified into inherited and acquired. Inherited forms may be either isolated or associated with numerous genetic diseases or syndromes (e.g., Menkes disease, Björnstad syndrome, Netherton syndrome, and Bazex-Dupré-Christol syndrome). Moreover, pili torti may be a feature of various ectodermal dysplasias (such as Rapp-Hodgkin syndrome and Ankyloblepharon-ectodermal defects-cleft lip/palate syndrome). Acquired pili torti was described in numerous forms of alopecia (e.g., lichen planopilaris, discoid lupus erythematosus, dissecting cellulitis, folliculitis decalvans, alopecia areata) as well as neoplastic and systemic diseases (such as cutaneous T-cell lymphoma, scalp metastasis of breast cancer, anorexia nervosa, malnutrition, cataracts, and chronic graft-vs.-host disease). The condition may also be induced by several drugs (epidermal growth factor receptor inhibitors, oral retinoids, sodium valproate, and carbamide perhydrate). The diagnosis of pili torti is based on trichoscopic or microscopic examination. As pili torti is a marker of numerous congenital and acquired disorders, in every case, the search for the signs of underlying conditions is recommended.

Diagnosis of Woolly Hair Using Trichoscopy

Hair shaft abnormalities including woolly hair are traditionally diagnosed by clinical examination and light microscopy which involves plucking of multiple hairs for examination. This is usually an inconvenient procedure especially in children. Trichoscopy may be a useful tool allowing close visualization of multiple hairs without causing discomfort to the patients. Trichoscopic findings of woolly hair have been described only in few reports. We report all of the trichoscopic findings of this rare disorder in one case which have only been reported separately in previous reports.

Clinical Significance of Trichoscopy in Common Causes of Hair Loss in Children: Analysis of 134 Cases

Introduction:

Hair loss is a common and distressing clinical complaint in the dermatology clinics. Common causes of hair loss in children include alopecia areata, tinea capitis, traction alopecia, and trichotillomania. Newly, trichoscopy allows differential diagnosis of hair loss in most cases and allows visualization of hair shafts and scalps without the need of removing hair.

Objective:

The main objective is to compare the different trichoscopic features of common causes of patchy hair in children loss including tinea capitis, alopecia areata, traction alopecia, and trichotillomania.

Patients and Methods:

This study included 134 patients, 63 patients with tinea capitis, 38 patients with alopecia areata, 18 patients with traction alopecia, and 15 patients with trichotillomania. The diagnostic tools for the diagnosis of hair loss problem included a detailed history, evaluation of the child's hair and scalp, fungal scrapping, and trichoscopy.

Results:

Tinea capitis was the most common, and the trichoscopic features were comma-shaped hairs, corkscrew hairs, short broken hairs, and interrupted hairs. While in alopecia areata patients, the most specific features were yellow dots and black dots, microexclamation mark, hair shafts with variable thickness, and vellus hairs, with uncommon features included: monilethrix, coiled, zigzag, and tulip hairs. Trichoscopy of trichotillomania showed hair with fraying of ends, breakage at different lengths, short and coiled hairs, and amorphous hair residues. The trichoscopic features of traction alopecia were similar to those of trichotillomania. However, flame hairs and coiled hairs were less common.

Conclusions:

Trichoscopy is a noninvasive method of examining hair and scalp. It allows differential diagnosis of hair loss in most cases.

A Comment on Trichoscopy

Trichoscopy is the term coined for the use of dermatoscope for the evaluation of hair and scalp. Dermatologists involved in the management of hair and scalp disorders have discovered dermatoscope to be useful in their daily clinical practice, and expert studies suggest that dermoscopy may improve diagnostic capability beyond simple clinical inspection. Therefore, trichoscopy has gained popularity as a tool in the differential diagnosis of hair and scalp disorders. Despite the enthusiasm emerging with its establishment as a valuable dermatologic tool, caution is warranted not to elevate trichoscopy to something like a fetish status. As a diagnostic procedure, trichoscopy remains to be understood as representing an integral part of a comprehensive dermatological examination. Furthermore, trichoscopy represents an integral part of surface or epiluminescence microscopy of the skin or dermoscopy. It seems that the dermatoscope for the evaluation of the hair and scalp picks up from the culture of a stethoscope within internal medicine, in terms of being a time-tested, sophisticated, hand-held diagnostic medical instrument conferring an uncontested dignity in the hands of a physician attending hair and scalp disorders.

Polarized transilluminating dermoscopy: Bedside trichoscopic diagnosis of trichothiodystrophy

Trichothiodystrophy is a rare autosomal recessive disorder resulting in a broad range of systemic abnormalities. Polarizing microscopy of the hair reveals the pathognomic "tiger tail" of alternating light and dark bands, but the need for a microscope prevents rapid bedside diagnosis. We describe a new technique for the bedside diagnosis of trichothiodystrophy using a handheld polarizing dermatoscope, precluding the need for microscopic examination.

Prognosis and Management of Congenital Hair Shaft Disorders with Fragility-Part I

Hair shaft disorders are characterized by congenital or acquired abnormalities of the hair shaft. The objective was to review the literature regarding the prognosis and treatment options of hair shaft disorders. We used keywords in the search engines PubMed and Medline to identify all publications in the English language related to the prognosis and management of hair shaft disorders. Data were extracted from 96 articles that met search criteria. Findings were limited to case reports and small case series, as no studies were found. Disorders that improve in childhood include pili torti, trichorrhexis invaginata, wooly hair, and pili trianguli et canaliculi. Others, such as trichorrhexis nodosa, monilethrix, pili annulati, and pili bifurcati improve with minoxidil. Oral retinoids have improved hair abnormalities in trichorrhexis invaginata and monilethrix. There is no specific treatment for congenital hair shaft abnormalities. Gentle hair care is the mainstay of care for hair shaft disorders associated with fragility. Practices for gentle care include no brushing, backcombing, chemical products, tight braids, heat exposure, or mechanical grooming. Any inherited or congenital disorder requires genetic counseling as part of management.

Trichodystrophies: A hair-raising differential diagnosis

The appearance of an individual's hair is said to be reflective of internal health. Patients with hair shaft disorders commonly present with fragile, lusterless, sparse hair in addition to psychosocial distress. Hair shaft disorders may be hereditary or acquired and may present in children or adults. Due to the varied presentations, the differential diagnosis for hair is broad and often confusing. The authors present a question-by-question guide to help clinicians arrive at the correct diagnosis.

Trichoscopy as a diagnostic tool in trichorrhexis invaginata and Netherton syndrome

Netherton syndrome is a rare autosomal recessive disease characterized by erythroderma, ichthyosis linearis circumflexa, atopy, failure to thrive and a specific hair shaft abnormality called trichorrhexis invaginata or bamboo hair, considered pathognomonic. We report the case of a 4-year-old boy with erythroderma since birth, growth deficit and chronic diarrhea. Trichoscopy was used to visualize typical bamboo and "golf tee" hair and of key importance to diagnose Netherton syndrome. We suggest the use of this procedure in all children diagnosed with erythroderma.

Trichoscopy findings in loose anagen hair syndrome: rectangular granular structures and solitary yellow dots

BACKGROUND

Loose anagen hair syndrome (LAHS) is typically diagnosed in girls older than 2 years who present with hair that "will not grow". Hair microscopic examination shows absent inner and outer root sheaths, ruffling of the cuticle on the proximal hair shaft and deformed pigmented anagen bulbs.

OBJECTIVE

The aim of the study was to assess whether there are characteristic trichoscopic features favoring the diagnosis of LAHS.

PATIENTS AND METHODS

Eighty nine children patients were included into the study (24 girls with LAHS, 25 with alopecia areata, 20 with telogen effluvium and 20 healthy children). In all groups trichoscopy was performed. Trichoscopy images were analyzed for abnormalities in the hairs shafts, the hair follicle openings and the interfollicular area.

RESULTS

Dirty dots were present in all groups. A unique feature of LAHS was the presence of rectangular black granular structures which differs from dense black dots seen in patients with alopecia areata. This feature was observed in 71% of patients with LAHS. Follicular units with single hairs constituted 92,9% of hair units in these patients (65,5% in telogen effluvium and 53% in the control group). Solitary yellow dots were found in 50% of patient with LAHS and in 24% of patients with alopecia areata, but was not found in control group or in patients with telogen effluvium.

CONCLUSION

The trichoscopy features favoring the diagnosis of LAHS are: rectangular black granular structures, solitary yellow dots and major predominance of follicular units with single hairs.

Evaluation and diagnosis of the hair loss patient: part II. Trichoscopic and laboratory evaluations

The use of trichoscopy for evaluating a number of hair and scalp disorders is gaining popularity. It is a simple and noninvasive in vivo tool for visualizing hair shafts and the scalp. Recently, alopecias have been classified according to their trichoscopic findings. The second part of this 2-part continuing medical education article reviews recent advances in this field and describes a systematic approach for using the differential diagnostic findings of trichoscopy in alopecia.

Woolly hair nevus in a toddler

Woolly hair nevus (WHN) is a rare hair condition, with only a few cases reported. It affects young children of both sexes and currently, there is no available treatment. When WHN is associated with an epidermal nevus, further study is required to rule out ophthalmologic and neurologic abnormalities. We present the case of a Chilean 3-year-old healthy girl with a WHN, with no other clinical findings. This case illustrates a WHN in which the benign and chronic nature of the disease must be advised to the parents in order to prevent further concerns.

Trichoscopy in alopecias: diagnosis simplified

Trichoscopy is the term coined for dermoscopic imaging of the scalp and hair. This novel diagnostic technique, both simple and non-invasive, can be used as a handy bed side tool for diagnosing common hair and scalp disorders. Trichoscopic observations can be broadly grouped as hair signs, vascular patterns, pigment patterns and interfollicular patterns. In this article, we have briefly described the trichoscopic findings in the common categories of cicatricial and non-cicatricial alopecias such as androgenetic alopecia, alopecia areata, telogen effluvium, tinea capitis, trichotillomania, lichen planopilaris, discoid lupus erythematosus and hair shaft disorders. Besides diagnosing alopecia, it has the potential for obviating unnecessary biopsies and when a biopsy is still needed it is helpful in choosing an ideal biopsy site. Moreover, trichoscopy is a valuable tool for evaluating the treatment response photographically at each follow-up. The last statement here is deleted as asked.

Is trichoscopy a reliable tool to diagnose early female pattern hair loss?

Background:

Female pattern hair loss (FPHL) presents with visible patterns of hair loss, thus making a bedside diagnosis possible. However, there are cases of FPHL presenting without any visible hair thinning, making it necessary to subject them to a scalp biopsy to make a diagnosis.

Aim:

The aim of the following study is to determine if trichoscopy can be used as a bedside tool to diagnose Early FPHL in women presenting without any visible thinning of hair, using >20% hair diameter diversity – anisotrichosis, as the diagnostic criteria.

Materials and Methods:

Trichoscopy was performed on 20 cases of early FPHL (biopsy proven), 63 normal controls and 29 Grade 2 FPHL Controls.

Results and Discussion:

In the biopsy proven FPHL cases, 75% showed anisotrichosis on trichoscopy. This finding was significantly higher in FPHL Cases compared to normal controls. As expected, 93% of Grade 2 FPHL controls also showed the same finding. Trichoscopy was found to be 75% sensitive and 61.54% specific in diagnosing early FPHL. Thus, a negative result would be more indicative of absence of disease, however, a positive result would not always indicate the presence of disease.

Krtap11-1, a hair keratin-associated protein, as a possible crucial element for the physical properties of hair shafts

BACKGROUND

The physical properties of the hair are predominantly determined by the assembly of keratin bundles. The keratin-associated proteins (Krtaps) are thought to be involved in keratin bundle assembly, however, the functional role of the individual member still remains largely unknown.

OBJECTIVE

The aim of this study is to clarify the role of a unique class of Krtaps, Krtap11-1, in the development and physical properties of the hair.

METHODS

The expression regulation of Krtap11-1 was analyzed and its binding partners in the hair cortex were determined. Also, the effects of the forcible expression of this protein on the hair follicle development were analyzed in culture.

RESULTS

The expression pattern of Krtap11-1 was concentrically asymmetric in the faulty hair that develops in Foxn1nu mice. In cultured keratinocytes, the expression of Krtap11-1 transgene product was strictly regulated by the keratinization process and proteasome-dependent protein elimination. While the association with keratin as well as the cohesive self-assembly of Krtap11-1 appeared to be stabilized by disulfide cross-links, the biotinylated Krtap11-1 probe enabled the adherence to certain type I keratins in the hair cortex, including K31, 33 and 34, in the absence of disulfide formation. When embryonic upper lip rudiments were forcibly introduced with Krtap11-1, the hair follicles formed irregularly arranged globular hair keratin-clumps surrounded by multilayered epithelial cells in culture.

CONCLUSION

Krtap11-1 may play an important role on keratin-bundle assembly in the hair cortex and this study provides insight into the physical properties of the hair shaft.

Role of trichoscopy in children's scalp and hair disorders

Hair and scalp disorders in children may originate from the hair itself, scalp skin, or infectious causes and be congenital or acquired. The most common sign is alopecia, frequently brought on by tinea capitis, patchy alopecia areata, or trichotillomania. Sometimes less frequent and clinically more elusive conditions such as initial androgenetic alopecia, congenital triangular alopecia, or alopecia areata incognita may be responsible for hair loss. The noninvasive technique known as trichoscopy is being used more frequently, aiding in the prompt differential diagnosis and follow-up of many of these diseases, oftentimes providing further examination before a treatment decision is made. This review of trichoscopy of the main scalp and hair disorders afflicting children and adolescents discusses the most important dermoscopic criteria and the usefulness of this technique.

The importance of trichoscopy in clinical practice

Trichoscopy corresponds to scalp and hair dermoscopy and has been increasingly used as an aid in the diagnosis, follow-up, and prognosis of hair disorders. Herein, we report selected cases harbouring scalp or hair diseases, in whom trichoscopy proved to be a valuable tool in their management. A review of the recent literature on this hot topic was performed comparing the described patterns with our findings in clinically common conditions, as well as in rare hair shaft abnormalities, where trichoscopy may display pathognomonic features. In our view, trichoscopy represents a valuable link between clinical and histological diagnosis. We detailed some trichoscopic patterns, complemented with our original photographs and our insights into nondescribed patterns.

Dermoscopy for the pediatric dermatologist part I: dermoscopy of pediatric infectious and inflammatory skin lesions and hair disorders

The dermoscope allows physicians to examine the macroscopic and microscopic primary morphology of skin lesions, identify subtle clinical clues, confirm naked-eye clinical diagnoses, and monitor treatment progress while posing little threat to the young patient. This review summarizes important dermoscopic structures seen in infectious and inflammatory skin conditions and hair disorders in children. Scabies, pediculosis, phthiriasis, molluscum contagiosum, tinea nigra, and verrucae are well characterized dermoscopically by delta-shaped structures, ovoid-shaped nits, the crab louse, red corona, brown strands or spicules, and multiple densely packed papilla with a central black dot surrounded by a whitish halo, respectively. These dermoscopic structures will be discussed, focusing on the dermoscopic morphologies and dermoscopic sensitivity for diagnosis and its utility in monitoring treatment progress. Dermoscopy has also been shown to significantly improve the clinician's diagnostic and monitoring accuracy of inflammatory skin lesions such as psoriasis, which is characterized dermoscopically by uniformly distributed dotted blood vessels, and lichen planus, which is characterized by whitish lines on a purple to reddish background. Dermoscopy of the hair and scalp (trichoscopy) facilitates the differential diagnosis of hair diseases in children, including alopecia areata, trichotillomania, and tinea capitis. It can also assist in the diagnosis of multiple genetic hair shaft disorders, such as monilethrix, trichorrhexis invaginata, trichorrhexis nodosa, pili torti, and pili annulati.

Trichoscopy update 2011

Trichoscopy performed with a handheld dermoscope or a videodermoscope became an indispensable tool in differential diagnosis of hair and scalp diseases. Current research is focusing on trichoscopy of: 1) non-cicatricial alopecia, 2) cicatricial alopecia, 3) hair shaft disorders, and 4) inflammatory scalp diseases. This review summarizes current knowledge in these four fields of research. In all non-cicatricial alopecias presence of empty follicular openings is a common trichoscopy finding. In alopecia areata black dots and micro-exclamation mark hairs and tapered hairs correlate with disease activity, whereas yellow dots and vellus hairs correlate with disease severity. In androgenic alopecia trichoscopy shows hair shaft thickness heterogeneity, multiple thin and vellus hairs, yellow dots, perifollicular discoloration, and predominance of follicular units with only one hair. These features predominate in the frontal area. In all forms of cicatricial alopecia, trichoscopy shows milky-red or ivory-white areas lacking follicular openings. In classic lichen planopilaris trichoscopy shows perifollicular inflammation, tubular perifollicular scaling, elongated, concentric blood vessels and "classic white dots", which merge to form white areas. Frontal fibrosing alopecia shows mild perifollicular scaling. Folliculitis decalvans is characterized by tufted hairs, large follicular pustules with emerging hair shafts and perifollicular starburst pattern hyperplasia. In dissecting cellulitis characteristic findings are "3D" yellow dots imposed over dystrophic hairs, large, yellow amorphous areas and pinpoint white dots with a whitish halo. Trichoscopy is particularly useful to diagnose hair shaft abnormalities in trichorrhexis nodosa, trichorrhexis invaginata, monilethrix, pili torti, and pili annulati. The method may be also useful in diagnosing inflammatory scalp diseases. In discoid lupus erythematosus trichoscopy shows large arborizing vessels and large hyperkeratotic folliculilar yellow dots. Trichoscopy of scalp psoriasis shows regularly distributed twisted and lacelike blood vessels, whereas in seborroic dermatitis thin arborizing vessels may be observed. In tinea capitis trichoscopy shows comma, corkscrew and zigzag hairs. Examination tinea capitis may be facilitated by UV-light enhanced trichoscopy (UVET). In conclusion, trichoscopy is a non-invasive method which may be applied in differential diagnosis of most hair and scalp diseases.

Pili annulati coincident with alopecia areata, autoimmune thyroid disease, and primary IgA deficiency: case report and considerations on the literature

Pili annulati is a rare autosomal dominant hair disorder clinically characterized by a pattern of alternating bright and dark bands of the hair, the bright bands appearing dark if observed by transmitted light. This pattern is due to the periodic occurrence of air-filled cavities along the hair cortex which scatter and reflect the light while precluding its transmission. A susceptibility region, including a possibly responsible Frizzled gene, has been mapped to the telomeric region of chromosome 12q, although a specific mutation has not been identified. The condition has sometimes been observed in concurrence with alopecia areata, and in this paper we report a case in whom the concomitant severe alopecia areata was associated with autoimmune thyroid disease and primary IgA deficiency - a quadruple complex which, to our knowledge, has never been previously described. The occurrence of multiple immune disorders in the same patient affected by pili annulati could represent a key to understanding the high prevalence of alopecia areata in this condition. Specifically, in individuals predisposed to autoimmune disease, the molecular alterations that cause the anatomical changes of pili annulati could prompt the immune response against the hair root that underlies alopecia areata.

Trichoscopy (hair and scalp videodermoscopy) in the healthy female. Method standardization and norms for measurable parameters

BACKGROUND

Trichoscopy is a newly developed method of hair image analysis, based on videodermoscopy of hair and scalp.

OBJECTIVE

The aim of the study was to establish normal values and set the standard for trichoscopy in female population.

PATIENTS AND METHODS

A total of 60 healthy females with no symptoms of hair or scalp diseases in anamnesis, upon clinical examination and in classic hair diagnostic techniques were included into the study. Mean age of these females was 36.5 (19-64) years. Trichoscopy was performed with the use of Fotofinder II. In all patients trichoscopy was performed in four locations (frontal area, occipital area, left and right temporal area). Hair and perifollicular area were evaluated. Measurements were performed with the application of the MoleAnalyzer software.

RESULTS

Mean hair thickness was 0.061mm±0.008mm in frontal area vs. 0.057mm±0.007mm in occiput (p<0,001) and vs. 0.058mm±0.008mm in left temporal area and 0.059mm±0.008mm in right temporal area (p>0.005). The percentage of thin hairs (below 0.03mm) was 5%±4.3 in frontal area vs. 5.5%±4.8 in occiput vs. 6.4%±5.7 in right temporal area. The highest proportion of single-hair pilosebaceous units was observed in the temporal areas (29.1±16.2 vs. 23.2±13.5 in frontal and 18.4±12.1 in occipital areas; p<0.005). Based on study results, the norms for parameters measured in trichoscopy were assessed: mean hair thickness bigger than 0,053mm in frontal area and bigger than 0,050mm in others; percentage of thin hairs should be less than 10% in frontal and occipital area and less than 13% in temporal areas. The percentage of pilosebaceous units with single hair should be less than 35% in frontal area, 30% in occiput and 40% in temporal areas. Yellow dots were seen sporadically and they shouldn't be in a higher number than 3 in 4 fields of vision with 70-fold magnification in frontal area and only 1 in others. Perifollicular discoloration should be lower than 25% for frontal area, lower than 15% in occiput and 20% for temporal areas.

CONCLUSION

A standard procedure to perform trichoscopy (hair and scalp videodermoscopy) for diagnostic purposes was developed. Norms of measurable parameters were established for the population of adult white females.

In vivo reflectance confocal microscopy: usefulness for diagnosing hair diseases

BACKGROUND

Reflectance confocal laser scanning microscopy (R-CSLM) is a new diagnostic technique which allows visualization of "optical intersections" within the epidermis and superficial layers of the dermis. Outlines of cells and their architecture are imaged and may be analyzed both horizontally and vertically to the skin surface. The method proved useful in early melanoma detection. We evaluated the potential usefulness of this method in a short series of patients with hair diseases.

MAIN OBSERVATIONS

Two healthy persons and 6 patients with hair diseases (1 with alopecia areata, 1 with androgenic alopecia and 4 with genetic hair shaft abnormalities) were examined with the use of Vivascope 1500. In all patients one scalp location and one location in the mid forearm were evaluated. R-CSLM examination gave in all cases high quality images of the hair shaft intersections, at 1µm intervals, which allowed detailed analysis of the hair structure. Hair follicles could be partly visualized at a depth of up to 200µm, which allowed analysis of only superficial parts of the hair follicles. An additional hurdle was bright reflection within the follicular ostia, which decreased the perception of details in these images. Hair could be best visualized, when analyzed on flat surfaces. Receiving good quality images from convex surfaces on the scalp required additional effort from the patient (to not move) and from the physician (to obtain best possible fit of the "optic window" to the scalp).

CONCLUSIONS

These preliminary data show that R-CSLM may develop into a valuable tool in evaluation of hair shaft diseases. Further development is needed to apply this technique in abnormalities of the hair follicle and the perifollicular area.

Dermoscopy in female androgenic alopecia: method standardization and diagnostic criteria

Objective:

Establishing the trichoscopy criteria of female androgenic alopecia (FAGA).

Design:

Trichoscopy images were retrospectively evaluated.

Setting:

Dermatologic hospital-based clinic and private practice offices.

Patients and methods:

One hundred and thirty-one females (59 with androgenic alopecia, 33 with chronic telogen effluvium (CTE), 39 healthy controls). The diagnosis was based on clinical examination and confirmed by histopatology.

Main Outcome Measure:

Trichoscopy results obtained in frontal, occipital and both temporal areas of the scalp under a 20-fold and 70-fold magnification, including average hair thickness, number of 'yellow dots' and vellus hairs, number of hairs in one pilosebaceous unit and percentage of follicular ostia with perifollicullar hyperpigmentation.

Results:

Average hair thickness in frontal area versus occiput was, respectively, 0.061 ± 0.008 mm versus 0.058 ± 0.007 mm in healthy controls, 0.047 ± 0.007 mm versus 0.052 ± 0.008 mm in androgenic alopecia and 0.056 ± 0.007 mm versus 0.053 ± 0.009 mm in CTE. Mean percentage of thin hairs (< 0.03 mm) in androgenic alopecia was 20.9 ± 12% and was significantly higher than in healthy controls (6.15 ± 4.6%, P < 0.001) or in CTE (10.4 ± 3.9%, P < 0.001). The number of yellow dots, pilosebaceous units with only one hair and with perifollicular hyperpigmentation was significantly increased in androgenic alopecia. Classification and Regression Tree Analysis was performed to establish diagnostic criteria for FAGA.

Conclusion:

FAGA may be differentiated from CTE based on trichoscopy criteria. Major criteria are ratio of (1) more than four yellow dots in four images (70-fold magnification) in the frontal area, (2) lower average hair thickness in the frontal area compared to the occiput and (3) more than 10% of thin hairs (below 0.03 mm) in the frontal area. Minor criteria encompass increased frontal to occipital ratio of (1) single-hair pilosebaceous units, (2) vellus hairs and (3) perifollicular discoloration. Fulfillment of two major criteria or one major and two minor criteria allows to diagnose FAGA based on trichoscopy with a 98% specificity.

Comma hairs: a dermatoscopic marker for tinea capitis: a rapid diagnostic method

BACKGROUND

Dermatoscopy and videodermatoscopy have been used for several years in the diagnosis of skin disorders.

OBJECTIVE

We sought to determine whether tinea capitis (TC) shows characteristic videodermatoscopy features that may facilitate its differentiation from alopecia areata (AA).

METHODS

Two patients with TC caused by Microsporum canis, confirmed by mycological culture and fluorescence under Wood lamp, were examined with videodermatoscopy and results were compared with videodermatoscopy results of 12 patients with AA.

RESULTS

The distinctive and most prominent feature of TC was presence of commalike structures (comma hairs). These were accompanied by broken and dystrophic hairs. Videodermatoscopy features of AA included exclamation mark hairs, vellus and dystrophic/cadaverized hairs, and yellow dots corresponding to hyperkeratotic hair follicle plugs.

LIMITATIONS

This study was conducted on two patients, both with M canis infection.

CONCLUSIONS

Comma hairs were observed as a distinctive videodermatoscopy feature of M canis-induced TC. This finding was not observed in AA, typified generally by exclamation mark hairs.