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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 118-122

Trichoscopic evaluation of alopecia areata of the scalp and clinical correlation of these findings with disease activity and severity


1 Department of Dermatology, Venereology and Leprology, Sawai Mansingh Medical College, Jaipur, Rajasthan, India
2 Department of Dermatology, Venereology and Leprology, Era's Lucknow Medical College, Lucknow, Uttar Pradesh, India
3 Department of Dermatology, Venereology and Leprology, Government Medical College, Kota, Rajasthan, India
4 Department of Dermatology, Venereology and Leprology, Geetanjali Medical College, Udaipur, Rajasthan, India

Date of Submission14-Jan-2020
Date of Decision15-Apr-2020
Date of Acceptance10-May-2020
Date of Web Publication18-Aug-2020

Correspondence Address:
Suresh Kumar Jain
Department of Dermatology, Venereology and Leprology, Government Medical College, Kota - 324 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_3_20

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  Abstract 


Background: Alopecia areata (AA) is a common, chronic inflammatory disease characterized by nonscarring hair loss on the scalp or any hair-bearing area of the body. Recently, trichoscopy has emerged as a noninvasive method for the evaluation of AA. Aim: Evaluating trichoscopic patterns in AA and correlating these with the disease activity and severity. Materials and Methods: Noncontact trichoscopy was performed on AA patients using polarized mode of DermLite dermatoscope. The trichoscopic patterns were recorded and analyzed to cognize their correlation with the disease activity and severity. Results: In our study, we observed 10 distinct types of hair under dermascope in 260 cases of AA. The most common type of AA was localized patch type. On trichoscopy, the most common finding was yellow dots (YDs) in 189 (72.71%) cases and other findings were short vellus hair (SVH), broken hair (BH), tapering hair (TH), black dot (BD), and trichoptilosis. Statistically significant positive correlation was observed between YDs, BD, BHs, TH, CD, and T and disease activity (r = 0.204, 0.389, 0.568, 0.683, 0.504, and 0.347 and P = 0.001, 0.000, 0.000, 0.000, 0.000, and 0.000, respectively). Statistically significant positive correlation was observed between TH, BH, and T and disease severity (r = 0.276, 0.250, and 0.146 and P = 0.000, 0.000, and 0.019, respectively). SVHs were correlated negatively with the disease activity and severity (r = −0.111, P = 0.075 and r = −0.141, P = 0.075, respectively). Conclusion: Our study has proved the utility of trichoscopy in evaluating AA. It has emerged as a useful noninvasive tool for evaluating classical and novel patterns and their correlation with the different determinants of the disease and assessing disease severity.

Keywords: Alopecia areata, trichoptilosis yellow dots, trichoscopy


How to cite this article:
Vijay A, Kumari P, Mohta A, Vyas K, Kushwaha RK, Jain SK. Trichoscopic evaluation of alopecia areata of the scalp and clinical correlation of these findings with disease activity and severity. Clin Dermatol Rev 2020;4:118-22

How to cite this URL:
Vijay A, Kumari P, Mohta A, Vyas K, Kushwaha RK, Jain SK. Trichoscopic evaluation of alopecia areata of the scalp and clinical correlation of these findings with disease activity and severity. Clin Dermatol Rev [serial online] 2020 [cited 2020 Sep 24];4:118-22. Available from: http://www.cdriadvlkn.org/text.asp?2020/4/2/118/292475




  Introduction Top


Alopecia areata (AA) is a chronic inflammatory disease that involves the hair follicle and sometimes the nails. It presents as well-defined and completely bald patches with no change in the skin's texture.[1]

Diagnosis of AA is based on clinical examination, and in doubtful situations, biopsy may aid in reaching diagnosis. Recently, trichoscopy has emerged as an effective noninvasive method of assessing scalp hair, eyebrow, and eyelashes with dermatoscope. It has been used in the diagnostic evaluation of AA for predicting disease activity, severity, and prognosis.[2],[3],[4],[5],[6] Its advent has even obviated the need of biopsy. Classical and pathognomonic trichoscopic patterns of AA have already been mentioned in the literature. These include black dots (BD) (cadaverous hairs), yellow dots (YD), tapering hairs (THs) (exclamation mark hairs), broken hairs (BHs), coudability hair, vellus hair, pig tail hair, and Pohl–Pinkus hair.[4],[7] With this background, we designed a study, utilizing trichoscopy for observing different patterns of AA and judging the course of disease by correlating these patterns with disease activity and severity in order to plan a timely intervention.


  Materials and Methods Top


It was a prospective noninterventional, observational descriptive study conducted on patients attending the outpatient clinic at our tertiary care center. The study was approved by the Ethics Committee of our institution. The study included 260 patients of AA who were recruited irrespective of age and sex. Written informed consent was taken and patients were explained about the nature of study before enrolment. Diagnosis of AA was based on clinical examination and biopsy was done in case of doubt. Inclusion and exclusion criteria were designed and following patients were excluded from the study: patients with AA on sites other than the scalp, patients with coexisting hair disorders at the time of examination (such as seborrheic dermatitis and tinea capitis), patients receiving any therapy for AA in the last 1 month, and patients not willing for scalp examination by trichoscope. Patients recruited to the study were assessed for disease activity and severity by detailed clinical history, hair pull test, and National AA Foundation's grading protocol [Table 1] known as Severity of Alopecia Tool score. Noncontact trichoscopy was performed using the polarized mode of DermLite dermatoscope (magnification of ×10) without any linkage fluid [Figure 1] and images were captured using iPhone 6 750 × 1334 pixels camera; the results and photographic documentation were recorded. The trichoscopic patterns were analyzed and correlation was sought between various trichoscopic findings and the disease activity and severity using the SSLT score by Spearman's rank-order correlation and statistical significance was set at P < 0.05.
Table 1: NAAF grading

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Figure 1: (a) DermLite dermatoscope × 10, (b) dermatoscope with iPhone 6 attachment

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  Results Top


A total 260 patients of AA were recruited in the study. Age ranged from 4 to 45 years with mean an age being 26.80 ± 9.816 years. Male-to-female ratio was 1.7:1. There was a wide variation in the duration of the disease, ranging from 10 days to 6 months with a mean duration being 1.873 ± 0.9632 months. The most common type of AA in the present study was localized patch type (1–3) seen in 135 (51.92%) cases, while multiple patches (>3) were seen in 70 (26.92%) cases, and the other patterns observed are represented in [Figure 2]. Demographic and clinical details were given in [Table 2].
Figure 2: Pie chart showing various pattern of alopecia areata

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Table 2: Demographic and clinical characters of study population

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Hair pull test was done to assess the activity and it was found to be positive in 105 (40.38%) cases. Subjective assessment revealed the progressive, remitting, and stable AA to be 122 (46.92%), 62 (23.84%), and 76 (29.2%) patients, respectively.

Based on disease severity, the patients were allocated into two groups, disease severity group-1 (DSG-1) and DSG-2. These groups included grade S1, S2, S3, and S4, S5, S6 grades, respectively (according to NAAF protocol). We found 142 (54.6%) cases in DSG-1 group and 118 (45.4%) cases in DSG-2 group.

Trichoscopic evaluation of the scalp revealed myriad abnormalities and patterns against the background of honeycomb pigment network. A total of 10 distinct patterns of hair were seen under the trichoscope. The most common finding was YDs in 189 (72.69%) cases, followed by short vellus hair (SVH) in 160 (61.53%) cases, BH in 154 (59.23%) cases, TH in 100 (38.46%) cases, BD in 95 (36.53%) cases, and coudability hair (CD) in 70 (26.92%) cases [Figure 3], [Figure 4], [Figure 5]. Another pattern observed in our study was trichoptilosis present in 88 (33.84%) cases as shown in [Figure 6].
Figure 3: Trichoscopy of alopecia areata showing (a) broken hair (red arrow) and black dot (yellow arrow) along with honey comb pigment network in background skin (b) tapering hair, (green arrow) (×10)

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Figure 4: Trichoscopy of alopecia areata showing (a) yellow dot (pink arrow) (b) cumulus white dot (red arrow) and coudability hair (yellow arrow) (×10)

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Figure 5: Trichoscopy of alopecia areata showing (a) short vellus hair (yellow arrow), pigtail hair (red arrow) and few upright regrowing hair (green arrow), (b) Pohl–Pinkus constriction (pink arrow (×10)

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Figure 6: Trichoscopy of alopecia areata showing trichoptilosis (red arrow) (×10)

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Rare trichoscopic pattern observed was cumulus white dot in 20 (7.69%) cases, pig tail in 34 (13.07%) cases, and Pohl–Pinkus constriction in one patient [Figure 4] and [Figure 5].

Positive correlation was observed between YDs, BD, BHs, TH, CD, and T and disease activity (r = 0.204, 0.389, 0.568, 0.683, 0.504, and 0.347 and P = 0.001, 0.000, 0.000, 0.000, 0.000, and 0.000, respectively) [Table 3]. Similarly, a positive correlation was observed between TH, BH, and T and disease severity (r = 0.276, 0.250, and 0.146 and P = 0.000, 0.000, and 0.019, respectively) [Table 4]. SVHs was correlated negatively with the disease activity and severity (r = −0.111, P = 0.075 and r = −0.141, P = 0.075, respectively). Similarly, YDs was correlated negatively with the disease severity (r = −0.108, P = 0.082).
Table 3: Trichoscopic features seen in patients with each group of alopecia areata activity

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Table 4: Dermoscopic features seen in patients with each group of alopecia areata severity

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  Discussion Top


Trichoscopy has been established as an essential tool in the diagnosis of various hair disorders. Our study utilized trichoscopy for observing different patterns of AA and judging the course of disease for planning a timely intervention.

YDs were among the most common pattern observed. It represents the distension of affected follicular infundibulum with keratinous material and sebum. Variable prevalence of YD has been observed in studies.[8],[9],[10],[11],[12] This variation in results can be attributed to the difference in skin types (yellowish color of skin in Asians may make it difficult to perceive the YDs on trichoscopy), different shampooing habits, and difference in the type of dermoscope used.[10],[13] It has been regarded as most sensitive tricoscopic feature for the diagnosis of AA because of higher frequency reported by different studies.

Inui et al.[10] reported 63.7% while Ross et al.[8] reported 94.8% prevalence of YD among cases of AA. Our study observed YDs in 72.7% of cases of AA. However, some studies reported lesser incidence.[10],[11],[12]

BHs result either from the transverse fracture of terminal hair shafts weakened by the inflammatory process or by rapid regrowth of incompletely destroyed hair shafts that previously formed the BDs. Although observed in other disorders, such as trichotillomania, BH may be regarded as important finding in AA as its prevalence reflects severity of underlying inflammation. In AA, usually hairs are broken at the same level above the skin surface, whereas in trichotillomania, BH has a variable length above surface.[14] This can be explained on the basis of difference in degree of mechanical shear at different level, in the latter condition as compared to the inflammation at same level (bulb region) in AA. In the present study, BH was seen in 59.2% of the cases which is at par with findings of Mane et al.[3] Few studies reported lesser incidence.[9],[10],[11] These variations may be due to difference in activity, severity, and duration of the disease in various studies.[14]

Tapering hairs (TH/exclamation mark hairs) represent fractured hairs with frayed thicker distal end and thinner proximal shaft. Trichoscopy is more sensitive in picking up TH at an earlier course of disease, thereby enabling timely intervention. In the present study, TH was seen in 38.5% of the cases as compared with other studies which reported prevalence to be 31.7% to 61.54%.[10],[12],[15],[16] This variation could be due to different proportions of active disease in the study population.

BDs (cadaverous hairs) BD are the remnants of BH and TH. Lesser incidence of BD in our study can be explained by difficulty in appreciating BD against background of darker skin in our study subjects.

In the present study, BD was seen in 36.5% of the cases, which is far less as compared to other studies by Inui et al.[6] (44.3%), Kibar et al.[15] (66.6%), and Mane et al.[3] (67.7%).

Coudability hairs (CHs) are the normal-looking hairs that can be made to kink easily when bent or pushed inward.[17] CHs are not pathognomonic of AA, they remain a useful clinical feature and a marker of disease activity. They were seen in 26.9% of cases in the present study, as compared with studies done by Kibar et al.[15] (20.5%) and Guttikond et al.[7] (14%).

SVHs are patterned regrowth of hair as the disease activity diminishes. Regrowth of SVH after treatment can be seen in trichoscopy even before they can be perceived by the naked eye. In the present study, SVH was seen in 64.6%% of the patients, as compared with other studies which reported prevalence ranging from 40.9% to 72.7%.[3],[7],[8],[9],[10],[11],[12] The variable prevalence may be attributed to the difference in exposure of patients to various treatment modalities before being included in the study.

Pohl–Pinkus constrictions (PPCs) represent constrictions in the hair shafts at irregular intervals. Repeated formation of these PPCs during the course of disease activity results in the formation of monilethrix-like hairs. In our study, PPC was observed in one patient and Mane et al.[3] reported in two of their patients.

Another rare pattern seen in our study was trichoptilosis, which may be defined as “a single hair arising from a follicular unit and splitting into multiple ends after growing away from the scalp. It was seen in 88 (33.84%) cases. In the present study, most commonly, this finding was seen in acute onset cases, near the margin of the lesions, which was progressive in nature. It has not been described in AA till now. It has also been described by various authors in the past a dermascopic finding of AA.[18],[19],[20] Our study also observed a significant positive correlation of this trichoscopic finding with disease activity and severity. This correlation warrants further speculation to justify its validity.

Correlation between trichoscopy features and disease activity

Positive correlation was observed between different trichoscopic findings (YDs, BD, BH, CD, T, and TH) and the disease activity, whereas SVH is correlated negatively with the disease activity. Positive correlation between trichoscopic findings with activity of AA has been observed in earlier studies[3],[10] and the present study further confirms the correlation. Few studies as Peter et al.[12] failed to find any correlation with the disease activity. Positive correlation in the present study explains that various trichoscopic features represent distinct ways; the hair follicle responds to an initial inflammatory insult at the hair bulb region. Moreover, in the present study, these trichoscopic markers of disease activity were found at clinically inactive patches (negative hair pull test), thus proving trichoscopy as a more sensitive objective tool in recognizing the active patches than the subjective hair pull test.

Correlation between trichoscopic features and the disease severity

In contrast to most of the earlier studies, our study find significant positive correlation between various trichoscopic features BH, TH, and T and the severity of AA. Our study also observed negative correlation of severity of disease with some of the trichoscopic features YD and SVH. This was in contrast with the study by Inui et al.[10] wherein BD and YD were correlated positively and SVH negatively, with the severity of AA.


  Conclusion Top


Trichoscopy is a noninvasive diagnostic tool capable of delineating subtle details unperceivable to the unaided eye. It can be utilized in diagnosis and management of AA. It is a more sensitive tool in recognizing the active patches than the subjective hair pull test. Our study has proved the utility of trichoscopy in the assessment of various pattern, severity, and activity of AA. Although it is less time-consuming, expertise is needed to interpret various findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Alkhalifah A, Alsantali A, Wang E, McElwee KJ, Shapiro J. Alopecia areata update. J Am Academy Dermatol 2010;62:177-88.  Back to cited text no. 1
    
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Rudnicka L, Olszewska M, Rakowska A. In vivo reflectance confocal microscopy: Usefulness for diagnosing hair diseases. J Dermatol Case Rep 2008;2:55-9.  Back to cited text no. 2
    
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Mane M, Nath AK, Thappa DM. Utility of dermoscopy in alopecia areata. Indian J Dermatol 2011;56:407-11.  Back to cited text no. 3
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Inui S, Nakajima T, Nakagawa K, Itami S. Clinical significance of dermoscopy in alopecia areata: Analysis of 300 cases. Int J Dermatol 2008;47:688-93.  Back to cited text no. 4
    
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Inui S, Nakajima T, Itami S. Coudability hairs: A revisited sign of alopecia areata assessed by trichoscopy. Clin Exp Dermatol 2010;35:361-5.  Back to cited text no. 5
    
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Inui S, Nakajima T, Itami S. Dry dermoscopy in clinical treatment of alopecia areata. J Dermatol 2007;34:635-9.  Back to cited text no. 6
    
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Guttikonda AS, Aruna C, Ramamurthy DV, Sridevi K, Alagappan SK. Evaluation of clinical significance of dermoscopy in alopecia areata. Indian J Dermatol 2016;61:628-33.  Back to cited text no. 7
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Ross EK, Vincenzi C, Tosti A. Videodermoscopy in the evaluation of hair and scalp disorders. J Am Acad Dermatol 2006;55:799-806.  Back to cited text no. 8
    
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Karadaǧ Köse Ö, Güleç AT. Clinical evaluation of alopecias using a handheld dermatoscope. J Am Acad Dermatol 2012;67:206-14.  Back to cited text no. 9
    
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Inui S, Nakajima T, Itami S. Significance of dermoscopy in acute diffuse and total alopecia of the female scalp: Review of twenty cases. Dermatology 2008;217:333-6.  Back to cited text no. 10
    
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Hegde SP, Naveen KN, Athanikar SB, Reshme P. Clinical and dermatoscopic patterns of alopecia areata: A tertiary care centre experience. Int J Trichology 2013;5:132-6.  Back to cited text no. 11
    
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Peter D, George L, Pulimood SA. Trichoscopic features of various types of alopecia areata in India: Application of a hand-held dermoscope. Australas J Dermatol 2013;54:198-200.  Back to cited text no. 12
    
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Tosti A, Duque-Estrada B. Dermoscopy in hair disorders. J Egypt Womens Dermatol Soc 2010;7:1-4.  Back to cited text no. 13
    
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Rudnicka L, Olszewska M, Rakowska A, Slowinska M. Atlas of Trichoscopy: Dermoscopy in Hair and Scalp Disease. London: Springer-Verlag; 2012.  Back to cited text no. 14
    
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Kibar M, Aktan Ş, Lebe B, Bilgin M. Trichoscopic findings in alopecia areata and their relation to disease activity, severity and clinical subtype in Turkish patients. Australas J Dermatol 2015;56:e1-6.  Back to cited text no. 15
    
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Ankad B, Beergouder SL, Panchkattimath VS, Sheik Ahmed M. Trichoscopy of alopecia areata: A diagnostic aide. Hair Ther Transplant 2014;04:45-8.  Back to cited text no. 16
    
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Shuster S. Coudability: A new physical sign of alopecia areata. Br J Dermatol 1984;111:629.  Back to cited text no. 17
    
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Khunkhet S, Vachiramon V, Suchonwanit P. Trichoscopic clues for diagnosis of alopecia areata and trichotillomania in Asians. Int J Dermatol 2017;56:161-5.  Back to cited text no. 18
    
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Park J, Kim JI, Kim HU, Yun SK, Kim SJ. Trichoscopic findings of hair loss in Koreans. Ann Dermatol 2015;27:539-50.  Back to cited text no. 19
    
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