Aqcuired nonscarring alopecia

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Main PageTrichoscopyAqcuired nonscarring alopeciaAlopecia areata
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 Editor: Anna Waskiel Burnat

 Author(s): Anna Waskiel Burnat     ·  Lidia Rudnicka
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Description This chapter describes the dermoscopyThe examination of [skin lesions] with a 'dermatoscope'. This traditionally consists of a magnifier (typically x10), a non-polarised light source, a transparent plate and a liquid medium between the instrument and the skin, and allows inspection of skin lesions unobstructed by skin surface reflections. Modern dermatoscopes dispense with the use of liquid medium and instead use polarised light to cancel out skin surface reflections. of acquired nonscarring alopeciaThis glossary term has not yet been described.
Author(s) Anna Waskiel Burnat · Lidia Rudnicka
Responsible author Anna Waskiel Burnat→ send e-mail
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Status update April 4, 2019
Status by Ralph P. Braun


This chapter describes the dermoscopy of acquired nonscarring alopecia

It has the following subchapters:

Androgenetic alopecia Anna Waskiel Burnat, Lidia Rudnicka
Alopecia areata Anna Waskiel Burnat, Lidia Rudnicka
Trichotillomania Anna Waskiel Burnat, Lidia Rudnicka
Telogen effluvium Anna Waskiel Burnat, Lidia Rudnicka


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Androgenetic alopeciaThis glossary term has not yet been described.

Androgenetic alopecia is characterized by predominance of trichoscopic abnormalities in the frontal area compared to the occipital area [1]. The progressive miniaturization of hair follicles is observed in trichoscopyThis glossary term has not yet been described. as hair shaftThis glossary term has not yet been described. thickness heterogenity (more than 20% of observed hair shafts are thinner that terminal hair shafts [3] and increased proportion of thin and vellus hairs (higher than 10%). Moreover, there is a tendency to observe follicular units with one or two hairs instead of predominance of follicular units with three or more hairs. [1] Other trichoscopic features are: presence of variable number of yellow dots and perifollicular discoloration (hyperpigmentation, peripilar sign) [1]

Diagnostic trichoscopic criteriameasure of how well one variable or set of variables predicts an outcome for female androgenetic alopeciaThis glossary term has not yet been described. [1]:


Major criteria Minor criteria
  1. More than four yellow dots in four imagesA representation of a person, animal or thing, photographed, painted or otherwise made visible. at a 70-fold magnification in the frontal area
  2. Lower average hair thickness in the frontal area in comparison with the occiput (calculated from not less than 50 hairs from each area)
  3. More the 10% of thin hairs (below 0.03 mm) in the frontal area
  1. Ratio of single-hair unit percentage, frontal area to occiput >2:1
  2. Ratio of number of vellus hairs, frontal area to occiput >1.5:1
  3. Ratio of hair follicles with perifollicular discoloration, frontal area to occiput >3:1

Fulfillment of two major criteria or one major and two minor criteria is required to diagnose female androgenetic alopecia.

FAGA1.jpg

Template:Trichoscopy of androgenetic alopecia with hair shafts thickness heterogeneity, yellow dots and predominance of single-hair units.

FAGA2.jpg

Template:Trichoscopy of androgenetic alopecia with hair shafts thickness heterogeneity, yellow dots and predominance of single-hair units.


Alopecia areataThis glossary term has not yet been described.


Trichoscopic findings of alopecia areataThis glossary term has not yet been described. include black dotsDots are small, round structures of less than 0.1 mm in diameter that have a red color when corresponding to blood vessels; however, when due to melanin, their color ranges from black, brown, to blue-gray depending on the depth and concentration of the melanin in the skin (Tyndall effect)., broken hairs, exclamation mark hairs, tapered hairs, Pohl-Pinkus constrictions, yellow dots, short vellus hairs, upright regrowing hairs and pigtail hairs [4].
Trichoscopic feature Reported prevalence in %* (mean value**)
Yellow dots 6 - 100 (62)
Black dots 0 - 84 (53)
Exclamation mark hairs 12 - 71 (39)
Tapered hairs 5 - 81 (51)
Broken hairs 0 - 71 (49)
Short vellus hairs 34 - 100 (61)
Upright regrowing hairs 11 - 96 (23)
Pigtail (circle) hairs 4 - 61 (21)
Pohl-Pinkus constrictions 2 - 10 (4)
Adapted from Waśkiel et al. [5]



Active hair loss in alopecia areata is characterized by presence of black dots, broken hairs, exclamation mark hairs, tapered hairs and Pohl-Pinkus constrictions [6, 7] [8] [9] [10]. In long-lasting, non-active disease mainly yellow dots and short vellus hairs are observed [10].

Good response to the therapy of alopecia areata is characterized the reduction followed by the loss of exclamation mark hairs, broken hairs and black dots [11]. Yellow dots are the least responsive [11]. In initial hair regrowth, increased number of short vellus hairs is observed. With the continuation of the therapy they are substituted by fully pigmented terminal hairs so a decreased number of short vellus hairs may be detected [12]. Hair regrowth is characterized by presence of upright regrowing hairs and pigtail hairs [10].
AA1.jpg

Template:Trichoscopy of alopecia areata with presence of exclamation mark hairs.

AA2.jpg

Template:Black dots, yellow dots and broken hairs in patient with alopecia areata.

AA3.jpg

Template:Multiple yellow dots in patient with inactive alopecia areata.


TrichotillomaniaThis glossary term has not yet been described.

TrichoscopyThis glossary term has not yet been described. of trichotillomaniaThis glossary term has not yet been described. is characterized by presence of hairs broken at different length, black dots, trichoptilosis, coiled hairs, flame hairs, V-sign and tulip hairs [13].

Moreover exclamation mark hairs, yellow dots and upright regrowing hairs may be observed [13]. Other characteristic, but rarely described trichoscopic findings include hair powder and follicular microhemorrhages [13, 14].
TM.jpg

Template:Trichoscopy of trichotillomania with presence of hairs broken at different length, black dots, and tulip hairs.

TM1.jpg

Template:Coiled hairs in patient with trichotillomania.

TM2.jpg

Template:Tulip hairs in patient with trichotillomania.


Telogen effluviumThis glossary term has not yet been described.

There are no specific trichoscopy findings of telogen effluviumThis glossary term has not yet been described. [4]. However, presence of upright regrowing hairs and predominance of single-hair follicular units with perifollicular discoloration may be indicative of telogen effluvium in absence of features characteristic for other causes of hair loss [4].



1. Rakowska, A., et al., DermoscopyThe examination of [skin lesions] with a 'dermatoscope'. This traditionally consists of a magnifier (typically x10), a non-polarised light source, a transparent plate and a liquid medium between the instrument and the skin, and allows inspection of skin lesions unobstructed by skin surface reflections. Modern dermatoscopes dispense with the use of liquid medium and instead use polarised light to cancel out skin surface reflections. in female androgenic alopecia: method standardization and diagnostic criteria. Int J Trichology, 2009. 1(2): p. 123-30.
2. Deloche, C., et al., Histological features of peripilar signs associated with androgenetic alopecia. Arch Dermatol Res, 2004. 295(10): p. 422-8.
3. Blume-Peytavi, U., et al., S1 guideline for diagnostic evaluation in androgenetic alopecia in men, women and adolescents. Br J Dermatol, 2011. 164(1): p. 5-15.
4. Rudnicka, L., et al., Trichoscopy update 2011. J Dermatol Case Rep, 2011. 5(4): p. 82-8.
5. Waskiel, A., et al., Trichoscopy of alopecia areata: An update. J Dermatol, 2018.
6. Guttikonda, A.S., et al., Evaluation of Clinical Significance of Dermoscopy in Alopecia Areata. Indian J Dermatol, 2016. 61(6): p. 628-633.
7. Inui, S., et al., Clinical significance of dermoscopy in alopecia areata: analysis of 300 cases. Int J Dermatol, 2008. 47(7): p. 688-93.
8. Kibar, M., et al., Trichoscopic findings in alopecia areata and their relation to disease activity, severity and clinical subtype in Turkish patients. Australas J Dermatol, 2015. 56(1): p. e1-6.
9. Inui, S., T. Nakajima, and S. Itami, Coudability hairs: a revisited sign of alopecia areata assessed by trichoscopy. Clin Exp Dermatol, 2010. 35(4): p. 361-5.
10. Rudnicka, L., M. Olszewska, and A. Rakowska, Atlas of trichoscopy: dermoscopy in hair and scalpThis glossary term has not yet been described. disease. 2012, London: Springer.
11. Ganjoo, S. and D.M. Thappa, Dermoscopic evaluation of therapeutic response to an intralesional corticosteroid in the treatment of alopecia areata. Indian J Dermatol Venereol Leprol, 2013. 79(3): p. 408-17.
12. El Taieb, M.A., et al., Platelets rich plasma versus minoxidil 5% in treatment of alopecia areata: A trichoscopic evaluation. Dermatol Ther, 2017. 30(1).
13. Rakowska, A., et al., New trichoscopy findings in trichotillomania: flame hairs, V-sign, hook hairs, hair powder, tulip hairs. Acta Derm Venereol, 2014. 94(3): p. 303-6.
14. Kowalska-Oledzka, E., et al., 'Black dots' seen under trichoscopy are not specific for alopecia areata. Clin Exp Dermatol, 2012. 37(6): p. 615-9.