Exclamation Mark Hairs Research Articles

Serum Interleukin-15 in Alopecia Areata and its correlation with dermoscopic findings

Abstract Background Alopecia areata is an autoimmune hair loss which frequently starts in childhood. Its presentation had an extreme variability not only in the time of initial onset but also in the duration, extent, and pattern of hair loss during any given episode of active loss. Moreover, the course of disease is unpredictable, with spontaneous regrowth of hair occurring in 80% of patients within the first year and sudden relapse at any given time. Due to the clinical variability and unpredictable nature of spontaneous regrowth, diagnosis and management may be difficult and challenging. Objective The aim of this study is to evaluate the serum levels of IL-15 in active alopecia areata and correlate them with disease severity and activity according to dermoscopic findings. Methods This case-control study were conducted in Dermatology, Venereology and Andrology department, Ain Shams University Hospitals included 30 patients with different clinical variants of AA, the diagnosis was made via clinical examination and dermoscopic findings. In addition, 30 apparently healthy individuals of matched age and sex as a control group were included in the study. Results Dermoscopic examination among cases showed that the most common dermoscopic findings in patients were vellus hair and yellow dots, while the least common finding was exclamation mark hairs. On comparing serum IL-15 in patients and control groups, it was found that serum levels of IL-15 in patients were significantly higher than those in the control group. There was no statistically significant difference in serum IL-15 levels between patients with negative and positive pull test, nail involvement, or body involvement. Similarly, no statistically significant difference in serum IL-15 levels in patients with various subjective disease activity was detected. However, there was a highly significant difference between serum IL-15 levels in different SALT score groups, with the highest levels being in the S3 group. There was a highly significant difference between IL-15 levels in patients with and without black dots. Also, there was significant difference between IL-15 in patients with and without broken hair, and exclamation mark hair. There was no significant difference in level of IL-15 among patients with and without yellow dots, and with and without vellus hair. Conclusion On the basis of the current study, we can conclude that IL-15 is significantly elevated in AA patients when compared to the control subjects. It is also a possible marker of AA severity. It is positively correlated with dermoscopic findings in AA patients, so dermoscopic findings can be useful in evaluating severity of alopecia areata.

Clinico-Epidemiological Profile of Childhood Alopecia Areata Along with Dermoscopic Correlation: A Cross-Section, Observational Study.

Background:Childhood alopecia areata (AA) is a common cause of dermatologic consultation; however, data is scarce in the present set-up.Objectives:To evaluate the clinico-epidemiological profile of childhood AA along with dermoscopic correlation.Methods:We conducted a cross-sectional study including 50 new cases of childhood AA for 1 year. Dermoscopy was performed in each child and findings recorded.Results:Childhood AA was more common in girls (M: F 1:1.4), mean age being 11.1 ± 3.7 years. Scalp was commonest site of involvement in 86% cases, while 32 (64%) children had mild disease (<25% involvement). Localized circumscribed patch was the commonest presentation in 37 (74%) children, while sisaipho was the least (2%). A positive family history of AA was noted in 5 (10%) children. Twenty-four children (48%) provided a history of atopic disorders, while 30% had a positive family history of atopy. Stress was the commonest precipitating factor in 13 (26%) subjects. Nail involvement was observed in 19 (38%) children (pitting >thinning), while systemic associations like vitiligo and thyroid dysfunction were present in 26% and 24% cases, respectively. Dermoscopy revealed yellow-dots to be the commonest finding in 44 (88%) cases, followed by short vellus hair and black dots in 76% and 28% children, respectively, while exclamation-mark hair was rare.Conclusion:Female gender, younger age, nail involvement, and presence of concomitant atopy, vitiligo, and thyroid dysfunction were associated with severe disease, but not statistically significant (p > 0.05). Regression model failed to detect any risk factors for severe AA. Dermoscopy is an important non-invasive tool for evaluating childhood AA.

To Study Dermoscopic Findings in Alopecia Areata

Introduction: Alopecia areata is a common chronic autoimmune inflammatory disease that involves hair follicles, characterized by hair loss on the scalp and/or body without scarring. Clinically, the disease presents as smooth, patchy hair loss with various patterns - diffuse or reticulate alopecia, ophiasis, ophiasis inversus, alopecia totalis (loss of hair all the scalp), or alopecia universalis (loss of hair all over the body). Clinical diagnosis of AA is made based on typical pattern of hair loss and the presence of characteristic exclamation mark hair in microscopy. Invasive (punch biopsy) techniques are often required in some cases where the clinical diagnosis is not straight forward Biopsy shows peribulbar lymphocytic infiltrates in a “swarm of bee pattern” which is characteristic of the acute stage of the disease.&#x0D; Dermoscopy is an imaging instrument that immensely magnifies surface features of skin lesions. It works on the principle of illumination and transillumination of skin with different light sources and studying it with a high magnification lens. Dry dermoscopy was done with heine delta 20 dermoscope which was followed by wet dermoscopy. Liquid paraffin was used as the immersion media. It is a noninvasive, repeatable, recordable bedside investigation.&#x0D; Objective: To study dermoscopic findings in alopecia areata.&#x0D; Materials and Methods: Study Design: Cross sectional study; Study Area: Skin Outpatient Department, Sree Balaji Medical College and Hospital; Study Population: All patients with hair loss, attending skin OPD, who are clinically diagnosed as Alopecia Areata; Study Method: Observational study; Sample Size: 30.&#x0D; Results: Clinically, the disease presents as smooth, patchy hair loss with various patterns. Dermoscopy is useful for diagnosis of AA clinically by the presence of cadaverized hairs (black dots), circle hair, coudablity hair, exclamation mark hairs (tapering hairs), broken hairs, yellow dots and clustered short vellus hairs in the hair loss areas. The results wear tabulated.

Childhood Alopecia Areata: An Overview of Treatment and Recent Patents.

Alopecia Areata (AA) is a systemic autoimmune condition that usually starts in childhood. This article aims to review genetics, therapy, prognosis, and recent patents for AA. We used clinical queries and keywords "alopecia areata" AND "childhood" as a search engine. Patents were searched using the key term "alopecia areata" in Patents.google.com and freepatentsonline. com. Due to an immune-mediated damage to the hair follicles, hair is lost from the scalp and other areas of the body temporarily or even permanently. Children with AA are generally healthy. Evidence of genetic association and increased predisposition for AA was found by studying families with affected members. Pathophysiologically, T- lymphocytes attack hair follicles and cause inflammation and destruction of the hair follicles and hair loss. In mild cases, there would be well-demarcated round patchy scalp hair loss. The pathognomonic "exclamation mark hairs" may be seen at the lesion periphery. In more severe cases, the hair loss may affect the whole scalp and even the whole body. The clinical course is also variable, which may range from transient episodes of recurrent patchy hair loss to an indolent gradually deteriorating severe hair loss. The treatment of AA depends on factors including patients' age, the extent of the hair loss, duration of disease, psychological impact, availability and side effect profile of the treatments. For localized patchy alopecia, topical application of corticosteroids and/or intralesional corticosteroids are the treatment of choice. Other topical treatments include minoxidil, anthralin, coal tar and immunotherapy. In severe resistant cases, systemic immunosuppressants may be considered. Although herbal medicine, acupuncture, complementary and alternative medicine may be tried on children in some Asian communities, the evidence to support these practices is lacking. To date, only a few recent patents exist in topical treatments, including Il-31, laser and herbal medications. Clinical efficacy is pending for these treatment modalities. None of the established therapeutic options are curative. However, newer treatment modalities, including excimer laser, interleukin-31 antibodies and biologics, are evolving so that there may be significant advances in treatment in the near future. AA can be psychosocially devastating. It is important to assess the quality of life, degree of anxiety, social phobia and mood of the patients and their families. Psychological support is imperative for those who are adversely affected psychosocially.

Trichoscopic findings in alopecia areata- a cross sectional study

Alopecia areata remains one of the common cases presenting in clinical practice. Considering the anxious state of patients it becomes very important to correctly diagnose the cause and type of alopecia followed by the appropriate treatment. Trichoscopy is a novel, sensitive, non invasive modality which provides rapid detection of alopecia areata with advanced diagnostic accuracy, predicts the cause of disease and decreases unnecessary biopsies. To determine the Trichoscopic findings in alopecia areata in adult population. 122 patients with clinically diagnosed alopecia areata were enrolled. After taking proper history and consent trichoscopy was done using a Dinolite digital microscope system in both non polarized and polarized modes and their photographs were taken. 122 patients with alopecia areata were enrolled. Yellow dots were the most common trichoscopic findings observed in 108 (88.5%) patients followed by short vellus hair 66 (54.1%), short regrowing hair 58 (47.5%), exclamation mark hair 56 (45.9%), black dots 44 (36.1%) and broken hair 34 (27.9%).

Trichotillomania is chronic obsessive compulsive disease with a diagnostic hair loss patterns

Background: Trichotillomania (TTM) is a common cause of childhood alopecia. It’s a traumatic alopecia and is defined as the irresistible urge to pull out the hair, accompanied by a sense of relief after the hair has been plucked. The condition maybe episodic and the chronic type is difficult to treat. There seem to be an increase in the prevalence of the condition probably due to the changing life style into a more stressful one. Objective: To do full evaluation of this disease and description of hair loss patterns. Patients and methods: In this descriptive study, we collected patients with trichotillomania who had attended department of dermatology, college of medicine, university of Baghdad, Baghdad teaching hospital during the period from 2011 through 2019 where 114 cases of TTM were seen. The diagnosis was established on clinical basis after exclusion of other dermatological diseases and medical problems.Full history was taken from each patient including demographic data, presence of stressful life event as a triggering factor. Psycholgical assessment was carried out for each patient by experienced dermatologist as psychiatric referral was refused by all patients and their families.Full description of patterns of hair loss was carried out after exclusion of other causes of hair loss especially alopecia areata. Results: A total of 114 patients diagnosed with TTM were enrolled in this study,88 (77.19%) patients were females and 26 (22.8%) males with female to male ratio: 3.38:1 . Age of patients ranged from 6 – 65 years with a median age of 16 years with the commonest age range between 10-19 years in 64(56.14%) patients.While the duration of the condition ranged from 3 months to 4 years. Family history was positive in 6 (5.3%) patients, all of them were first degree relatives. Psychological evaluation showed obsessive compulsive neurosis in all patients and all patients or parents denied their action. Patients usually presented with areas of different hair lengths. Some hairs may be broken mid-shaft or appeared as uneven, whereas others had small black dots at the surface of the scalp, these features simulating fire in field but no exclamation mark hair were seen. There is usually no scaling on the scalp and the hair does not pull out easily. The affected area often had a strange shape, which had a useful diagnostic clue. The hair loss in TTM can take many shapes; morphological forms or patterns and as follow: crest like in 2 patients (1.75%) both of them were females in the 2nd decade of life, there was loss of hair at the sides of the scalp leaving the frontovertical and occipital area not affected,the second pattern so called cap like were found in 39 patients (34.21%), most patients were in the second decade of life, there was a hair loss at the top of the scalp mainly frontovertical area and leaving the sides of the scalp,the third pattern alopecia areata- like, where multiple patches of hair loss were seen in 20 (17.5%) patients,the forth pattern frontal baldness like seen in 19 patients (16.66%), where the patients presented with complete hair loss of the frontal hair only. While the fifth pattern was the generalized (TTM totalis) type were seen in 19 (16.66%) patients all of them were females. Involvement of the eyebrows and eyelashes alone were seen in 6 (5.26%) patients, most of them were females, all but one in the first and second decade of their lives. Mixed patterns were seen in 8 (7.01%) patients all of them were females in their second decade and as follow: frontal plus eyebrows involvement was the most common in5 patients, followed by frontal plus patchy patterns in 2 patients, then totalis plus eyebrow in one patient. Only one patient was presented with beard involvement. Conclusion: TTM is disease of young female children with obsessive compulsive neurosis that presented with different patterns of hair loss that run chronic course . It is a debilitating disorder to the patients with emotional struggle as have to endure the embarrassment and shame of hair loss. A better understanding and awareness of the disorder is certainly the first step toward recognizing this disorder and management of these patients

Clinico-Dermoscopic Features and Treatment Responsiveness in Pediatric Alopecia - Experience from a Tertiary Care Pediatric Dermatology Clinic.

Background:Data on clinical and epidemiologic profile on pediatric alopecia is relatively scarce.Aims and Objectives:We aimed to study the clinical, epidemiological, and dermoscopic profile of children presenting with alopecia, and assess the responsiveness to different treatment modalities in a real-life setting.Materials and Methods:This cohort study involved analyzing children presenting with hair loss during the study period. After a detailed history, clinical, and trichoscopic examination, treatment offered to patients and follow-up response to treatment along with relapse of symptoms were noted.Results:Around 119 children were included. Nearly 90% were of acquired etiology. The most common cause of alopecia was alopecia areata (AA) in 85 (71%) patients followed by tinea capitis 9 (7.5%), lichen planopilaris 4 (3.3%), and other less common causes. In patients of AA, dermoscopy showed the presence of black dots in 68% cases, exclamation mark hair in 54% of patients followed by off-white dots, yellow dots, and vellus hair. Patients with an acute course and black dots on dermoscopy responded better to treatment. Relapse was common in patients with early age of onset and longer disease duration.Conclusions:Hair loss is frequently seen in pediatric dermatology clinics. Dermoscopy of pediatric AA shows scarce yellow dots while off-white dots are more frequent; the presence of black dots is a good prognostic indicator.

Trichoscopic findings of trichotillomania: new observations.

IntroductionRecently, dermoscopy of the hair and scalp, also known as trichoscopy, has become an important diagnostic tool in the diagnosis of hair diseases. There are few studies describing trichoscopic findings of trichotillomania (TTM).AimTo evaluate and identify specific trichoscopic features of TTM.Material and methodsThe study included 20 patients diagnosed with TTM on the basis of the clinical history, physical examination and trichoscopic findings. All of the trichoscopic images of the patients were retrospectively reviewed and the findings identified were recorded. Descriptive statistical analysis was performed.ResultsThe findings detected were broken hairs at different levels (100%), short vellus hairs ( 90%), black dots (85%), trichoptilosis (75%), V hair (70%), hair powder (65%), yellow dots (55%), Mace hair (45%), coiled hairs (45%), exclamation mark hair (40%), blood spots (40%), branched hair (40%), angulated hair (40%), concentric hair (35%), flame hair (30%), and tulip hair (25%).ConclusionsHere we have documented trichoscopic findings of TTM retrospectively. Trichoptilosis, V hair and hair powder were the most frequent relatively specific findings. We tried to define novel findings that we named branched hair and concentric hair. We also detected Mace hair in 9 cases. Mace hair was previously described just in 3 cases of TTM in a case study. Angulated hairs, to the best of our knowledge, were also firstly described for TTM in the present study. Lack of a comparison group is the main limitation of the study.

Alopecia areata predictive score: A new trichoscopy-based tool to predict treatment outcome in patients with patchy alopecia areata.

There are no evidence-based data how to predict response to therapy in patients with alopecia areata. The assessment of the predictive value of trichoscopy for the therapeutic outcome in patients with alopecia areata. A total of 65 patients with patchy alopecia areata were included into the study. Trichoscopy was performed at baseline and 2months after the treatment initiation. After 6months, patients were classified as responders (27/65) and nonresponders (38/65). There were no differences between the groups in baseline trichoscopy. After 2months, black dots, broken hairs, exclamation mark hairs, and tapered hairs occurred significantly more often in nonresponders compared to responders (19/38, 50% vs 3/27, 11%; 26/38, 68% vs 6/27, 22%; 23/38, 61% vs 5/27, 19% and 11/38, 29% vs 0/27, 0%, respectively). Upright regrowing hairs and pigtail hairs occurred significantly more often in responders compared to nonresponders (27/27, 100% vs 21/38, 55% and 9/27, 33% vs 3/38, 8%, respectively). A trichoscopy-based Alopecia Areata Predictive Score (min -4 to max 2) was developed. Probability of hair regrowth was 98.3%, 88.7%, 52.3%, 13.2%, 2.1%, 0.3%, and 0% in patients with score 2, 1, 0, -1, -2, -3, and -4, respectively. In patchyalopecia areata, upright regrowing hairs and pigtail hairs are positive, while black dots, broken hairs, exclamation mark hairs, and tapered hairs negative predictive markers. Alopecia Areata Predictive Score is new trichoscopy-based tool to predict treatment outcome in patients with patchy alopecia areata.

Sequential cyclic changes of hair roots revealed by dermoscopy demonstrate a progressive mechanism of diffuse alopecia areata over time.

Diffuse alopecia areata (DAA) often leads to a complete hair shedding within a few months. To explore features and mechanisms underlying DAA. Scalp and hair root dermoscopy were conducted on 23 DAA patients throughout the disease process, 20 patchy Alopecia areata patients, 23 acute telogen effluvium (ATE) patients and 10 normal controls. Histopathology was also evaluated. We found almost all hair roots were anagen in early stage DAA in 18 patients (18/23, 78.3%) within the first 4-8weeks after hair loss onset. Anagen effluvium (~4weeks) was followed by catagen (~4weeks) and then telogen/exogen (~8weeks) effluvium with overlap. Hair root and proximal hair shaft depigmentation was more prominent in later DAA disease stages. Black dots, exclamation mark hairs and inconsistent thickness of hair shafts were found more often in early than later DAA (Ps<0.01). Early DAA histopathology revealed more prominent inflammation and hair follicle regression than that observed in the later stages. Patchy alopecia areata patients showed mixed anagen, catagen and telogen hair roots while ATE patients showed increased exogen and mildly decreased hair root pigmentation. Sequential cyclic staging of shed hairs in DAA indicates the insult may be hair-cycle specific. We suggest that DAA is initially an anagen effluvium disease involving an intense inflammatory insult, later progressing to a brief catagen effluvium, and then to telogen effluvium with premature exogen, in later stages of DAA.

SnapshotDx Quiz: December 2018

SnapshotDx Quiz: December 2018

The value of dermoscopy in diagnosing eyebrow loss in patients with alopecia areata and frontal fibrosing alopecia

Alopecia areata and frontal fibrosing alopecia are common causes of eyebrow loss (madarosis). Assessment of trichoscopic markers of eyebrow loss in alopecia areata and frontal fibrosing alopecia. The analysis included 50 patients with scalp alopecia areata with madarosis, 50 patients with scalp frontal fibrosing alopecia with madarosis and 50 healthy controls. In every case, trichoscopy of the eyebrow area was performed. Empty follicular and eccrine duct openings were observed in all patients and presented predominantly as yellow dots. Exclamation mark hairs were only detected in patients with alopecia areata (30%). Tapered hairs, broken hair, black dots and Pohl-Pinkus constrictions were observed in 14%, 36%, 26% and 4% of patients with alopecia areata, respectively, 4%, 16%, 2% and 0% of patients with frontal fibrosing alopecia, respectively, and they were not present in healthy controls. Dystrophic hairs and whitish areas were observed only in patients with frontal fibrosing alopecia (28% and 32%, respectively). Eyebrow regrowth in distinct directions was present in 32% of patients with frontal fibrosing alopecia, 8% of patients with alopecia areata and 4% of healthy controls. Diffuse erythema was detected in 60% of patients with alopecia areata and frontal fibrosing alopecia and 56% of healthy controls. Vellus hairs and upright regrowing hairs were observed in patients with alopecia areata (62% and 58%, respectively), frontal fibrosing alopecia (60% and 84%, respectively) and healthy controls (100% and 100%, respectively). Trichoscopy of the eyebrow area is useful in diagnosing patients with isolated eyebrow loss. The most characteristic trichoscopic features of eyebrow loss in alopecia areata include exclamation mark hairs, tapered hairs, broken hairs and black dots. Frontal fibrosing alopecia of the eyebrows is characterized by the presence of dystrophic hairs, white areas and eyebrow regrowth in distinct directions.

Role of janus kinase inhibitors in the treatment of alopecia areata.

Alopecia areata (AA) is a common hair loss disorder worldwide with characteristic exclamation mark hairs. Although AA is self-limited, it can last for several months or even years in some patients. Currently, there is no US Food and Drug Administration-approved treatment for AA. Many off-label treatments are available but with limited efficacy. Through a better understanding of molecular biology, many targeted therapies have emerged as new alternatives for various autoimmune diseases. Various janus kinase (JAK) and signal transducer and activator of transcription (STAT) proteins form signaling pathways, which transmit extracellular cytokine signals to the nucleus and induce DNA transcriptions. By inhibiting JAK, T-cell-mediated inflammatory responses are suppressed. Increasing evidence suggests that JAK inhibitors (JAKis) are effective in the treatment of many autoimmune diseases, including AA. Among these, several studies on tofacitinib, ruxolitinib, and baricitinib in AA had been published, demonstrating promising outcomes of these agents. Unlike oral formulations, efficacy of topical forms of tofacitinib and ruxolitinib reported in these studies is still unsatisfactory and requires improvement. This review aims to summarize evidence of the efficacy and safety of JAKis in the treatment of AA.

Clinical and Trichoscopic Study of Tinea Capitis versus Alopecia Areata in Pediatric Patients

AbstractBackground: Trichoscopy (hair and scalp dermatoscopy) facilitates the diagnosis of hair and scalp disorders. The aim of this study was to identify the trichoscopic features in diagnosis of Tinea Capitis (TC) and to compare these findings with those of Alopecia Areata (AA).Material and Methods: The current study included 30 patients with TC and 30 patients with AA. They were recruited from Outpatient Clinics of Dermatology and Venereology Department, Tanta University Hospitals. Clinical examination, laboratory investigations (direct microscopic examination with 10% potassium hydroxide and fungal culture) were done to confirm clinical diagnosis and dermoscopically aiming at finding the different dermoscopic features of TC and AA.Results: Short broken hairs, black dots, comma shaped hairs, corkscrew hairs and zigzag shaped hairs were observed in patients with TC. Short vellus hairs, black dots, exclamation marks, white hairs and pig tail re-growing hairs were observed in patients with AA.Conclusion: Comma shaped hairs, zigzag shaped hairs and cork screw were observed only in patients with TC. Yellow dots, exclamation mark hairs and short vellus hairs were observed only in patients with AA. Dermoscopy is rapid and reliable confirmatory test used to differentiate between TC and AA by detecting their characteristic dermoscopic features.

Trichoscopy of alopecia areata: An update.

The diagnosis of alopecia areata is usually based on clinical manifestations. However, there are several hair and scalp disorders that share similar clinical features with alopecia areata, such as tinea capitis, trichotillomania or traction alopecia. Trichoscopy as a fast, non-invasive and easy-to-perform technique may help to identify subtle details and establish the correct diagnosis. The aim of this review is to present the spectrum of trichoscopic findings in alopecia areata. A systematic review of the published work was performed by searching the PubMed, Scopus and EBSCO databases, complemented by a thorough hand search of reference lists. Of 427 articles retrieved, 30 studies were eligible for quantitative analysis. The reported features of alopecia areata were: yellow dots (6-100% patients), short vellus hairs (34-100%), black dots (0-84%), broken hairs (0-71%) and exclamation mark hairs (12-71%). Tapered hairs (5-81%) were reported in few studies, but a relatively high frequency of this finding in alopecia areata may indicate their important role in the differential diagnosis of hair loss. Rarely reported features, which include upright regrowing hairs (11-96%), pigtail (circle) hairs (4-61%) and Pohl-Pinkus constrictions (2-10%), may also be helpful in the diagnosis of alopecia areata. There is no pathognomonic trichoscopic marker for alopecia areata and the most common trichoscopic features are not the most specific. Therefore, the diagnosis should be based on the coexistence of several trichoscopic findings, not on the presence of a single feature.

Indian Dermoscopic Study of One Thirty Eight Cases of Alopecia Areata

Alopecia areata (AA) is a type of non-scarring alopecia first described by Cornelius Celsus, characterized by hair loss without any clinical inflammatory signs and affecting both males and females equally. The activity of AA is by the presence of black dots, broken hair, and tapering, furthermore black dots and yellow dots are equated to severity of AA.&#x0D; Aim - To study dermoscopic features of untreated cases of alopecia areata. Study subjects-All the patients who attended the dermatology clinic from March 2015 to March 2017 with the clinical diagnosis of alopecia areata and who fulfilled the inclusion and exclusion criteria.&#x0D; Study period - Two year (from March 2015 to March 2017).&#x0D; Methodology - All the patients who attended the dermatology clinic from March 2015 to March 2017 with the diagnosis of alopecia areata and who fulfilled the inclusion and exclusion criteria were recruited for the study. Trichoscopy was performed with DL4 dermatoscope. The images were further magnified with smart phone.&#x0D; Results - We got various dermoscopic signs in different combinations in our study. Yellow dots were seen in 10 cases, White dots in cotton wool pattern were seen in 3 cases, Black dots were seen in 25 cases, Dermoscopic coudability sign was demonstrated in 38 cases, Pigtail hairs were present in 2 cases, five cases showed short vellus hairs, Short broken hairs were found in 18 cases, Exclamation mark hairs were very common and were detected in 131 patients out of 138.&#x0D; Discussion - Single feature is not leading to the diagnosis so we should use combination of features which will help in difficult cases like AA incognito. Dermatoscope is an indispensible valuable tool in trichology practice which helps in prognosticating and making early diagnosis of AA. It also helps to differentiate it from trichotillomania and other causes of alopecia. In our study the incidence of AA was almost similar in both sexes. Our study revealed that exclamation mark hair is very common and sensitive dermoscopic marker of AA.

Dermoscopic Findings in 126 Patients with Alopecia Areata: A Cross-Sectional Study.

Background:Dermoscopy is used increasingly in dermatological practice. Although dermoscopic findings of alopecia areata (AA) are described in the literature, studies are limited.Aim:Our aim was to evaluate dermoscopic findings of Iranian patients with AA and correlate them with disease activity and severity.Subjects and Methods:Totally 126 patients were examined using a Dermlite II multispectral dermoscope. Severity, activity, pull test, nail changes, treatments, and dermoscopic findings were recorded.Statistical Analysis Used:Statistical analysis was done by SPSS version 22, using appropriate statistical tools.Results:The most common dermoscopic findings were yellow dots (84.1%), vellus hairs (62.6%), black dots (48.4%), exclamation mark (30.9%), and broken hair (9.5%), in decreasing order. Furthermore, the most common dermoscopic findings in patients on diphencyprone were vellus hairs and yellow dots. Yellow dots and vellus hairs were most common in patients with alopecia universalis. However, broken hairs and exclamation mark hairs were mostly observed in patchy multiple AA patients. Yellow dots and exclamation mark hairs were also significantly more common in patients with positive pull test. Furthermore, vellus hairs were more common in patients with remitting disease pattern. With regard to scalp severity, yellow dots related positively, while vellus hairs, broken hairs, and exclamation mark hairs related negatively with severity of disease.Conclusions:Dermoscopic findings differ in various stages of activity and severity of AA. Dermoscopy is a valuable tool for the dermatologist for the diagnosis, follow-up, and evaluation of response to treatment.

A tricky case of hair loss in a child: Trichoscopy saves the day

Dear Editor, A 7-year-old, otherwise healthy Indian girl presented with asymptomatic sparsening of hair on the sides and posterior scalp of 6 months duration. The parents reported no improvement with oral iron and multivitamin supplements taken for 3–4 months, betamethasone, and 2% minoxidil lotion applied for 2–3 months, and three doses of weekly oral fluconazole 50 mg. Examination revealed numerous coalescing patches of nonscarring alopecia, with the left parieto-occipital scalp being more involved [Figure 1]. There was mild scalp scaling but no visible broken hair shafts or exclamation-point hair. Hair pull test was negative. A 10% potassium hydroxide (KOH) mount preparation of hair shafts from multiple areas was negative for fungal elements. Specimen was also sent for fungal culture. Provisionally, differential diagnoses of noninflammatory tinea capitis (TC), diffuse alopecia areata (AA), and trichotillomania (TTM) were considered. Trichoscopy using a hand-held dermoscope (Heine Delta® 20T) under polarized light (×10) revealed several “comma,” and “corkscrew” hairs in addition to few black dots and focal scale-crust. A dead head louse was also detected incidentally, however, no nits were visualized [Figure 2]. In the absence of defining trichoscopic features of AA or TTM, and the unmissable presence of typical trichoscopic features of TC, the patient was treated with oral terbinafine (125 mg/day) and 2% ketoconazole shampoo. Our diagnosis of TC was reaffirmed when the fungal culture reported growth of Trichophyton violaceum. The child achieved complete clinical cure by the 6th week of treatment initiation. The utility of trichoscopy is being increasingly recognized in the diagnosis of alopecia in children. The dermoscopic features of various causes of alopecia, including AA, TTM and TC are now well-recognized.[1] The trichoscopic features of TC vary in inflammatory and noninflammatory variants. While the typical black-dot tinea is characterized black dots and short broken hair, inflammatory variant shows additional features such as erythema, scaling, pustules and follicular scale-crusts. Though black dots and broken hair are non-specific findings that can also be seen in AA and TTM, presence of comma, corkscrew and zig-zag hairs are specific to TC.[23] “Comma hair,” observed in both endothrix and ectothrix-infections appear as slightly curved hair shafts, fractured close to the scalp surface and result from hyphal invasion of the hair shaft.[23] Corkscrew and zigzag hair represent variations of the comma hair.[23] The trichoscopic hallmarks of AA are exclamation mark hairs and yellow dots,[4] while TTM shows broken hair shafts of uneven length, follicular hemorrhage, trichoptilosis, tulip hair, flame hair, and other specific features, which were absent in our patient.[5]Figure 1: Patchy-to-diffuse hair loss in a 7-year-old girl; more prominent on the left side of the scalpFigure 2: Trichoscopy [Polarized, 10×] showing multiple comma hairs (green arrows), corkscrew hairs (red arrows), in addition to black dots and focal scale crust. A dead head louse was seen incidentally (Yellow circle)The clinical pattern of alopecia was not very typical of TC in our patient, with diffuse nonscarring alopecia, minimal inflammation, and a negative hair pluck test. A negative KOH rendered the diagnosis tricky. Fungal culture, the gold standard of diagnosis of TC, takes approximately 4 weeks for growth of dermatophytes. The correct diagnosis was initially suggested by trichoscopy that showed characteristic comma and corkscrew hairs, which allowed us to start the treatment early. The diagnosis of TC was later confirmed by a positive fungal culture. With this report, we wish to highlight the utility of dermoscopy as a quick, simple and noninvasive technique in the differential diagnosis of nonscarring alopecia in children and as an aid in instituting the optimal treatment without delay. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Dermoscopy of alopecia areata-a retrospective analysis.

BackgroundDermoscopy devices can overcome the refractive properties of stratum corneum by interface medium or cross polarization such that the lesion can be easily seen.AimTo examine the dermoscopic feature in alopecia areata and correlate the severity of disease with dermoscopic features.Materials and methodsRetrospective analysis of 72 patients suffering from alopecia areata (AA), irrespective of age and sex, who visited the dermatology outpatient department of a tertiary care center in Eastern India was carried out. The most recently developed cases of AA were examined dermoscopically. Variables included yellow dots (YDs), black dots (BDs), broken hair (BH), short vellus hair (SVH), and exclamation mark hair (EMH) on the basis of available literature and expertise.ResultsYellow dots was the most common finding seen in 57 cases (79.16%), black dots in 51 cases (70.8%). Short vellus hair was seen in 32 cases (44.44%), broken hair was seen in 31 cases (43.05%), and exclamation mark hair in 23 cases (31.9%). YDs per field of vision was considered as the most common finding with increased severity of AA.ConclusionYDS, in increased number per field of vision, is the most consistent finding seen in severe cases of AA, as they are in progressive AA and alopecia universalis. An increased number of SVH and terminal hairs were seen in patients who were being treated.

Trichoscopic clues for diagnosis of alopecia areata and trichotillomania in Asians.

Trichoscopy has become a useful diagnostic tool for various hair and scalp diseases, including alopecia areata (AA) and trichotillomania (TTM), which are sometimes difficult to distinguish clinically. To describe trichoscopic findings of AA and TTM in an Asian population and to establish diagnostic clues for these conditions. Trichoscopy was performed with a handheld dermoscope in 52 patients diagnosed with AA and 23 patients diagnosed with TTM. Trichoscopic images were then blindly evaluated. The trichoscopic features more frequently observed in AA than in TTM included exclamation mark hairs (AA 59.6%, TTM 26.1%), tapered hairs (AA 59.6%, TTM 4.3%), yellow dots (AA 46.2%, TTM 21.7%), and angulated hairs (AA 26.9%, TTM 0%) (P<0.05). On the other hand, broken hairs of different lengths (TTM 100%, AA 3.8%), trichoptilosis (TTM 78.3%, AA 5.8%), V-sign (TTM 43.5%, AA 3.8%), flame hairs (TTM 43.5%, AA 0%), and hair powder (TTM 13%, AA 1.9%) were more commonly demonstrated in TTM than in AA (P<0.05). Exclamation mark hairs indicate a diagnosis of AA but not pathognomonic. In addition, angulated hairs, fractured hairs forming a sharp angle along the hair shaft, appear to be typical for AA in Asians when differentiating from TTM. It is important to consider various trichoscopic findings together to establish the diagnosis of AA or TTM.