Abstract
Background and Aims:
Alopecia areata (AA) is a common nonscarring alopecia that affects the hair follicles on the scalp and/or body and occasionally, the nails. Clinical examination is the cornerstone of diagnosis of AA. In recent times, trichoscopy has emerged as a useful noninvasive tool for the diagnosis of disorders of the scalp. This study was undertaken in an attempt to study various trichoscopic patterns seen in AA and to co-relate the trichoscopic findings with the clinical subtypes of the disease, disease activity and disease severity.
Materials and Methods:
This is a descriptive, observational and noninterventional study wherein 160 treatment-naïve patients with a clinical diagnosis of AA underwent trichoscopic examination. The trichoscopic patterns were evaluated to identify any relationships between specific features and the disease’s clinical activity and severity.
Results:
Black dots, cadaverised hair and exclamation mark hair co-related positively with the disease activity, whereas vellus hair, upright regrowing hair, pigtail hair and leucotrichia co-related negatively with the same. Severe disease was marked by the presence of yellow dots, coudability hair and white patches, while exclamation mark hair, vellus hair and leucotrichia signified less severe disease. Novel trichoscopic findings observed were cotton-wool like pattern, craters in moon appearance and honeycomb pigmentation.
Conclusion:
Trichoscopy can serve as an easy-to-use and noninvasive diagnostic modality that can delineate subtle findings which cannot be perceived by the naked eye. This study underscores the utility of trichoscopy in the assessment of the activity and severity of AA.
Introduction
Alopecia areata (AA) is a common, autoimmune, nonscarring alopecia that involves the hair follicles on the scalp and/or body and occasionally, the nails.[1,2] It presents as noninflamed, well-defined, smooth patches of hair loss with no observable changes in skin texture.[3,4] The identification of AA is primarily clinical. Rarely, a scalp biopsy maybe needed to ascertain the diagnosis in doubtful cases.
In recent times, trichoscopy has emerged as a useful noninvasive tool for the diagnosis of disorders of the scalp.[5] It can even obviate the need for scalp biopsy in many cases. Classical trichoscopic signs of AA, namely, black dots (BD), yellow dots (YD), exclamation mark hair (EMH), vellus hair (VH), broken hair (BH) and Pohl-Pinkus constriction (PPC) have been well described in literature.[6–9]
This study was undertaken in an attempt to study various trichoscopic patterns seen in AA and to co-relate the trichoscopic findings with the clinical subtypes of the disease, the disease activity and the disease severity. Three new trichoscopic findings were also seen in our study and an association of AA with trichotillomania (TTM) was observed.
Materials and Methods
This was a descriptive, observational and noninterventional study carried out after obtaining permission from the Institutional Ethics Committee (xxxx/2k21p-TH/xxx). One-hundred sixty patients with a clinical diagnosis of AA were included in the study irrespective of age and sex. The patients were explained about the nature of the study and written informed consent was obtained from them prior to enrolment in the study. Patients of AA already on treatment and patients not willing for participation in the study were excluded.
Patients recruited for the study were assessed for disease activity and severity by detailed clinical history and National AA Foundation’s grading protocol [Table 1] known as Severity of Alopecia Tool score. Contact trichoscopy was conducted using the nonpolarised mode of a Heine Delta 20T dermatoscope (10× magnification) without the application of immersion fluid. Images were acquired using the rear camera of a Samsung S21 Ultra. Patients were stratified into two groups based on disease severity: Disease Severity Group 1 (DSG-1) and DSG-2. DSG-1 comprised grades S1, S2 and S3, while DSG-2 included S4 and S5, as per the NAAF classification system. Progressive AA was defined as an increase in total hair loss of more than 5%; stable, a change in total hair loss of less than 5%; remitting AA, a decrease in total hair loss of more than 5% over the month prior to the dermoscopic examination. The results were tabulated and analysed statistically using SPSS Software 25.0 version. For calculating frequencies and finding correlation between different variables, chi-squared test, Fisher’s exact test and Spearman’ rank correlation test were used. Results were considered significant if P < .05.
National alopecia areata foundation (NAAF) grading[1]
Results
A total of 160 patients were included in this study. The demographic details of the study population have been outlined in Table 2. The study population consisted of 88(55%) males and 72(45%) females. The age of the patients included ranged from 6 to 54 years with a mean age of 24.5 ± 11.2 years. The duration of the disease ranged from 15 days to 12 years with a mean duration of 10.8 ± 18 months. Distribution according to the clinical subtype has been shown in Figure 1. The most common clinical subtype encountered was localised patchy that included 96(60%) of the patients followed by reticulate pattern and alopecia universalis that had 20(12%) patients each. There were 8(5%) patients with ophiasis and 12(7%) patients were sisaipho pattern. The least number of patients, that is, four (3%) patients were of the alopecia totalis type. According to the disease severity, 108 patients fell into DSG-1 and 52 patients were included in DSG-2 category.
Demographic details of the study population
Distribution of the study population according to the clinical subtype of the disease
Characteristic Dermoscopic Findings
The various dermoscopic findings seen using Heine Delta 20T dermatoscope (contact, nonpolarised mode, 10x) were YD [Figure 2] in 75% (n = 120) patients, BD [Figure 3] in 60% (n = 96) patients, cadaverised hair [(CVH), Figure 3] in 37.5% (n = 60), EMH [Figure 4] in 55% (n = 88), VH [Figure 5] in 40% (n = 64), coudability hair [(CH), Figure 6] in 37.5% (n = 60), coudability sign [(CS), Figure 4] in 32.5% (n = 52), tulip hair [(TH), Figure 7] in 25% (n = 40), pigtail hair [(PTH), Figure 8] in 27.5% (n = 44), white patches [(WP), Figure 9] in 2.5% (n = 4), cotton wool spots [(CWS), Figure 10] in 10% (n = 16), craters in moon [(CM), Figure 11] appearance in 5% (n = 8), honeycomb pigmentation [(HCP), Figure 12] in 10% (n = 16), upright regrowing hair [(URH), Figure 5] in 22.5% (n = 36), PPC [Figure 4] in 17.5% (n = 28) and leucotrichia [(LT), Figure 8] in 50% (n = 80) and arborising vessels [(ARV), Figure 13] in 2.5% (n = 4) patients. The most common trichoscopic finding seen was YD in 75% of the patients and the least common findings seen were WP and ARV in four patients each.
Trichoscopic examination showing yellow dots (red circle) (Heine Delta 20T dermatoscope, nonpolarised, contact mode, 10×)
Trichoscopic examination showing black dots (red circle) and cadaverised hair (blue circle) (Heine Delta 20T dermatoscope, nonpolarised, contact mode, 10×)
Trichoscopic examination showing exclamation mark hair (red arrow), coudability sign (green arrow) and Pohl-Pinkus constriction (yellow arrow) (Heine Delta 20T dermatoscope, nonpolarised, contact mode, 10×)
Trichoscopic examination revealing upright regrowing hair (yellow arrow) and vellus hair (green arrow) (Heine Delta 20T dermatoscope, nonpolarised, contact mode, 10×)
Trichoscopic examination showing coudability hair (red arrow) (Heine Delta 20T dermatoscope, nonpolarised, contact mode, 10×)
Trichoscopic examination showing tulip hair (yellow arrow) (Heine Delta 20T dermatoscope, nonpolarised, contact mode, 10×)
Trichoscopic examination revealing leucotrichia (red arrow) and pigtail hair (blue circle) (Heine Delta 20T dermatoscope, nonpolarised, contact mode, 10×)
Trichoscopic examination revealing white patches signifying fibrosis (Heine Delta 20T dermatoscope, nonpolarised, contact mode, 10×)
Cotton wool spots revealed by trichoscopic examination (Heine Delta 20T dermatoscope, nonpolarised, contact mode, 10×)
Craters in moon appearance visualised by trichoscopic examination (Heine Delta 20T dermatoscope, nonpolarised, contact mode, 10×)
Trichoscopy showing honey comb pigmentation in a patient of alopecia areata (Heine Delta 20T dermatoscope, nonpolarised, contact mode, 10×)
Arborising red vessels (blue arrow) seen along with pigtail hair (yellow circle) in a patient of alopecia areata (Heine Delta 20T dermatoscope, nonpolarised, contact mode, 10×)
According to the Activity of the Disease
According to the disease activity, there were 72(45%) patients of progressive, 52(32.5%) patients of stable and 36(22.5%) patients of remitting disease. The presence of various trichoscopic signs according to the activity of the disease has been tabulated in Table 3. BD were present in 100% of the patients with progressive disease (P = .001). EMH also showed a positive correlation with the disease activity (P = .001). Stable disease was marked by the presence of WP (P = 1.000), CWS (P = 1.000), CM (P = 1.000) and HCP (P = .083). VH (P = .058), URH (P = .182), PTH (P = .041), ARV (P = 1.000) and LT (P = .008) marked remitting disease.
Various trichoscopic signs according to the activity of the disease
According to the Severity of the Disease
Based on the disease severity, patients were grouped into either DSG-1 or DSG-2, as mentioned before. DSG-1 consisted of 108 patients, while DSG-2 had 52 patients. The various trichoscopic findings according to the disease severity have been listed in Table 4. EMH (P = .007), VH (P = .134) and LT (P = .026) were markers of less severe disease in our study and more severe disease was marked by YD (P = .055), CH (P = .196), WP (P = 1.000), CWS (P = 1.000), CM (P = 1.000) and HCP (P = 1.000).
Trichoscopic signs according to the severity of the disease
According to the Clinical Subtype
The most common clinical subtype encountered was localised patchy that included 96(60%) of the patients followed by reticulate pattern and alopecia universalis that had 20(12%) patients each. There were 8(5%) patients with ophiasis and 12(7%) patients were sisaipho pattern, while alopecia totalis consisted of only 4(2.5%) patients. The various trichoscopic findings according to the clinical subtype of the disease have been tabulated in Table 5. HCP (P = .083), WP (P = 1.000), CM (P = 1.000), PPC (P = 1.000) and CWS (P = .083) were present more significantly in alopecia universalis subtype in our study. CWS were also a marker of reticulate pattern of AA and HCP pattern was also present in the alopecia totalis subtype significantly.
Trichoscopic findings according to the clinical subtype of the disease
Novel Trichoscopic Findings
A few scarcely reported trichoscopic findings were found in our patients of AA. One of the findings included cotton-wool like pattern which is formed due to multiple coalescing white dots. CWS were seen in 16(10%) of our patients, all in the DSG-2 category and of stable disease. CWS also served as a marker for reticulate AA and alopecia universalis. The second finding reported was CM appearance, which is formed due to extensive YD and the depressions are formed by sebum with minimal keratin. CM pattern was seen in 8(5%) patients in this study and like CWS, it was present in patients with stable disease of DSG-2 category, all with alopecia universalis. The final trichoscopic sign seen was HCP pattern which is characterised by grids due to melanocytes in the rete ridges and holes due to thin suprapapillary epidermis. HCP was found in 16(10%) of our patients, 4 with progressive disease and 12 with stable disease, all in the DSG-2 category. HCP pattern was statistically significantly present in patients with alopecia totalis (n = 4) and alopecia universalis (n = 12) clinical subtype.
Association with Trichotillomania
Trichoscopy helped to diagnose TTM in four of our patients of AA, which is a rarely reported association. Specific trichoscopic signs of TTM such as V-sign and trichoptilosis were found in 2.5% of our patients along with the various specific trichoscopic signs of AA [Figure 14].
A case of alopecia areata-trichotillomania overlap showing V-sign (blue circle), Pohl-Pinkus constriction (red arrow) and coudability hair (yellow arrow) (Heine Delta 20T dermatoscope, nonpolarised, contact mode, 10×)
Discussion
AA is an autoimmune disorder of the hair follicles that leads to patchy hair loss.[10] Trichoscopy is being increasingly used as an easy and noninvasive modality for the diagnosis of various disorders of the scalp.[5] This study aimed to determine various trichoscopic findings in patients of AA and co-relating them with the disease activity, severity and the clinical subtype.
One-hundred sixty clinically diagnosed patients of AA underwent trichoscopic examination in our study. Localised patchy was the most common clinical pattern encountered in our study that was present in 60%(96) of our patients. This number is almost comparable to that seen by Sahu et al. (66.7%),[11] however, lesser than that observed by, Hegde et al. (73.3%),[12] Guttikonda et al. (84%),[7] and Bapu et al. (87.9%).[13] In studies by Mahmoudi et al.[14] and Inui et al.[6] patchy subtype accounted for only 34.1% and 46.7% of the total cases respectively.
Looking at the trichoscopic findings, YD that represent distended follicular infundibula filled with keratinaceous material and sebum were the most common finding seen in 75%(120) of our patients. BD that are remnants of BH shafts inside the follicular ostia were also seen in a major proportion, that is, 60%(96) of our patients. Mane et al.[15] (81.8%), Bapu et al.[13] (89.6%), Guttikonda et al. (88%)[7] and Mahmoudi et al.[14] (81.8%) also reported YD to be the most common trichoscopic finding in patients of AA. However, research done by Inui et al.[6] (80.46%), Hegde et al.[12] (84%) and Peter et al.[16] (75%) showed BD to be the most common trichoscopic sign in AA.
EMH represent fractured hair with a wider diameter of the distal shaft and a thinner proximal end. Fifty-five per cent (88) of the patients in this study showed the presence of EMH. Prevalence of EMH ranging from 31.7% to 61.54% has been reported previously in various studies.[6,16–19] CH are normal looking hair that have a tendency to kink when pushed inwards. CH were seen in 37.5%(60) of our patients, which is way higher than that reported by Vijay et al. (26.9%),[17] Kibar et al. (20.5%)[18] and Guttikonda et al. (14%).[7]
VH are short, nonpigmented hair that signify regrowth and were seen in 40% of the patients. A variable prevalence ranging from 40.9% to 72.7% has been reported in studies done previously.[6,12,15–17] Another sign of regrowth is PTH which are coiled VH growing in a circular pattern. These were seen in 27.5%(44) of the patients in our study as opposed to 14% as reported by Guttikonda et al. (14%)[7] and 17.5% as reported by Peter et al.[16] However, our findings are in line with the study done by Bains et al.[20] who reported PTH in 28.8% of their patients of AA.
PPC refer to constrictions present at irregular intervals in the hair shafts. This sign was observed in 28 patients in this study. It has been reported only in one patient of AA by Vijay et al.[17] and two patients by Mane et al.[15]
Correlation with Activity of the Disease
BD and EMH were found to be associated with active disease in our study. Stable disease was marked by the presence of WP, CWS, CM and HCP, whereas VH, URH, PTH, ARV and LT marked remitting disease. These findings are in line with those reported previously by many studies.[6,15,17] However, few studies failed to demonstrate any correlation between trichoscopic findings and the disease activity.[11,16]
Correlation with Disease Severity
EMH, VH and LT were markers of less severe disease in this study and a more severe disease was marked by YD, CH, WP, CWS, CM and HCP. Similar findings have been reported by studies done previously.[6,7,11,14] In contrast to these findings, Vijay et al. (26.9%) reported YD to be negatively correlated with the disease activity.
Correlation with Disease Subtype
HCP, WP, CM, PPC and CWS were present more significantly in alopecia universalis subtype in our study. CWS were also a marker of reticulate pattern of AA and HCP pattern was also present in the alopecia totalis subtype significantly. Most of the studies carried out previously have not reported any correlation between the trichoscopic findings and the clinical subtype of AA.[6,18] Bains et al.[20] reported YD to be present in all patients of alopecia totalis and alopecia universalis. They also reported maximum prevalence of BH in patchy subtype and least in alopecia universalis.
Novel Trichoscopic Findings
Trichoscopic signs that have been scarcely reported previously were observed in our study. Cotton-wool pattern that is formed due to coalescing white dots was seen in 16(10%) of the patients in this study. This pattern has been reported only twice till date by Kibar et al.[18] and Ankad et al.[19] The second rare pattern observed was CM appearance, which is formed due to extensive YD and the depressions are formed by sebum with minimal keratin. CM pattern was seen in 8(5%) patients in this study and has been reported only by Malakar et al.[21] as a marker of disease severity in AA, which is comparable to our findings. The final rare trichoscopic sign seen was HCP pattern which is characterised by grids due to melanocytes in the rete ridges and holes due to thin suprapapillary epidermis. HCP was found in 16(10%) of our patients. Like CWS, HCP has also been reported only by Kibar et al.[18] and Ankad et al.[19] till date.
Association with Trichotillomania
Occurrence of TTM along with AA is a once in a blue moon phenomenon. This association is difficult to diagnose clinically as both the diseases present as patchy hair loss. Trichoscopy helped to diagnose TTM in four of our patients of AA. Specific trichoscopic signs of TTM such as V-sign and trichoptilosis were found in 2.5% of our patients along with the various specific trichoscopic signs of AA. This association has been infrequently reported in occasional case reports.[22–24]
Conclusion
Dermoscopic examination of scalp disorders has gained momentum in recent times. Trichoscopy can serve as a noninvasive and easy to use tool in the diagnosis and management of various disorders of the scalp, case in point, AA. This study proves the ability of trichoscopic examination not only to assess the activity and severity of the disease but also to correlate the findings with the clinical subtype. Though the learning curve to delineate subtle findings is steep, trichoscopy can undoubtedly obviate the need of histopathological examination in many difficult to diagnose cases.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
Institutional ethical committee approval number
Ethical Approval number: BFUHS/2k20p-TH/476 (dated 20/12/2020). Institution: Baba Farid University of Health Sciences, Faridkot, Punjab, India.
Informed consent
All appropriate patient consent has been obtained.
Credit author statement
Samridhi Gulati contributed as principal investigator. He helped in literature search and review, data Analysis, writing the manuscript, critical revision and approval of final version.
Sharang Gupta was involved in designing the study, data collection and analysis, literature search and review, writing the manuscript, critical revision and approval of the final version.
Anjana Rajenesh helped in designing the study, literature search and review, writing the manuscript and approval of the final version.
Dimple Chopra was involved in designing the study, literature search and review, data collection, critical revision and approval of the final version.
Preeyati Chopra contributed to literature search and review, data Analysis, writing the manuscript, critical revision and approval of final version.
Data availability statement
The data that support the findings of this study are available from the corresponding author, [SG], upon reasonable request.
Use of artificial intelligence
No generative artificial intelligence tools or software was used in writing this work.