10.5826/dpc.1202a78
Introduction: Currently, the mostly used classifications of androgenetic alopecia (AGA), only provide a macroscopic and subjective description of this disorder, without evaluating trichoscopic features.
Objective: The aim of this study is to elaborate a graded live visual AGA severity scale including macroscopic and microscopic (trichoscopic) pictures, and to determine the most frequent trichoscopic characteristics associated to each grade.
Methods: A retrospective observational study was conducted on 122 patients (50 females and 72 males) affected by AGA. Macroscopic and trichoscopic photographs were taken at standardized scalp points.
Results: Each picture was ranked from AGA stage I to VII, according to Hamilton scale for men and Savin scale for women, and the most representative images of each severity degree were collected to produce a graded live visual scale. In males, two live visual scales, one for the anterior and one for posterior region of the scalp were created. In females, only one scale of the anterior region was realized. For each stage of severity, the corresponding trichoscopic parameters were statistically analyzed.
Conclusions: We realized new macroscopic and trichoscopic graded live visual scales for male and female patients affected by AGA, which could help physicians in giving an objective evaluation of the disease and in better managing it.
text/xml
2160-9381
1921
en
Marta Carlesimo
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
scale
Clinical and Trichoscopic Graded Live Visual Scale for Androgenetic Alopecia
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-05-02
2021-07-29
2022-05-02
2022-05-24
e2022078
Dermatol Pract Concept
Introduction: Currently, the mostly used classifications of androgenetic alopecia (AGA), only provide a macroscopic and subjective description of this disorder, without evaluating trichoscopic features.
Objective: The aim of this study is to elaborate a graded live visual AGA severity scale including macroscopic and microscopic (trichoscopic) pictures, and to determine the most frequent trichoscopic characteristics associated to each grade.
Methods: A retrospective observational study was conducted on 122 patients (50 females and 72 males) affected by AGA. Macroscopic and trichoscopic photographs were taken at standardized scalp points.
Results: Each picture was ranked from AGA stage I to VII, according to Hamilton scale for men and Savin scale for women, and the most representative images of each severity degree were collected to produce a graded live visual scale. In males, two live visual scales, one for the anterior and one for posterior region of the scalp were created. In females, only one scale of the anterior region was realized. For each stage of severity, the corresponding trichoscopic parameters were statistically analyzed.
Conclusions: We realized new macroscopic and trichoscopic graded live visual scales for male and female patients affected by AGA, which could help physicians in giving an objective evaluation of the disease and in better managing it.
Marta Carlesimo
2022/05/02
10.5826/dpc.1202a78
e2022078
Dermatology Unit, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
2160-9381
scale
en
e2022078
Govindarajulu SM, Srinivas RT, Kuppuswamy SK, Prem P. Trichoscopic Patterns of Nonscarring Alopecia's. Int J Trichology. 2020;12(3):99-106. DOI: 10.4103/ijt.ijt_1_19. PMID: 33223733. PMCID: PMC7659741.
Clinical and Trichoscopic Graded Live Visual Scale for Androgenetic Alopecia
https://dpcj.org/index.php/dpc/article/download/1921/1599
   Clinical and Trichoscopic Graded Live Visual Scale
               for Androgenetic Alopecia
Alfredo Rossi1, Martina Ferranti2, Francesca Magri1, Marco Di Fraia1, Gemma Caro1, Maria
       Caterina Fortuna1, Marta Muscianese1, Simone Michelini1, Marta Carlesimo1


1 Dermatology Unit, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
2 Dermatology Unit, Department of Medicine, University of Padua, Italy



Key words: androgenetic, alopecia, trichoscopy, scale
Citation: Rossi A, Ferranti M, Magri F, et al. Clinical and trichoscopic graded live visual scale for androgenetic alopecia.
Dermatol Pract Concept. 2022;12(2):e2022078. DOI: https://doi.org/10.5826/dpc.1202a78
Accepted: September 15, 2021; Published: April 2022
Copyright: ©2022 Rossi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Alfredo Rossi, MD, PhD. Dermatologic Unit, Department of Clinical Internal, Anesthesiologic and Cardiovascular
Sciences, Sapienza University of Rome, Italy. E-mail: alfredo.rossi@uniroma1.it




  ABSTRACT              Introduction: Currently, the mostly used classifications of androgenetic alopecia (AGA) only provide
                        a macroscopic and subjective description of this disorder, without evaluating trichoscopic features.
                        Objectives: The aim of this study is to elaborate a graded live visual AGA severity scale including
                        macroscopic and microscopic (trichoscopic) pictures, and to determine the most frequent trichoscopic
                        characteristics associated to each grade.
                        Methods: A retrospective observational study was conducted on 122 patients (50 females and 72 males)
                        affected by AGA. Macroscopic and trichoscopic photographs were taken at standardized scalp points.
                        Results: Each picture was ranked from AGA stage I to VII, according to Hamilton scale for men and
                        Sinclair scale for women, and the most representative images of each severity degree were collected to
                        produce a graded live visual scale. In males, 2 live visual scales, 1 for the anterior and 1 for posterior
                        region of the scalp were created. In females, only 1 scale of the anterior region was realized. For each
                        stage of severity, the corresponding trichoscopic parameters were statistically analyzed.
                        Conclusions: We realized new macroscopic and trichoscopic graded live visual scales for male and
                        female patients affected by AGA, which could help physicians in giving an objective evaluation of the
                        disease and in better managing it.




Original Article | Dermatol Pract Concept. 2022;12(2):e2022078                                                                           1
Introduction                                                       density, vellus/terminal hairs ratio, and produced a graded
                                                                   visual scale of six macroscopic AGA photographs [11].
Androgenetic alopecia (AGA) is one of the most common
causes of hair loss in both sexes. The development and oc-
currence of AGA depends on multiple factors, such as ge-
                                                                   Objectives
netic predisposition, endocrine and metabolic factors and          The aim of this study is to elaborate a graded live visual
exogenous causes. AGA prevalence rates in the Caucasian            AGA severity scale including macroscopic and microscopic
population are around 12% among men younger than                   (trichoscopic) pictures, and to determine the most frequent
30 years, 50% in the fourth decade and over 90% in indi-           trichoscopic characteristics associated to each grade.
viduals older than 80 [1]. In women, prevalence is estimated
around 16% under 50 years and 30-40% in subjects older
than 70 years [2].                                                 Methods
    In male patients, hair loss typically involves temporal
                                                                   We performed a single-center observational study on 122
and vertex regions, sparing the occiput. In women, the pro-
                                                                   patients (72 men and 50 women) affected by AGA. Patients were
cess starts with frontal area hair thinning. Then, the parietal
                                                                   recruited in our “Skin Appendages Physiopathology Center” of
regions of the scalp become gradually more visible, leaving
                                                                   Sapienza, University of Rome, from January 2019 to January
the frontal hairline intact. These different hair loss patterns
                                                                   2020. AGA diagnosis was formulated through classical clinical
are determined by differences in androgen-sensitivity of the
                                                                   and trichoscopic parameters, such as alopecia clinical extension
scalp areas. Frontal and vertex regions are characterized by
                                                                   and hair shaft thickness heterogeneity (anisotrichosis).
high expression of androgen receptors. On the contrary, oc-
                                                                      We took macroscopic photographs of each patient’s
cipital and temporal regions contain androgen-insensitive
                                                                   scalp using a video-dermoscope (FotoFinder®). The instru-
hair follicles [3]. Furthermore, male and female individuals
                                                                   ment was attached to a rotating arm of a head-positioning
show different expression of enzymes: high expression of
                                                                   device (Canfield Scientific®) in order to take pictures in
aromatase in the anterior region of female scalp and high
                                                                   standardized areas of the scalp: 2 for men (frontal and ver-
expression of 5- αR2 in the anterior region of male scalp.
                                                                   tex region) and 1 for women (only frontal region). The scalp
    In both sexes, AGA is characterized by progressive min-
                                                                   of all subjects was combed along the midline to the sides
iaturization of hair follicles and evolution of terminal hairs
                                                                   and evaluated using the video-dermoscope. Digital tricho-
to vellus hairs. This is due to hair cycle dynamics alteration,
                                                                   scopic photographs were obtained in standardized scalp
with progressive anagen phase shortening and telogen phase
                                                                   areas according to patient sex: in women, photographs were
prolonging [4]. Currently, the most widely used method of
                                                                   collected in the scalp point corresponding to the intersection
measuring the male AGA (MAGA) is the Hamilton–Nor-
                                                                   between the line connecting the ears and the line connecting
wood classification, developed in 1975 and characterized by
                                                                   the tip of the nose and the vertex (“P point”). In men, pho-
stages I–VII and special types IIa–Va [5].
                                                                   tographs were collected at the vertex (“V point”) and 2 cen-
    In 1977, Ludwig proposed a 3-grade classification for
                                                                   timeters ahead of the intersection point previously described
the female AGA (FAGA) [6], which is still in use today. How-
                                                                   for women (“F point”). These images were taken at 20-fold
ever, in 2004, Sinclair introduced a more detailed scale, con-
                                                                   magnification, which allows high-quality enlargement of a
sisting of 5 pictures [7].
                                                                   0.903 cm2 area (field of view).
    In 2007, Lee et al proposed a new universal classification
                                                                      All the 122 trichoscopic pictures were analyzed with
of pattern hair loss, independent from gender: the basic and
                                                                   Trichoscale Pro® software, which allows to perform accu-
specific classification, which is based on observed patterns of
                                                                   rate automatic measurements of scalp structures, with subse-
hair loss, including anterior hairline shape and hair density
                                                                   quent manual verification. In our analysis, we considered the
on the frontal and vertex areas [8].
                                                                   following trichoscopic parameters:
    However, all the classifications formulated so far provide
a descriptive, macroscopic and subjective assessment of alo-       1. the percentage of anisotrichosis (determined as the number
pecia extent and hair loss patterns.                                  of not terminal hair divided by total hairs number);
    In the last decade, several studies accumulated evidence       2. the percentage of vellus hairs (defined as hairs with a
about the use of trichoscopy in the daily clinical evalua-            diameter lower than 0.03 mm and shorter than 30 mm);
tion of hair disorders, improving the diagnostic capability        3. the number of empty follicles;
beyond the simple clinical inspection [9,10]. According to         4. the percentage of single-hair follicular units (SHFUs);
this progress, a new semi-quantitative grading scale was           5. the percentage of follicles with peripilar sign;
recently proposed by Jin Nie et al. In their study, they consid-   6. the presence of honeycomb pigment pattern (HCPP);
ered some objective parameters, such as hair coverage, hair        7. the presence of fibrosis.



2                                                                      Original Article | Dermatol Pract Concept. 2022;12(2):e2022078
The first 5 parameters were selected as activity indexes, while             (Figures 1, 3 and 5). Then, we selected 1 trichoscopic pho-
HCPP and fibrosis were considered as marker of long-lasting                 tograph for each grade represented on the macroscopic scale
disease.                                                                    (micro and macro pictures of the same grade were taken
                                                                            from the same patient), producing 3 microscopic graded live
Statistical Analysis                                                        visual scales (2 for men, 1 for women) (Figures 2, 4 and 6).
The tests used to produce the graphics of the quantitative                      For each AGA and FAGA stage, the number of empty
variables were a one-way ANOVA corrected with the Sidak                     follicles, the percentage of vellus hairs, single-hair follicular
method and multiple t-tests, setting 95% confidence in-                     units and follicles with peripilar sign were reported as graphs
tervals. The P values of the ANOVA tests were considered                    (Figures 7-9). We did not report data for AGA stage VII and
statistically significant when less than 0.05.. For the bino-               FAGA stage V, since patients affected by very severe alopecia
mial variables we used Fisher Exact Tests with the Baptis-                  only showed fibrosis and HCPP. In MAGA, in both frontal
ta-Pike method.                                                             and vertex areas, we observed a statistically significant in-
                                                                            crease of vellus hairs and empty follicles in relation to the

Results                                                                     clinical severity of AGA. In addition, a statistically significant
                                                                            increase of SHFUs correlated to the clinical stage was detected
Mean age was 34 (standard deviation [SD] ± 11.7) years                      in the frontal region of MAGA patients, but not in the vertex
(range: 21-83 years) for men and 52 (± 17.8 SD) years                       (Figures 7, 8). In FAGA, the percentage of vellus hairs, the
(range: 23-82 years) for women. Macroscopic pictures were                   number of empty follicles and the number of SHFUs showed
then ranked by severity (7 degrees for men and 5 degrees for                a significant increase correlated to clinical severity of alope-
women), and the most representative image for each degree                   cia (Figure 9). In all cases, the peripilar sign did not show
of severity was selected and collected, producing 3 macro-                  significant variations (Figures 7-9). Prevalence of fibrosis and
scopic graded live visual scales (2 for men, 1 for women)                   HCPP for each AGA and FAGA stage are reported in Table 1




Figure 1. Graded live visual scale of male androgenetic alopecia (anterior region of the scalp): stage I, II, III, IV, V, VI and VII.




Figure 2. Corresponding trichoscopic photographs of figure 1, taken at 20-fold magnification.




Figure 3. Graded live visual scale of male androgenetic alopecia (posterior region of the scalp): stage I, II, III, IV, V, VI and VII.



Original Article | Dermatol Pract Concept. 2022;12(2):e2022078                                                                              3
Figure 4. Corresponding trichoscopic photographs of figure 3, taken at 20-fold magnification.




Figure 5. Graded live visual scale of female androgenetic alopecia (anterior region of the scalp): stage I, II, III, IV and V.




Figure 6. Corresponding trichoscopic photographs of figure 5, taken at 20-fold magnification.




and Table 2. We also evaluated the correlation between HCPP                which lead us to different therapeutic choices. In this study
and AGA stages, finding a proportional relation between                    we wanted to underly the importance of trichoscopy in
HCPP and the clinical worsening of AGA (Table 3).                          AGA classification, elaborating three macroscopic live visual
    The most widely used methods to classify AGA only                      scales associated to three microscopic ones. In addition, we
give an idea of the
                ​​ extent and pattern of hair loss, without                wanted to evaluate the prevalence of trichoscopic parame-
evaluating the actual severity of the disease with objective               ters for each AGA stage and if prevalence variations between
parameters. The chance to use trichoscopy in the daily clini-              stages were statistically significant.
cal practice has revolutionized the approach to AGA in terms                    Hair shaft thickness heterogeneity (anisotrichosis) is an
of classification and disease management. In our clinical                  expression of the terminal hair transformation into vellus
practice, we noted that some cases of alopecia improved vis-               hair, suggesting that it might represent an accurate clinical
ibly after treatment, but their grade of classification did not            sign reflecting the miniaturization process evolution, which
vary. Moreover, some patients who were assigned the same                   is the basis of AGA pathogenesis [1].
grade of severity, according to the classic scales, presented                   Anisotrichosis higher than 20% is an essential criterion
important differences in their trichoscopic characteristics,               for the diagnosis of AGA [12].


4                                                                                Original Article | Dermatol Pract Concept. 2022;12(2):e2022078
                                                                                                                                   N˚ FRONTAL EMPTY FOLLICLES
                                                       % FRONTAL VELLUS HAIRS
                                                                                100                                                                              40
                                                                                 80                                                                              30
                                                                                 60
                                                                                                                                                                 20
                                                                                 40
                                                                                                                                                                 10
                                                                                 20
                                                                                  0                                                                                  0




                                                                                                        IV



                                                                                                                    VI




                                                                                                                                                                                        IV



                                                                                                                                                                                                 VI
                                                                                                 III




                                                                                                                                                                                  III
                                                                                                                V




                                                                                                                                                                                             V
                                                                                           II




                                                                                                                                                                             II
                                                                                      I




                                                                                                                                                                         I
                                                                                                MAGA STAGE                                                                    MAGA STAGE




                                                                                                                                   % FRONTAL PERIPILAR SIGN
                                            % FRONTAL SINGLE HAIR




                                                                                100                                                                             150
                                              FOLLICOLAR UNITS




                                                                                 80
                                                                                                                                                                100
                                                                                 60
                                                                                 40
                                                                                                                                                                 50
                                                                                 20
                                                                                  0                                                                                  0
                                                                                                       IV



                                                                                                                    VI




                                                                                                                                                                                        IV



                                                                                                                                                                                                 VI
                                                                                                 III




                                                                                                                                                                                  III
                                                                                                                V




                                                                                                                                                                                             V
                                                                                           II




                                                                                                                                                                             II
                                                                                      I




                                                                                                                                                                         I
                                                                                                MAGA STAGE                                                                    MAGA STAGE

                                               Figure 7. Graphic distribution of the quantitative trichoscopic parameters according to
                                               the visual stage of male androgenetic alopecia, evaluated in a standardized area of 0.903
                                               cm2 at “F point”, accompanied by the P (* = low statistically significant, ** = mildly
                                               statistically significant, *** = highly statistically significant) of the differences observed
                                               between the various androgenetic alopecia stages.
                                                                                                                         % VERTEX N˚ EMPTY FOLLICLES




                                                      150                                                                                                       50
                       % VERTEX VELLUS HAIRS




                                                                                                                                                                40
                                                      100
                                                                                                                                                                30
                                                                                                                                                                20
                                                       50
                                                                                                                                                                10
                                                           00                                                                                                    0
                                                                                                                                                                                        IV




                                                                                                                                                                                                 VI
                                                                                                                                                                                  III




                                                                                                                                                                                             V
                                                                                                                                                                             II
                                                                                                                                                                         I
                                                                                                   IV




                                                                                                                VI
                                                                                            III




                                                                                                            V
                                                                                      II
                                                                                I




                                                                                           MAGA STAGE                                                                             MAGA STAGE
                         % VERTEX SINGLE HAIR UNITS




                                                                                                                            % VERTEX PERIPILAR SIGN




                                                      80                                                                                               150

                                                      60
                                                                                                                                                       100
                                                      40
                                                                                                                                                                50
                                                      20

                                                       0                                                                                                         0
                                                                                                                                                                                        IV




                                                                                                                                                                                                  VI
                                                                                                  IV




                                                                                                                VI




                                                                                                                                                                                  III
                                                                                           III




                                                                                                                                                                                             V
                                                                                                        V




                                                                                                                                                                             II
                                                                                      II




                                                                                                                                                                         I
                                                                                I




                                                                                           MAGA STAGE                                                                             MAGA STAGE

                         Figure 8. Graphic distribution of the quantitative trichoscopic parameters according to the
                         visual stage of male androgenetic alopecia, evaluated in a standardized area of 0.903 cm2 at
                         “V point”, accompanied by P (* = low statistically significant, ** = mildly statistically signif-
                         icant, *** = highly statistically significant) of the differences observed between the various
                         androgenetic alopecia stages.



Original Article | Dermatol Pract Concept. 2022;12(2):e2022078                                                                                                                                         5
                                                      100                                                          40




                                                                                              N˚ EMPTY FOLLICLES
                           % VELLUS HAIRS
                                                       80
                                                                                                                   30
                                                       60
                                                                                                                   20
                                                       40
                                                                                                                   10
                                                       20
                                                        0                                                           0




                                                            I




                                                                                                                          I
                                                                      II




                                                                                                                                 II
                                                                            III




                                                                                                                                         III
                                                                                        IV




                                                                                                                                                    IV
                                                                      FAGA STAGE                                                FAGA STAGE
                     % SINGLE HAIR FOLLICOLAR UNITS




                                                      80                                                           150




                                                                                             % PERIPILAR SIGN
                                                      60
                                                                                                                   100
                                                      40
                                                                                                                   50
                                                      20

                                                       0                                                             0
                                                            I




                                                                                                                           I
                                                                     II




                                                                                                                                  II
                                                                           III




                                                                                                                                          III
                                                                                       IV




                                                                                                                                                    IV
                                                                     FAGA STAGE                                                   FAGA STAGE

                        Figure 9. Graphic distribution of the quantitative trichoscopic parameters according to the
                        visual stage of female androgenetic alopecia, evaluated in a standardized area of 0.903 cm2
                        at “P point” accompanied by the P (* = low statistically significant, ** = mildly statistically
                        significant, *** = highly statistically significant) of the differences observed between the var-
                        ious androgenetic alopecia stages.




Table 1. Presence of fibrosis at F, V and P Point, i                                                Table 3. Odds Ratio (OR) for Honeycomb
            for each AGA stage (%).                                                               Pigment Pattern (HCPP) Associated to different
        AGA        F point                                  V point          P point                               AGA stages.
 I                      0                                       0                  0                                     HCPP                  OR                    p
 II                     0                                       0                  0              F point                                    67.5                0.0001
 III                    0                                       0                  0              V point                                    37.1                0.0001
 IV                     0                                       0                 33              P point                                    19.5                0.0001
 V                   22                                         22                 -         F point: Correlation between MAGA IV-VI and MAGA I-III
 VI                  25                                         25                 -         patients in the frontal area.

AGA = androgenetic alopecia.                                                                 V Point: Correlation between MAGA IV-VI and MAGA I-III
                                                                                             patients in the vertex area.
        Table 2. Presence of Honeycomb Pigment                                               P Point: Correlation between FAGA III-IV and FAGA I-II
       Pattern (HCPP) at F, V and P Point, foreach                                           patients.
             androgenetic alopecia stage (%).                                                AGA = androgenetic alopecia;
        AGA        F point                                  V point          P point         FAGA = female androgenic alopecia;
 I                       0                                       0                 0
                                                                                             MAGA= male androgenic alopecia.
 II                      0                                       0                20
 III                 11                                         27                40
                                                                                                                   Indeed, all enrolled patients presented a percentage of
 IV                  63                                         62                100
                                                                                             anisotrichosis higher than 20%. In our study, male patients,
 V                   77                                         75                 -
                                                                                             at F and V points, presented a vellus hairs rate of 24% at
 VI                 100                                         100                -
                                                                                             AGA stage I and 73% at stage VI. In women, the vellus hairs
AGA = androgenetic alopecia.                                                                 rate ranged from 32% of stage I to 68% of stage IV.



6                                                                                                                  Original Article | Dermatol Pract Concept. 2022;12(2):e2022078
    In our study population, the increase of vellus hairs rate            Although AGA is classified within the nonscarring alope-
is related to the increase of severity stage, in both sexes.          cia, the micro-inflammation involving the follicles (trichoscop-
These results agree with the concept that vellus hairs rate is        ically corresponding to the peripilar sign) could slowly induce
a trichoscopic index of disease severity.                             the development of perifollicular fibrosis. Hence, in severe dis-
    Empty follicles have been described in AGA, especially            ease, it is possible for hair follicles to be replaced by connective
in advanced stages of the disease [13,14]. Trichoscopically           tissue, leading to fibrous tracts, and finally causing atrophy.
they appear as yellow dots (YD), which correspond to empty            These empty follicles appear as white dots, which are usually
follicles filled with keratotic material and/or sebum, or             observed in cicatricial alopecia, or as amorphous white cicatri-
follicles containing a completely miniaturized hair or a keno-        cial area, when the follicular ostia cannot be observed anymore
gen hair. If the scalp is exposed to the sun, these follicles can     [14]. In our experience, we found the highest prevalence of
appear as pinpoint white dots. They occur predominantly in            fibrosis in the most advanced stages of AGA reflecting a pre-
the frontal region, have irregular size and distribution, and         vious perifollicular inflammation and a long disease duration.
are less numerous when compared to the amount found in                    HCPP corresponds to contiguous brown rings, usually
alopecia areata. Moreover, the presence of 4 or more YD in            related to chronic actinic damage due to its preferentially
4 trichoscopic fields in the frontal region is one of the major       presence in sun-exposed areas of the scalp, where hair cover-
trichoscopic criteria for the diagnosis of FAGA [15]. In our ex-      age is reduced. Therefore, this do not correspond to a specific
perience, as expected, we observed that the increase in number        trichoscopic finding of AGA, but it is a marker of chronic
of empty follicles significantly correlates with AGA severity.        and long-lasting disease, much more evident in cases of de-
    One follicular unit is able to produce up to 6 hairs, de-         creased hair density [18]. In our study, HCPP has been rarely
pending on the body region. In the human scalp, follicular            observed in lower stages of AGA, with progressive increase
units usually contain 2-4 terminal hairs and 1-2 vellus hairs.        till the 100% in the last stages. Moreover, we found a sig-
A decreased number of hairs per follicle is a characteristic          nificant positive correlation between HCPP and AGA wors-
feature of AGA [16, 17]. Indeed, this finding is present also         ening. Intuitively, this result expresses the fact that, with
in healthy individuals and patients with chronic telogen ef-          the increase of hair thinning and hair loss, the scalp is more
fluvium, but it is usually limited to the temporal areas.             exposed to UV lights and cutaneous photodamage, with con-
    We observed that differences in number of SHFUs be-               sequent occurrence of HCPP. Certainly, the extension of the
tween the lower stages of AGA were very little. This could            bald area and especially the duration of the disease influence
be the expression of a general shortening of anagen and               the occurrence and severity of HCPP.
prolongation of telogen, which is characteristic of AGA
pathogenesis, and reaches its peak in the advanced stages of
                                                                      Conclusions
this condition. Actually, in our study, the number of SHFUs
correlated with AGA severity in women and in male frontal             The classification methods currently used for male and fe-
region, but not in the vertex.                                        male AGA only describe the clinical pattern and the extent
    Peripilar sign had been described as significantly more fre-      of disease. Therefore, they cannot be considered as objective
quent in AGA, if compared with healthy people or patients             classifications, and, frequently, do not allow to describe the
with chronic telogen effluvium. Rakowska et al observed that          real trend of hair loss because of the wide gap between dif-
the mean percentage of hair follicles with surrounding discol-        ferent stages and since they do not take into account tricho-
oration was around 32% in the frontal area and around 7%              scopic parameters.
in the occipital area in patients with FAGA. Nevertheless, they           Nowadays, trichoscopy is a fundamental tool for the
documented that healthy subjects presented perifollicular dis-        management of hair loss diseases, showing high utility for
coloration in less than 25% of the follicles in the frontal area,     their diagnosis and follow-up. Thus, trichoscopy should be
less than 15% in the occiput and less than 20% in the temporal        considered when trying to assess a severity degree, as we per-
areas [15]. In our experience, the percentage of follicles involved   formed for AGA.
by peripilar sign ranged from 13% to 43% in women, and                    Thus, we created 6 graded live visual scales, 3 macro-
from 9% to 37% in men. Interestingly, in our sample size, the         scopic and 3 microscopic, which could help physicians in
peripilar sign did not show statistically significant variations in   giving an objective evaluation of the disease and in better
relation with the severity of alopecia. In fact, this trichoscopic    managing it.
finding corresponds to a not constant sign of inflammation and            Further studies are needed, but it is evident that only
clinical activity, which may be present in both early and late        an objective trichoscopic evaluation could guide physicians
stages, with no proportional correlation with the stage of AGA.       to the correct management and to an appropriate “phase
Certainly, in case of peripilar sign, and consequently of inflam-     therapy” for AGA, as we already do for other trichological
mation, the progression of alopecia is more rapid.                    diseases.



Original Article | Dermatol Pract Concept. 2022;12(2):e2022078                                                                          7
    Informed Consent: The patients in this manuscript have                       DOI: 10.4103/0974-7753.130385. PMID: 24778525. PMCID:
given written informed consent to publication of their case                      PMC3999645.
                                                                           11.   Nie J, Hou W. A semiquantitative grading scale for frontal and
details.
                                                                                 vertex of androgenetic alopecia. Int J Dermatol. 2019;58(5):582-
                                                                                 588. DOI: 10.1111/ijd.14324. PMID: 30592306.

References                                                                 12.   Galliker NA, Trüeb RM. Value of trichoscopy versus trichogram
                                                                                 for diagnosis of female androgenetic alopecia. Int J Trichology.
 1. Lolli F, Pallotti F, Rossi A et al. Androgenetic alopecia: a review.         2012;4(1):19-22. DOI: 10.4103/0974-7753.96080. PMID:
    Endocrine. 2017;57(1):9-17. DOI: 10.1007/s12020-017-1280-y.                  22628985. PMCID: PMC3358933.
    PMID: 28349362.                                                        13.   Kasumagic-Halilovic E. Trichoscopic Findings in Androge-
 2. Norwood OT. Incidence of female androgenetic alopecia (female                netic Alopecia. Med Arch. 2021;75(2):109-111. DOI: 10.5455/
    pattern alopecia). Dermatol Surg. 2001;27:53-54. PMID:                       medarh.2021.75.109-111.        PMID:       34219869.      PMCID:
    11231244                                                                     PMC8228579.
 3. Banka N, Bunagan MJ, Shapiro J. Pattern hair loss in men: diagno-      14.   Hu R, Xu F, Han Y, Sheng Y, Qi S, Miao Y, et al. Trichoscopic find-
    sis and medical treatment. Dermatol Clin. 2013;31(1):129-140.                ings of androgenetic alopecia and their association with disease
    DOI: 10.1016/j.det.2012.08.003. PMID: 23159182.                              severity. J Dermatol. 2015;42(6):602-607. DOI: 10.1111/1346-
 4. Ellis JA, Sinclair R, Harrap SB. Androgenetic alopecia:                      8138.12857. PMID: 25810236.
    pathogenesis and potential for therapy. Expert Rev Mol                 15.   Rakowska A, Slowinska M, Kowalska-Oledzka E, et al. Der-
    Med. 2002;4(22):1-11. DOI: 10.1017/S1462399402005112.                        moscopy in female androgenic alopecia: method standardization
    PMID: 14585162.                                                              and diagnostic criteria. Int J Trichology. 2009;1(2):123-130.
 5. Norwood OT. Male pattern baldness: classification and incidence.             DOI: 10.4103/0974-7753.58555. PMID: 20927234. PMCID:
    South Med J. 1975;68(11):1359-1365. DOI: 10.1097/00007611-                   PMC2938574.
    197511000-00009. PMID: 1188424.                                        16.   Yazdabadi A, Magee J, Harrison S, Sinclair R. The Ludwig pat-
 6. Ludwig E. Classification of the types of androgenetic alopecia               tern of androgenetic alopecia is due to a hierarchy of androgen
    (common baldness) occurring in the female sex. Br J Derma-                   sensitivity within follicular units that leads to selective minia-
    tol. 1977;97(3):247-254. DOI: 10.1111/j.1365-2133.1977.                      turization and a reduction in the number of terminal hairs per
    tb15179.x. PMID: 921894.                                                     follicular unit. Br J Dermatol. 2008;159(6):1300-1302. DOI:
 7. Biondo S, Goble D, Sinclair R. Women who present with female                 10.1111/j.1365-2133.2008.08820.x. PMID: 18795932.
    pattern hair loss tend to underestimate the severity of their hair     17.   Sinclair R, Torkamani N, Jones L. Androgenetic alope-
    loss. Br J Dermatol. 2004 Apr;150(4):750-2.                                  cia: new insights into the pathogenesis and mechanism of
 8. Lee WS, Ro BI, Hong SP, et al. A new classification of pattern               hair loss. F1000Res. 2015;4(F1000 Faculty Rev):585. DOI:
    hair loss that is universal for men and women: basic and specific            10.12688/f1000research.6401.1. PMID: 26339482. PMCID:
    (BASP) classification. J Am Acad Dermatol. 2007;57(1):37-46.                 PMC4544386.
    DOI: 10.1016/j.jaad.2006.12.029. PMID: 17467851.                       18.   Govindarajulu SM, Srinivas RT, Kuppuswamy SK, Prem P.
 9. Rudnicka L, Olszewska M, Waśkiel A, Rakowska A. Trichoscopy                  Trichoscopic Patterns of Nonscarring Alopecia’s. Int J Trichol-
    in Hair Shaft Disorders. Dermatol Clin. 2018;36(4):421-430.                  ogy. 2020;12(3):99-106. DOI: 10.4103/ijt.ijt_1_19. PMID:
    DOI: 10.1016/j.det.2018.05.009. PMID: 30201151.                              33223733. PMCID: PMC7659741.
10. Jain N, Doshi B, Khopkar U. Trichoscopy in alopecias: di-
    agnosis simplified. Int J Trichology. 2013;5(4):170-178.




8                                                                                Original Article | Dermatol Pract Concept. 2022;12(2):e2022078
