10.5826/dpc.1304S1a310S
Hair and scalp disorders are of significant interest for physicians dealing with dark phototypes due to their prevalence and potential aesthetic impact resulting from a higher tendency for scarring. In order to facilitate their non-invasive diagnosis, several dermoscopic studies have been published, yet data are sparse and no systematic analysis of the literature has been performed so far. This systematic literature review summarizes published data on trichoscopy of hair and scalp diseases (trichoscopic findings, used setting, pathological correlation, and level of evidence of studies). A total of 60 papers addressing 19 different disorders (eight non-cicatricial alopecias, nine cicatricial alopecias, and two hair shaft disorders) were assessed, for a total of 2636 instances. They included one cross-sectional analysis, 20 case-control studies, 25 case-series, and 14 single case-reports, so the level of evidence was V and IV in 65% and 33% of cases, respectively, with only one study showing a level of evidence of III. Notably, although there is a considerable body of literature on trichoscopy of hair/scalp diseases, our review underlined that potentially significant variables (e.g., disease stage or hair texture) are often not taken into account in published analyses, with possible biases on trichoscopic patterns, especially when it comes to hair shaft changes. Further analyses considering all such issues are therefore needed.
text/xml
2160-9381
3539
en
Enzo Errichetti
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
dermoscopy, dermatoscopy, epiluminescence, hair diseases, scalp diseases, skin of color, dark skin, black skin, ethnic skin, dark phototype, african skin, systematic review
Dermoscopy of Hair and Scalp Disorders (Trichoscopy) in Skin of Color—A Systematic Review by the International Dermoscopy Society “Imaging in Skin of Color” Task Force
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Review
2023-10-04
2023-05-13
2023-10-04
2023-11-27
e2023210S
Dermatol Pract Concept
Hair and scalp disorders are of significant interest for physicians dealing with dark phototypes due to their prevalence and potential aesthetic impact resulting from a higher tendency for scarring. In order to facilitate their non-invasive diagnosis, several dermoscopic studies have been published, yet data are sparse and no systematic analysis of the literature has been performed so far. This systematic literature review summarizes published data on trichoscopy of hair and scalp diseases (trichoscopic findings, used setting, pathological correlation, and level of evidence of studies). A total of 60 papers addressing 19 different disorders (eight non-cicatricial alopecias, nine cicatricial alopecias, and two hair shaft disorders) were assessed, for a total of 2636 instances. They included one cross-sectional analysis, 20 case-control studies, 25 case-series, and 14 single case-reports, so the level of evidence was V and IV in 65% and 33% of cases, respectively, with only one study showing a level of evidence of III. Notably, although there is a considerable body of literature on trichoscopy of hair/scalp diseases, our review underlined that potentially significant variables (e.g., disease stage or hair texture) are often not taken into account in published analyses, with possible biases on trichoscopic patterns, especially when it comes to hair shaft changes. Further analyses considering all such issues are therefore needed.
Enzo Errichetti
2023/10/04
10.5826/dpc.1304S1a310S
e2023210S
University of Udine, Italy
2160-9381
dermoscopy, dermatoscopy, epiluminescence, hair diseases, scalp diseases, skin of color, dark skin, black skin, ethnic skin, dark phototype, african skin, systematic review
en
e2023210S
Patil S, Marwah M, Nadkarni N, Gautam M, Godse K. The medusa head: dermoscopic diagnosis of woolly hair syndrome. Int J Trichology. 2012;4:184-185.
Dermoscopy of Hair and Scalp Disorders (Trichoscopy) in Skin of Color—A Systematic Review by the International Dermoscopy Society “Imaging in Skin of Color” Task Force
https://dpcj.org/index.php/dpc/article/download/3539/2343
         Dermoscopy of Hair and Scalp Disorders
      (Trichoscopy) in Skin of Color – A Systematic
    Review by the International Dermoscopy Society
          “Imaging in Skin of Color” Task Force
          Soumil Khare1, Biswanath Behera2, Delaney D Ding3, Aimilios Lallas4,
   Payal Chauhan5, Nkechi Anne Enechukwu6, Martyna Sławińska7, Bengu Nisa Akay8,
   Balachandra S Ankad9, Yasmeen J Bhat10, Abhijeet Kumar Jha11, Feroze Kaliyadan12,
 Awatef Kelati13, Shekhar Neema14, Nisha V Parmar15, Jennifer Stein16, Richard P Usatine17,
                         Keshavamurthy Vinay18, Enzo Errichetti19


 1 Department of Dermatology, Venereology and Leprosy, AIIMS, Raipur, India
 2 Department of Dermatology and Venereology, AIIMS, Bhubaneswar, India
 3 University of Florida College of Medicine, Gainesville, FL, USA
 4 First Department of Dermatology, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece
 5 Department of Dermatology, All India Institute of Medical Sciences (AIIMS), Bilaspur, Himachal Pradesh, India
 6 Nnamdi Azikiwe University/Nnamdi Azikiwe Teaching Hospital Nnewi, Anambra State, Nigeria
 7 Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, Poland
 8 Department of Dermatology, School of Medicine, Ankara University, Ankara, Turkey
 9 Department of Dermatology, Venereology and Leprosy, SN Medical College, Bagalkot, Karnataka, India
10 Department of Dermatology, Venereology and Leprology, Government Medical College, University of Kashmir, Srinagar, Jammu and
    Kashmir, India
11 Department of Dermatology & STD, Patna Medical College & Hospital, Patna, India
12 Department of Dermatology, Sree Narayana Institute of Medical Sciences, Ernakulum, India
13 Dermatology Department, Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS),
    Casablanca, Morocco
14 Department of Dermatology, Venereology and Leprology, Armed Force Medical College, Pune, Maharashtra, India
15 Department of Dermatology, Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates
16 The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY, USA
17 Department of Dermatology and Cutaneous Surgery, Department of Family and Community Medicine, University of Texas Health San
    Antonio, San Antonio, TX, USA
18 Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
19 Institute of Dermatology, “Santa Maria della Misericordia” University Hospital, Udine, Italy



Key words: dermoscopy, dermatoscopy, epiluminescence, hair diseases, scalp diseases, skin of color, dark skin, black skin, ethnic skin,
dark phototype, african skin, systematic review
Citation: Khare S, Behera B, Ding DD. Dermoscopy of Hair and Scalp Disorders (Trichoscopy) in Skin of Color – a systematic review
by the International Dermoscopy Society “Imaging in Skin of Color” Task Force. Dermatol Pract Concept. 2023;13(4)S1:e2023310S.
DOI: https://doi.org/10.5826/dpc.1304S1a310S
Accepted: September 3, 2023; Published: October 2023
Copyright: ©2023 Khare 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.




Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S                                                                                   1
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Enzo Errichetti, MD, Institute of Dermatology, “Santa Maria della Misericordia” University Hospital, Piazzale
Santa Maria della Misericordia, 15. 33100-Udine, Italy. E-mail: enzoerri@yahoo.it




    ABSTRACT           Hair and scalp disorders are of significant interest for physicians dealing with dark phototypes due
                       to their prevalence and potential aesthetic impact resulting from a higher tendency for scarring. In
                       order to facilitate their non-invasive diagnosis, several dermoscopic studies have been published, yet
                       data are sparse and no systematic analysis of the literature has been performed so far. This systematic
                       literature review summarizes published data on trichoscopy of hair and scalp diseases (trichoscopic
                       findings, used setting, pathological correlation, and level of evidence of studies). A total of 60 papers
                       addressing 19 different disorders (eight non-cicatricial alopecias, nine cicatricial alopecias, and two
                       hair shaft disorders) were assessed, for a total of 2636 instances. They included one cross-sectional
                       analysis, 20 case-control studies, 25 case-series, and 14 single case-reports, so the level of evidence was
                       V and IV in 65% and 33% of cases, respectively, with only one study showing a level of evidence of
                       III. Notably, although there is a considerable body of literature on trichoscopy of hair/scalp diseases,
                       our review underlined that potentially significant variables (e.g., disease stage or hair texture) are often
                       not taken into account in published analyses, with possible biases on trichoscopic patterns, especially
                       when it comes to hair shaft changes. Further analyses considering all such issues are therefore needed.




Introduction                                                             “dark skin” OR “black skin” OR “ethnic skin” OR “dark
                                                                         phototype” OR “african skin” OR “indian skin”. Titles and
Hair and scalp disorders represent a relevant part of der-               abstracts were screened by two independent reviewers to
matologist’s practice when it comes to dark-skinned patients             identify papers reporting trichoscopic findings of hair and
due to their significant prevalence as well as potential aes-            scalp disorders; non-English articles, reviews, personal opin-
thetic impact resulting from a higher tendency for scarring              ions and editorials as well as duplicates were excluded. A
in case of cicatricial alopecias [1]. Additionally, there are sev-       manual search was also performed by assessing the reference
eral alopecic diseases that are exclusively or predominantly             sections of all significant studies or reviews on this topic.
seen in darker phototypes (Fitzpatrick’s phototypes IV-VI),                   Articles considered not relevant and those not provid-
especially subjects of African descent [1,2]. In order to facili-        ing trichoscopic structures according to specific dermatosis/
tate the recognition of hair and scalp disorders, some studies           number of patients with particular tichoscopic structures
focusing on their dermoscopic pattern have been performed,               were excluded after full-text reading. Only articles specif-
yet data are sparse and no systematic analysis of the litera-            ically dealing with Fitzpatrick’s phototypes IV-VI were in-
ture evidence has been published so far 2.                               cluded. In case information on the skin phototype was not
    This review, performed by the International Dermoscopy               provided, decision on inclusion was made based on a title/
Society (IDS) Task Force on “Imaging in Skin of Color”,                  abstract/full text showing that the manuscript concerned
sought to systematically analyze trichoscopic findings of hair           “dark skin” or “skin of color” and for single cases also based
and scalp diseases reported in dark-skinned patients.                    on the attached figures. We also included papers from Afri-
                                                                         can, Indian subcontinent, and Caribbean countries as most
                                                                         of patients from these areas feature IV-VI skin phototype.
Materials and Methods
                                                                         Importantly, studies grouping light and dark phototypes
This systematic review was performed in accordance with                  without dedicated subanalyses were excluded, apart from
the PRISMA (Preferred Reporting Items for Systematic                     those with only a minority of light-skinned patients being
Reviews and MetaAnalyses) guidelines. A search of the
­                                                                        involved (i.e., less than 20% of total).
articles published up to 30th June 2022 was performed                         All of the retrieved studies were classified based on
through the PubMed electronic database using the following               standard definitions for diagnostic accuracy studies [3,4]
search terms: “trichoscopy” OR “dermoscopy” OR “epilu-                   and their level of evidence was assigned according to The
minescence” OR “dermatoscopy” AND “skin of color” OR                     Oxford 2011 Levels of Evidence [5]. Trichoscopic findings,




2                                                                                 Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S
histopathological background (if available), trichoscopic set-        description of each of the study evaluated in the review
ting (polarized vs non-polarized/magnification degree), skin          (number of patients, type of study and level of evidence),
type of the patient (if specified), and number of cases were          trichoscopic features, skin type of the patient. Table 1 also
assessed and summarized.                                              displays the general prevalence of trichoscopic findings for
                                                                      each condition, calculated considering all the data available
                                                                      from the literature. For practical purpose, we have grouped
Results                                                               analyzed disorders into non-cicatricial alopecias, cicatricial
The initial PubMed search showed 1287 publications, with              alopecias, and hair shaft disorders. Figures 2 and 3 show
a total of 71 items admitted to the full-text reading after title     dermoscopic clues of such conditions.
and abstract screening and excluding duplicates. Of these,
eleven papers were ruled out according to the exclusion cri-          Non-Cicatricial Alopecias
teria, with 60 articles being eventually admitted to the re-          Alopecia Areata
view analysis. The flow chart displaying the study selection          Alopecia areata (AA) is one of the most studied
process is showed in Figure 1.                                        non-cicatricial alopecias from a trichoscopic point of view
   The full-text review included a total of 60 studies, in-           in skin of color, with 24 studies (11 case-control analyses
cluding one cross-sectional analysis, 20 case-control studies,        [6-16], 11 case-series [7-27], and two single case-reports
25 case-series, and 14 single case-reports; the number of re-         [28,29]) retrieved from the literature with a total of 1206
cords according to the level of evidence presented were as            patients. The most commonly observed finding were yel-
follows: I: 0; II: 0; III: 1; IV: 20; and V: 39. In detail, 19        low dots, found in 67% of cases, followed by black dots
different disorders (also accounting for relevant disease vari-       and short vellus hairs, detected in 62% and 48% of cases,
ants with clinical/trichoscopic peculiarities) were evaluated,        respectively. Other frequent features included broken hairs
including eight non-cicatricial alopecias, nine cicatricial           (36%) and “micro-exclamation mark” hairs (31%). Pigtail
­alopecias, and two hair shaft disorders for a total of 2636          and straight regrowing hairs, coudability hairs (hairs tapered
cases. Table 1 shows the number of studies and total number           at the proximal end), off-white dots (empty follicles), ery-
of included instances for each condition.                             thema, honeycomb pigmentation, white dots, i-hairs, tulip
   Trichoscopic setting (polarized vs non-polazised) was              hairs, Pohl-Pinkus constrictions, perifollicular scales, and
reported in 24/60 records (14 polarized; 5 non-polarized;             perifollicular discoloration were all observed in less than
5 both), magnification in 46/60 records (24: x10; 7: x20;             10% of cases.
1: x30; 1: x58; 1: x60; 12: variable magnification), and                  With regard to diagnostic accuracy, yellow dots have
trichoscopic-pathological correlation in 18/60 records (even          been identified as a sensitive marker for AA diagnosis,
though some correlated not all trichoscopic findings). Supple-        though their sensitivity increased from 89.6% to 97.4%
mental Table summarizes all such data, along with analytical          when associated with short vellus hairs according to a study




         Figure 1. PRISMA flowchart displaying the selection process for study inclusion in the systematic review.



Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S                                                                           3
4
                                                                         Table 1. Total number of studies, instances and prevalence of trichoscopic findings of hair and scalp disorders in skin of color.
                                                                                      Total number   Total number of
                                                                  Disorder              of studies      instances                                           Trichoscopic findings* (total prevalence)
                                                          Non-cicatricial alopecias
                                                          Alopecia areata                 24            1206           Common findings: Yellow dots (67%); Black dots (62%)
                                                                                                                       Less common findings: Short vellus hair (48%); Broken hair (36%); Exclamation mark hair (31%); Pigtail hair
                                                                                                                       (9%); Straight regrowing hair (9%); Coudability hair (8%); Off white dots (6%); White dots (5%); Honeycomb
                                                                                                                       pigment pattern (3%); Erythema (3%); Vascular pattern (3%); Atypical red vessels (1%); Perifollicular scales
                                                                                                                       (1%); Tulip hair (1%); Leukotrichia (1%); Perifollicular pigmentation (1%)
                                                          Androgenetic alopecia

                                                             Female pattern hair                         544           Common findings: Hair diameter diversity >20% (87%); Short vellus hair (66%)
                                                                                           9
                                                             loss                                                      Less common findings: Brown peripilar sign (35%); Single-hair follicular unit (29%); Thin hair (22%); Yellow
                                                                                                                       dots (18%); Lower mean hair thickness in frontal area (9%); >10% thin hairs in frontal area (9%); Honeycomb
                                                                                                                       pigment pattern (6%); White dots (5%); Focal atrichia (5%); White peripilar sign (4%); >2:1 single hair units,
                                                                                                                       frontal: occiput (4%); >3:1 hair follicles with perifollicular discoloration, frontal: occiput (4%); >4 yellow dots in
                                                                                                                       frontal area (3%); >1.5:1 vellus hair, frontal: occiput (3%); Scales (1%); Off white dots (1%); Broken hair (1%)


                                                            Male pattern hair loss         3             102           Common findings: Hair diameter diversity >20% (85%); Yellow dots (84%); Honeycomb pigment pattern (78%);
                                                                                                                       Brown peripilar sign (67%)
                                                                                                                       Less common findings: White peripilar sign (39%); Short vellus hair (22%); Thin hair (19%); Focal atrichia
                                                                                                                       (13%); White dots (8%)
                                                          Pressure-induced alopecia        1                6          Common findings: Yellow dots (100%); Short vellus hair (100%); Black dots (83%); Comedo-like black dots
                                                                                                                       (67%); Broken hair (50%); Areas of scarring (50%)
                                                                                                                       Less common findings: -
                                                          Telogen effluvium                3              53           Common findings: Straight regrowing hair (81%)
                                                                                                                       Less common findings: Single-hair follicular unit (38%); Off white dots (28%); Yellow dots (17%); Thin hair
                                                                                                                       (13%); Perifollicular erythema (2%)




Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S
                                                                                  Total number   Total number of
                                                                   Disorder         of studies      instances                                          Trichoscopic findings* (total prevalence)
                                                          Tinea capitis               14             261           Common findings: Black dots (57%); Comma hair (55%)
                                                                                                                   Less common findings: Broken hair (47%); Corkscrew hair (31%); Perifollicular scales (22%); Zigzag hair
                                                                                                                   (20%); Erythema, telengectasia heamorrhage (13%); Morse code hair (11%); i-hair (8%); Pustules (4%); White
                                                                                                                   dots (3%); Perifollicular pigmentation (3%); Off white dots (empty follicle) (2%); Flame hair (1%); Honeycomb
                                                                                                                   pigment pattern (1%); Thin hair (1%); White areas (1%); Loss of follicles (1%)
                                                          Traction alopecia            3               9           Common findings: -
                                                                                                                   Less common findings: Peripilar casts (44%); Single-hair follicular unit (40%); Loss of follicles (33%); Black dots
                                                                                                                   (11%); Follicular pustules (11%); Short vellus hair (11%)
                                                          Trichotillomania            14              46           Common findings: Broken hair at different length (93%); Trichoptilosis (67%); Black dots (63%);
                                                                                                                   Hook hair (52%)
                                                                                                                   Less common findings: Peripilar haemorrhages (48%); V-sign (30%); Flame hair (26%); Tulip hair (17%); Straight
                                                                                                                   regrowing hair (17%); Yellow dots (11%); Perifollicular scales (11%); Variation-HDD (9%); White dots (9%);




Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S
                                                                                                                   Short vellus hair (7%); Hair dust (7%); Honeycomb pigment pattern (7%); Pigtail hair (4%); Single-hair follicular
                                                                                                                   unit (4%); Blotchy-pigmentation (2%); Perifollicular whitish halo (2%)
                                                          Cicatricial alopecias
                                                          Central centrifugal          2              65           Common findings: Honeycomb pigment pattern (100%); Perifollicular whitish halo (95%); Pinpoint white dots
                                                          cicatricial alopecia                                     (81%); Terminal hair (78%); Cicatricial white patches (74%); Short vellus hair (74%)
                                                                                                                   Less common findings: Erythema (48%); Broken hair (40%); Scales (36%); Asterisk like brown areas (19%); Dark
                                                                                                                   peripilar halo (7%)
                                                          Discoid lupus                9             159           Common findings: Follicular plugging (68%); Cicatricial white patches (50%)
                                                          erythematosus                                            Less common findings: Scales (47%); Perifollicular whitish halo (43%); Telangiectasias (39%); Red dots (35%);
                                                                                                                   Brown dots (30%); Rosettes (19%); Thick arborizing vessels (17%); Perifollicular scales (17%); Blue-grey dots
                                                                                                                   (14%); Honeycomb pigment pattern (11%); Perifollicular erythema (9%); Scalp erythema (8%); Enlarged
                                                                                                                   branching vessels (5%); Red loop vessels (5%); White dots (eccrine openings) (3%); Black dots (2%); Crust
                                                                                                                   formation (1%); Short vellus hair (1%); Blue-white veil (1%); Peripilar casts (1%); Fibrotic white dot (1%)




                                                                                                                                                                                                                     Table 1 Continues




5
6
                                                                                         Total number   Total number of
                                                                   Disorder                of studies      instances                                         Trichoscopic findings* (total prevalence)
                                                          Dissecting cellulitis of the
                                                          scalp

                                                            Scarring stage                    2                9          Common findings: Loss of follicles (100%); Cicatricial white patches (78%); Black dots (78%); Crust formation
                                                                                                                          (67%); Perifollicular scales (67%); Yellow dots (67%); Elongated linear vessels (67%); Interfollicular scaling
                                                                                                                          (67%); Scalp erythema (67%)
                                                                                                                          Less common findings: 3D yellow dots (44%); Hair shaft disorder (pili torti and Pohl-Pinkus constrictions)
                                                                                                                          (44%); Epidermal atrophy (33%); Follicular pustules (33%); Honeycomb pigment pattern (33%); Follicular
                                                                                                                          hyperkeratosis (22%); Red loop vessels (22%); Blue-grey dots (22%); Perifollicular erythema (11%); Peripilar
                                                                                                                          casts (11%); Fibrotic white dot (11%);
                                                                                                                          Perifollicular pigmentation (11%)

                                                            Early (non-scarring)              1                5          Common findings: Yellow dots (100%); Red dots (100%); Empty follicular openings (100%); Black dots (100%);
                                                            stage                                                         Cadaverized hairs (100%)
                                                                                                                          Less common findings: -
                                                          Fibrosing alopecia in a             1              16           Common findings: Loss of follicles (100%); Hair diameter diversity (100%); Perifollicular
                                                          patterned distribution                                          erythema and scaling (88%); Hyperpigmented perifollicular halo (75%); Scattered white
                                                                                                                          patches (75%); Honeycomb pigment pattern (75%); Perifollicular whitish halo (56%)
                                                                                                                          Less common findings: Follicular plugging (19%)
                                                          Folliculitis decalvans              5              12           Common findings: Loss of follicles (83%); Perifollicular scales (67%); Follicular pustules (58%);
                                                                                                                          Hair tufting (50%)
                                                                                                                          Less common findings: Cicatricial white patches (42%); Perifollicular erythema (42%); Scalp erythema (42%);
                                                                                                                          Scales (33%); Crust formation (33%); Black dots (25%); Perifollicular whitish halo (25%); White dots (eccrine
                                                                                                                          openings) (25%); Honeycomb pigment pattern (25%); Epidermal atrophy (17%); Elongated linear vessels (17%);
                                                                                                                          Yellow dots (17%); Arborizing vessels (17%); Follicular plugging (17%); Red loop vessels (8%); Fibrotic white
                                                                                                                          dot (8%); Speckled pigmentation (8%); Blue-grey dots (8%); Hair shaft disorder (pili torti and Pohl Pinkus
                                                                                                                          constrictions) (8%)
                                                          Frontal fibrosing alopecia          4              14           Common findings: Loss of follicles (93%); Perifollicular erythema (57%); Perifollicular scales (57%); Cicatricial
                                                                                                                          white patches (50%); Honeycomb pigment pattern (50%);
                                                                                                                          Less common findings: Telangiectasias (36%); Scalp erythema (29%); Blue-grey dots (29%); Predominance
                                                                                                                          of one hair follicles (14%); Epidermal atrophy (14%); Follicular hyperkeratosis (14%); Peripilar casts (14%);
                                                                                                                          Interfollicular scaling (14%); Hair shaft disorder (pili torti and Pohl Pinkus constrictions) (14%); Black
                                                                                                                          dots (14%); White dots (14%); Off white dots (empty follicles) (7%); Scattered brown discoloration (7%);
                                                                                                                          Perifollicular pigmentation (7%); Short vellus hair (7%); Yellow dots (7%)




Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S
                                                                                         Total number        Total number of
                                                                    Disorder               of studies           instances                                               Trichoscopic findings* (total prevalence)
                                                           Lichen planopilaris                   8                  107              Common findings: Loss of follicles (98%); Perifollicular scales (78%); Cicatricial white patches (69%);
                                                                                                                                     Honeycomb pigment pattern (60%); Scalp erythema (57%)
                                                                                                                                     Less common findings: Blue-grey dots in targetoid pattern (42%); Perifollicular erythema (37%); Scales (34%);
                                                                                                                                     Blue-grey dots (21%); White dots (eccrine openings) (19%); Blue-grey dots in speckled pattern (16%); Hair shaft
                                                                                                                                     disorder (pili torti and Pohl Pinkus constrictions) (14%); Red loop vessels (13%); Enlarged branching vessels
                                                                                                                                     (12%); Peripilar casts (12%);
                                                                                                                                     Fibrotic white dot (10%); Black dots (10%); Follicular plugging (9%); Hair tufting (5%); Elongated linear vessels
                                                                                                                                     (4%); Red dots (2%); Off white dots (empty follicles) (1%)
                                                           Pseudopelade of Brocq                 6                   13              Common findings: Loss of follicles (100%)
                                                                                                                                     Less common findings: White dots (eccrine openings) (46%); Cicatricial white patches (46%); Perifollicular scales
                                                                                                                                     (39%); Yellow dots (23%); Blotchy pigmentation (23%); Epidermal atrophy (16%); Perifollicular erythema
                                                                                                                                     (16%); Thin hair (16%); Honeycomb pigment pattern (7%); Scales (7%); Broken hair (7%); Black dots (7%)
                                                           Hair shaft disorders




Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S
                                                           Monilethrix                           6                    8              Common findings: Beaded hair with equidistant nodes and internodes (100%)
                                                                                                                                     Less common findings: Broken hair (25%); Angulated hair (25%); Yellow dots (13%) Perifollicular Scales (13%)
                                                           Woolly hair syndrome                  1                    1              Common findings: Short wave circles of hair shaft - “crawling snake appearance” (100%)
                                                                                                                                     Less common findings: -
                                                          *Trichoscopic findings are divided into common (prevalence ≥ 50%) and less common (prevalence < 50%).




7
Figure 2. Examples of trichoscopic clues of non-cicatricial alopecias in dark-skinned patients: Exclamation mark hairs (arrows) in alopecia
areata (A); Hair diameter diversity along with thin hairs in early androgenetic alopecia (B); Multiple vellus hairs and brown pigmentation
round follicular ostia (brown peripilar sign – arrows) in advanced androgenetic alopecia (C); Comedo-like black dots and yellow dots in
­pressure-induced alopecia (D); Several follicular units with single hair shaft and lack of other specific trichoscopic criteria in telogen effluvium
 (E); Comma-like hairs as well as corkscrew-like hairs in tinea capitis (F); Diffuse and perifollicular white scaling along with “Morse code”
 hairs (arrow) in tinea capitis (G); White peripilar casts, single-hair follicular units, loss of follicles and thin/vellus hair (arrow) in traction
 alopecia (H); Broken hairs at different length, trichoptilosis, black dots and flame hairs (arrow) in trichotillomania (I).


by Bapu et al. [6] Similarly, diagnostic value of exclamation               alopecia universalis (50.3 ± 53.6) and the lowest density
mark hairs in AA was higher when detected along with yel-                   (22.2±13.1) being detected in localized patchy AA. Con-
low dots, black dots, short vellus hairs and/or short regrow-               versely, the study by Kibar et al found no relationship
ing hairs based on the study by Amer et al [15]. Additionally,              between the number of yellow dots and AA subtype and
the same authors found that the presence of pigtail hairs was               activity, while the authors observed honeycomb-pattern
related to spontaneous remission [15].                                      pigmentation, cumulus-like clustered white dots, white
    Moving to disease activity, yellow dots and short vellus                dots and black dotted pigmentation to be positively cor-
hairs were related to stability, while black dots, broken hairs,            related with disease severity [9]
coudability hairs, tapering hairs, and exclamation mark hairs                    Finally, Ganjoo et al evaluated trichoscopic changes
were are all positively correlated with disease activity, with              following intralesional steroid therapy and found that the
coudability hairs being reported to be more specific than                   presence of exclamation mark hairs was the first feature to
broken hairs [22]. However, exclamation mark hairs have                     disappear after four weeks of treatment, followed by broken
also been observed in long-standing non-progressive AA in a                 hairs/black dots and yellow dots (12 and 16 weeks, respec-
study by Govindarajulu et al [14].                                          tively). At four weeks of treatment, the appearance of pigtail
    Of note, based on the studies by Bapu et al [6] and                     hairs and pigmented hairs was also noted [20]. Other stud-
Jha et al [19], a higher density of yellow dots would be                    ies showed that treated or remitting lesions of AA showed
related to the disease severity, with the highest mean                      an increased number of short vellus hairs and terminal hairs
number of yellow dots per field of view being seen in                       [14,18,19].



Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S                                                                                           8
Figure 3. Examples of trichoscopic clues of cicatricial alopecias in dark-skinned patients: Honeycomb pigment pattern, pinpoint white
dots and the characteristic perifollicular thick whitish halo in central centrifugal cicatricial alopecia (A); Brown follicular plugs (arrow),
cicatricial white patches and diffuse brown honeycomb pigmentation in discoid lupus erythematosus (B); loss of follicles, cicatricial white
patches, a black dot, yellow crusting and the characteristic “3D yellow-brown dots” (arrow) in dissecting cellulitis (scarring stage) (C); Loss
of ­follicles, perifollicular white scaling, hyperpigmented perifollicular halo (white arrow), and perifollicular whitish halo (back arrow) in
fibrosing ­alopecia in a patterned distribution (D); Yellow crusting and white scaling in folliculitis decalvans (early stage) (E); Loss of follicles,
­cicatricial white patches and hair tufting in folliculitis decalvans (advanced stage) (F); Perifollicular scales, multiple fibrotic white dots and
 small patches, blue-grey dots in targetoid pattern (around fibrotic white dots) in lichen planopilaris (G); Loss of follicles but evidence of
 white dots (eccrine openings) along with honeycomb pigment pattern in pseudopelade of Brocq (H); Beaded hair with equidistant nodes and
 internodes (arrow) in monilethrix (I).



Androgenetic Alopecia                                                            Bhrama et al focused on the diagnostic value of HDD
A total of nine studies (eight case-control analyses                         >20% in FPHL, with a sensitivity of 75% for Grade 1 FPHL
[10-12,14,30-33] and one case-series [34]) assessing
­                                                                            and 93% for FPHL in general, thereby underling that it is a
trichoscopic features of female pattern hair loss (FPHL)
­                                                                            consistent feature in pattern hair loss and can be used as a
comprising a total of 544 cases were identified. The most                    diagnostic tool [33].
prevalent finding was hair diameter diversity (HDD), seen                        Notably, Nikam et al found that the brown peripilar sign,
in 87 % of cases (also including two studies which consid-                   which represents perifollicular inflammation, was seen more
ered HDD of more than 10% of hair instead of the most                        frequently in cases of androgenetic alopecia compared to
used cutoff of 20% [14,34]). Further notable findings in-                    tinea capitis and trichotillomania [11]. Finally, Tawfik et al
cluded short vellus hairs (66%), brown peripilar sign (35%),                 observed that yellow dots and white dots were positively
­single-hair ­follicular units (29%), thin hairs (20%), and yel-             correlated with advanced stages of hair loss and that all pa-
low dots (18%), while several other features were found in                   tients displayed HDD with an increased percentage of min-
less than 10% of cases, such as honeycomb pigment pat-                       iaturized vellus hairs in the frontal and temporal areas [31].
tern, white dots, white peripilar sign, and focal atrichia                       Moving to male pattern hair loss (MPHL), a total of
[10-12,14,30-34].                                                            three trichoscopic studies (two case-control [12,14] and one



9                                                                                     Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S
case-series [34]) were retrieved for a total of 102 instances.       Importantly, trichoscopic variability according to the
The most common finding was still HDD greater than 20%,           clinical/microbiological subtype was also observed. In detail,
observed in 85% of cases, whereas additional common               corkscrew hairs, comma hairs and zigzag hairs turned out
features included yellow dots (84%), honeycomb pigment            to be more suggestive of the endothrix variant, while peri-
pattern (78%), brown peripilar sign (67%), white peripilar        follicular scales were more specific of “grey patch” TC and
sign (39%), and short vellus hairs (22%). Thin hairs, focal       black dots, erythema, telangiectasias and haemorrhages of
atrichia and white dots were seen in less than 20% of cases.      kerion [35]. Finally, comma hairs, black dots, and perifol-
                                                                  licular scaling were reported to be more frequent in “black
Pressure-Induced Alopecia                                         dot” TC [35].
A single retrospective case-control study by Neema et al on          With regard to post-treatment monitoring, the disap-
trichoscopy of pressure-induced alopecia (PIA) was found          pearance of dystrophic hairs was reported as a marker of
in the literature [13]. The most common features included         therapeutic success in a prospective study by Campos et al
yellow dots and short vellus hairs, while black dots, come-       involving 50 patients [42]. In the same study, the authors
do-like black dots, broken hairs and areas of scarring were       also found persistence of perifollicular scaling despite nega-
additional findings. When compared with alopecia areata,          tive results of mycological culture.
comedo-like black dots, black dots, and scarring areas were
significantly more prevalent in PIA, while exclamation mark       Traction Alopecia
hairs were significant for alopecia areata.                       A total of nine instances of traction alopecia (TA) with
                                                                  trichoscopic description have been reported in the literature
Telogen Effluvium                                                 (two case-control studies [8,10] and a single case series [43]),
Three case-control studies describing trichoscopy of telo-        with peripilar casts and single hair follicular units being the
gen effluvium (TE) were retrieved with a total of 53 cases        most common features (44% and 40% of cases, respectively).
[10,12,14]. In general, the most common reported tricho-          Peripilar casts have also been reported to be present in case
scopic feature was upright regrowing hairs seen in 81%            of diffuse TC at the margins of the patches. Additional less
of cases, followed by single hair follicular units (38% of        common findings included loss of hair follicles, black dots,
cases) and off-white dots (empty follicles) (28% of cases)        follicular pustules, and short vellus hairs.
[10,12,14]. Additional less commonly described findings
included thin hairs and perifollicular erythema. However,         Trichotillomania
prevalence variability among studies did exist [10,12,14].        We found five case-control studies [8,10-12,14] as well
Notably, unlike other studies, Chiramel et al found a low         as three case-series [44-46] and three single case-reports
prevalence of upright regrowing hairs, while thin hairs were      ­[47-49] on trichotillomania encompassing 46 cases. Broken
found to be the most common feature [12]. Moreover, the           hairs of variable length were the most common trichoscopic
same authors also observed honeycomb pigment pattern,             feature, being observed in 93% of cases. Further common
pigtail hairs and yellow dots in chronic TE [12].                 findings included trichoptilosis, black dots and hook hairs
                                                                  (more than half of all cases) as well as peripilar hemorrhages,
Tinea Capitis                                                     V-sign and flame hairs (more than one-fourth of all cases).
A total of 261 cases of tinea capitis (TC) have been inves-       On the other hand, less frequent features were tulip hairs,
tigated from a trichoscopic point of view in nine studies         straight regrowing hairs, yellow dots, perifollicular scales,
(one cross-sectional [35] and eight case-control [8,10-12,14-     hair diameter diversity, white dots (eccrine openings), short
16,36]) along with two case-series [37,38] and three single       vellus hairs, hair dust, and honeycomb pigment pattern. Of
case-reports [39-41]. The most prevalent finding was the          note, broken hairs of variable length and trichoptilosis were
presence of black dots (57% of cases). Other common fea-          found to be indicative of trichotillomania when compared
tures (observed in more than 20% of cases) included comma         to alopecia areata in a study by Chiramel et al [12]. Finally,
hairs, broken hairs, perifollicular white scales, and corkscrew   according to a study conducted by Saqib et al, the presence
hairs. Less frequent findings were zigzag hairs, erythema, tel-   of straight and pigtail hairs indicate hair regrowth in patients
angiectasias, hemorrhages, morse code hairs, i-hairs, pustules,   with trichotillomania [10].
and white dots (eccrine openings). Of note, the association
of perifollicular scaling with any dystrophic hairs or broken     Cicatricial Alopecias
hairs was found to be a specific trichoscopic pattern of TC in    Central Centrifugal Cicatricial Alopecia
a controlled study by Brasileiro et al [36 ], whereas Chiramel    A retrospective case-control study [50] and a case ­series [51]
et al showed that the presence of comma hairs was in favor        involving a total of 65 instances of central centrifugal cicatri-
of TC diagnosis when compared to ­alopecia areata [12].           cial alopecia (CCCA) were retrieved. In general, ­honeycomb



Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S                                                                        10
pigmentation pattern, perifollicular white halo, pinpoint           although considered to be a characteristic sign of DCS, they
white dots and cicatricial white patches were the main find-        were observed in 44% of cases in total [52, 53].
ings (100%, 95%, 81% and 74% of cases, respectively), being             Moving to early DCS, Tosti el al, described yellow dots,
commonly found in both studies. When compared to other              red dots, empty follicular openings, black dots, and cadav-
scarring alopecias, perifollicular white halo turned out to be      erized hairs, also emphasizing that the lack of exclamation
the most accurate finding, with 100% of specificity and 94%         mark hairs may be a clue to differentiate early DCS from
of sensitivity. Notably, this trichoscopic feature was present in   alopecia areata [58].
both early and late stages of CCCA. ­Additional trichoscopic
findings included terminal hairs, short vellus hairs, erythema,     Fibrosing Alopecia in a Patterned Distribution
scaling (mainly perifollicular), asterisk-like brown areas, bro-    A single trichoscopic study involving a total of 16 patients
ken hairs, black dots, and dark peripilar halos.                    with fibrosing alopecia in a patterned distribution (FAPD) is
                                                                    available from the literature [59]. Loss of follicle openings
Discoid Lupus Erythematosus                                         and hair diameter diversity were detected in all cases. Ad-
Discoid lupus erythematosus (DLE) was one of the most               ditionally, perifollicular scaling and erythema were present
studied form of scarring alopecias from a trichoscopic point        in 88% of cases, while hyperpigmented perifollicular halos,
of view, with seven case-control studies, [10-12,52-54] two         scattered white patches, and a honeycomb network were ob-
case-series, [55,56] and a single case-report [57] involving        served in 75% of cases. Lastly, white perifollicular halos and
a total of 159 instances. Follicular plugs, white scarring          follicular plugs were observed in 56% and 19% of cases, re-
patches and perifollicular white halos were the most com-           spectively. Importantly, the study underlined that FAPD and
mon findings, with a prevalence of 50%, 47% and 43%,                CCCA may share several trichoscopic findings, with possible
respectively. Other main features included telangiectasias,         difficulties in their differentiation.
red dots and brown dots (39%, 35% and 30% of cases).
Many additional less frequent findings have been reported           Folliculitis Decalvans
(Table 1 and Supplemental Table). Considering diagnostic            Twelve instances of folliculitis decalvans (FD) have been
accuracy, tortuous branching vessels (seen as irregular coiled      investigated on trichoscopy by five case-control studies
vessels) were found to be specific (100% specificity) of DLE        [8,10,12,52,53]. In general, loss of follicular openings, peri-
when compared to other forms of scarring alopecias based            follicular scaling, follicular pustules and hair tufting were the
on the study by Abedini et al [52]. In line with such a finding,    most common features, being detected in more than 50% of
­Chiramel et al showed that the detection of branching vessels      cases. Moreover, several additional findings were reported
was in favor of DLE compared to lichen planopilaris [12].           (Table 1/Supplemental table).
     Of note, follicular plugs, thick arborizing vessels, peri-         According to the study by Abedini et al, follicular pus-
follicular erythema, and follicular red dots have been found        tules may also be observed in dissecting cellulitis of the scalp,
to be indicators of disease activity [55]. On the other hand,       yet the prevalence was higher in FD [52]. Another hallmark
white areas and thin arborizing vessels have been reported          of FD was hair tufting, defined as tufts of ≥ 6 hair shafts
more commonly in inactive DLE [11, 55]. Finally, red dots           emerging from one follicular opening [8,10,12,52,53].
were found to be a positive prognostic factor of hair re-           Of note, pustules were found to be a marker of active FD,
growth in a study by Thakur et al [53].                             whereas hair tufting turned out to be an indicator of disease
                                                                    severity [53].
Dissecting Cellulitis of the Scalp
Fourteen instances of dissecting cellulitis of the scalp (DCS)      Frontal Fibrosing Alopecia
reporting trichoscopic findings have been retrieved (two            A total of 14 cases of frontal fibrosing alopecia (FFA) have
case-control studies including eight scarring cases [52,53]         been investigated from a trichoscopic point of view in three
and a case-series involving five early cases [58]).                 case-control studies [52-54] and one single case-report [60].
     Considering scarring cases, besides the lack of follicular     Besides the lack of follicular openings, showing a prevalence
openings, being seen in all instances, other frequent findings      of 93%, the main trichoscopic findings included perifollic-
(more than two-thirds of cases) included cicatricial white          ular erythema and scaling, both being detected in 57% of
patches, black dots, crusts, perifollicular scales, yellow dots,    cases. Several other additional features were reported and
elongated linear vessels, interfollicular scaling, and erythema.    are showed in Table 1/Supplemental table.
Less frequent findings are listed in Table 1/Supplemental
Table. Notably, according to the study by Abedini et al, black      Lichen Planopilaris
dots were observed with a higher prevalence compared to             Seven case-control studies [8,10-12,52-54] and a single
other cicatricial alopecias [52]. Regarding “3D yellow dots”,       case-report [57] on trichoscopy of lichen planopilaris (LPP)



11                                                                          Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S
were retrieved, for a total of 107 instances. Similarly to other    studies did not take into account disease stage, that may sig-
cicatricial alopecias, loss of follicular openings was the most     nificantly affect trichoscopic pattern. Finally, there is little
prevalent finding (98% of cases). Additionally, perifollicular      data on possible trichoscopic differences according to the
scales, white areas and honeycomb pigment network were              hair texture as a significant variability does exist in the spec-
generally the main features (prevalence of 78%, 69% and             trum of dark-skinned populations, with patients of African
60%, respectively), followed by erythema (57% of cases)             descent being typically characterized by tight curly hair, that
and blue-grey dots in a targetoid pattern (42% of cases). Less      may potentially influence the trichoscopic patterns, espe-
common findings are showed in Table 1/Supplemental table.           cially when it comes to hair shaft changes. Further analyses
   Of note, even though blue-grey dots are a common fea-            considering all such gaps are therefore needed.
ture in both LPP and discoid lupus erythematosus, targetoid
pattern arrangement were indicative of the former according
to the study by Chiramel et al [12]. Similarly, Ankad et al         References
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