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Chinmanat Tangjaturonrusamee, M.D.

Institute of Dermatology

Hair and scalp Dermoscopy

Outline

�Dermoscopy on the normal scalp

�Pattern of clinical presentation

• Scalp

• Hair

�Clinical implementation

Dermoscopy – x10 to x30 Videodermoscopy – x10 to

x1000 �Camera + lenses + computer storage

Normal scalp

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Follicular unit – 1-5 hair

follicles

40x

312

Normal scalp – Simple red

loops�Simple red loop = Pinpoint red dots

�Arborizing red line – wider caliber

Arborizing red line

Ross, J Am Acad Dermatol 2006; 55: 799-806.

Children – Dirty dots

20x

Children - Dirty dots

� sebaceous gl. activity à repel debris

Tosti, Arch Dermatol 2009; 145(5): 600-1.

20x 70x

Vascular pattern

Red loops

�Normal scalp

- simple red loops

�Psoriasis

- twisted red loops

� Psoriasis

� Seborrheic dermatitis

� Folliculitis decalvans

70x

Arborizing red line

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Psoriasis vs Seborrheic

dermatitis�Psoriasis

- red dots

- twisted red loops

- glomerular vessels

�Seborrheic dermatitis

- arborizing vessels

- atypical red vessels

- no red dots

Kim, Br J Dermatol 2011; 164(3): 652-6.

Psoriasis

Kim, Br J Dermatol 2011; 164(3): 652-6.

Red dots & globules

Glomerular vessels

Twisted red loops

Seborrheic dermatitis

Kim, Br J Dermatol 2011; 164(3): 652-6.

Atypical red vessels

Arborizing vessels

Pigment pattern

Honeycomb pigment pattern

�Normal scalp

- diffuse, homogenous

�Chronic alopecia

- patchy, scar

scar

honeycomb

honeycomb

40x 40x

Peripilar signs

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Yellow dots

= yellow round dots

40x 40x

AA AGA

AA, AGA,

Trichotillomania, Dissecting cellulitis,

Cong. hypotrichosis

Yellow dots

Dilated infundibulum with

keratinous material

Tosti, Arch Dermatol 2011; 147(1): 61-4.

Pinpoint white dots

�Regularly distributed

�Scalp with normal interfollicular epidermis

20x

Pinpoint white dots

Small pinpoint white dots = Epidermal portion of

eccrine sweat duct

Abraham, J Am Acad Dermatol 2010; 63: 721-2.

Normal,

FFA, LPP, AA, AGA,

CCCA

White patch - Scarring alopecia

20x

Follicular red dots - DLE

Tosti, Arch Dermatol 2009;145(12):1406-9.

Widened infundibula plugged by keratin

Dilated vessels and extravasated erythrocytes

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Peripilar sign – AGA

�Perifollicular inflammation à PIH

Tosti, J Am Acad Dermatol. 2012 [Epub ahead of print]

Hair presentation

Hair diversity > 20% - AGA

20x

Vellus

Black dots (Cadaverized hairs)

�Destroyed hair shaft à broken hair

Cadaverized hair

Broken hair40x

AA, Trichotillomania,

T. capitis

AA vs Trichotillomania (TT)

�Exclamation mark hair

**characteristic of AA

�Coiled hair

**characteristic of TT

AA TT

Coiled

Coiled

Broken

Broken

Broken

Exclamation

10x 10x

Abraham, An Bras Dermatol 2010; 85(5): 723-6.

Comma hair - Tinea capitis

Tosti, Mycoses 2011; 54(1): 87-8.

40x

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Corkscrew hair - Tinea capitis

Hughes, Arch Dermatol 2011 Mar;147(3):355-6.10x

Ectothrix

40x

Hair shaft disorders

Monilethrix

Int J Trichology. 2010 Jan-Jun; 2(1): 56–59.

Trichorrhexis nodosa

Int J Trichology. 2011 Jul-Dec; 3(2): 105–106.

Why is dermoscopy useful?

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Nonscarring or scarring

alopecia?

Scarring alopecia – DLE, LPP

Cicatricial white patch

Blue grey dots*

Broken hair

*Duque-Estrada, An Bras Dermatol 2010; 85: 179-83.

40x

AA or Trichotillomania ? Trichotillomania – Coiled hairs

40x

Tinea capitis Alopecia areata

Comma hair

Broken hair

Dystrophic hair

Exclamation hair

Slowinska, J Am Acad Dermatol 2008;59:S77-9.

Dermatoscopy guided scalp Bx

LPP FFA DLE

Tosti, J Eur Acad Dermatol Venereol 2012 Mar 26 [Epub ahead of print]

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Hair dermoscopy (Trichoscopy)

�Deny scalp biopsy

�Immediate differentiation between

• Scarring vs Nonscarring alopecia

• Nonscarring alopecia group:

- Psoriasis vs Seborrheic dermatitis

- AA vs Trichotillomania/Tinea capitis

-Telogen effluvium vs AGA