ESTUDIOS CIENTIFICO DE JOURNAL DERMATOLOGY ALOPECIA

8/18/2019 ESTUDIOS CIENTIFICO DE JOURNAL DERMATOLOGY ALOPECIA

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Clinical evaluation of alopecias using a handhelddermatoscope

€Ozlem Karada

g Köse, MD, and A. Tülin Güleç, MD

Ankara, Turkey

Background: There are numerous reports of the value of videodermatoscopy in the clinical evaluation of alopecia. Studies performed with a handheld dermatoscope are scarce and limited to a few disease entities.

Objective: The aim of this study was to evaluate the potential benefit of a handheld dermatoscope in theclinical diagnosis of alopecia.

Methods: In all, 144 patients with alopecia and 144 age- and sex-matched control subjects were enrolled inthe study. Diagnoses were established clinically, and confirmed by scalp biopsy in doubtful cases.Dermatoscopic examination was performed by a polarized-light handheld dermatoscope with a 10-foldmagnification. The images were obtained by a digital camera with a 3-fold optical zoom.

Results: The dermatoscopic patterns of circular hairs, dirty dots, epidermal scale, and pustules showed nostatistically significant difference between patients and control subjects. The following features weresignificantly more common, or observed solely, in particular types of alopecia: hair diameter diversity,peripilar sign, and empty follicles in androgenetic alopecia; yellow dots, black dots, tapering hairs, andbroken hairs in alopecia areata; absence of follicular openings, tufted hairs, white dots, follicularhyperkeratosis, pili torti, red dots, honeycomb pigment pattern, pink-white appearance, crusts, andpustules in primary cicatricial alopecias.

Limitations: Evaluation of all primary cicatricial alopecias in the same cluster.

Conclusions: We suggest that a polarized-light handheld dermatoscope attached to a digital camera

provides a practical and useful aid for the clinical diagnosis of alopecias. ( J Am Acad Dermatol2012;67:206-14.)

Key words: alopecia; dermatoscopy; hair; handheld dermatoscope; scalp; videodermatoscopy.

Scalp alopecias reflect a broad spectrum of heterogeneous diseases and are among themost common dermatologic disorders. A care-

ful history and a thorough clinical examination are

usually adequate to establish the correct diagnosis. Insome cases, eg, cicatricial alopecia, a scalp biopsy may be necessary. However, the histopathologicfeatures are not always diagnostic.1 Consequently,new diagnostic methods are required.

Scalp dermatoscopy is a promising way to facil-itate the diagnosis of scalp and hair disorders.2

Numerous reports1,3-9 have been published regard-ing the videodermatoscopic features of several

alopecias.

Abbreviations used:

AA: alopecia areata AGA: androgenetic alopeciaCTE: chronic telogen effluviumFD: folliculitis decalvansLPP: lichen planopilarisPCA: primary cicatricial alopecia

TE: telogen effluvium

From the Department of Dermatology, Baskent University Faculty

of Medicine.Funding sources: None.

Conflicts of interest: None declared.

Presented at 19th Congress of the European Academy of Derma-

tology and Venereology, Gothenburg, October 6-10, 2010.

Accepted for publication August 14, 2011.

Reprints not available from the authors.

Correspondence to: A. Tülin Güleç, MD, Department of

Dermatology, Baskent University Faculty of Medicine, 5.

sokak, No: 48, 06490 Bahçelievler/Ankara, Turkey. E-mail:

[email protected].

Published online October 24, 2011.

0190-9622/$36.00

2011 by the American Academy of Dermatology, Inc.

doi:10.1016/j.jaad.2011.08.019

206

mailto:[email protected]://dx.doi.org/10.1016/j.jaad.2011.08.019http://dx.doi.org/10.1016/j.jaad.2011.08.019mailto:[email protected]


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This study was undertaken to evaluate the poten-tial benefit of a handheld dermatoscope in theclinical diagnosis of alopecia.

METHODSStudy population

The study included 144 consecutive patients with a diagnosis of alopecia(80 female and 64male) who attended theDermatology Department of Baskent University in Ankara,Turkey, between November2008 and September 2009.The mean age in the patientgroup was 36.7 years (range,7-80 years). Patients with adiagnosis of seborrheic der-

matitis, psoriasis, and second-ary cicatricial alopecia wereexcluded from the study.

In all, 144 age- and sex-matched individuals withoutalopecia were randomly selected from the patients of our dermatology department to serve as control sub-jects. The study was approved by Baskent University Institutional Review Board, and all participants gaveinformed consent before study participation.

Study procedure

The same dermatologist investigated each patientaccording to a set protocol. Dermatologic evaluationincluded clinical observation along with a light pulltest, quantitative analysis of the shed hairs, and hairroot analysis by light microscopy when indicated.Diagnosis was established clinically, and confirmedby histopathologic examination of a scalp biopsy specimen in all primary cicatricial alopecias (PCAs)and in other doubtful cases.

Dermatoscopic examination was performed by apolarized-light handheld dermatoscope (Dermlite IIPro HR, 3Gen LLC, San Juan Capistrano, CA), which

permits scalp visualization at a 10-fold magnification, without an interface solution. Hair separation lines were examined in patients with diffuse alopecia andin control subjects, whereas central and peripheralparts of the lesions were observed in alopecia areata(AA) and PCAs. Images were obtained by a digitalcamera (Sony Cyber-shot DSC-W70, Sony Corp,Tokyo, Japan) that produced imagery with a magni-fication of 30-fold via its 3-fold optical zoom lens.

In each patient, several different images at 10- to30-fold magnifications were taken, and evaluated inaccordance with the checklist of dermatoscopic

features presented in Table I.

Statistical analysisContinuous variables were presented as means 6

SD, and discrete variables were shown as percent-ages. Both x 2 and Fischer x 2 testing were used forintergroup comparisons, and P less than .05 wasconsidered significant. Software (SPSS, Version 16.0statistical package for Microsoft Windows, SPSS Inc,

Chicago, IL) was usedthroughout.

RESULTSClinical diagnosis and de-

mographic features of the pa-tients are shown in Table II.Ten patients (4 female and 6male) had more than onetype of alopecia; 7 patientshad androgenetic alopecia

(AGA) and AA, two patientshad AGA and chronic telogeneffluvium (CTE), and one pa-tient had AGA and PCA.

Dermatoscopic featuresThe distribution and prevalence rates of the

dermatoscopic features in each patient group aresummarized in Table III.

Follicular features Yellow dots (Fig 1, A), black dots (Fig 1, D ),

and broken hairs (Fig 1, A) were significantly more common in AA than in the other alopecias.Tapering hairs (Fig 1, D ) were detected only in AA. Short vellus hairs (Fig 1, B , and Fig 2, E ) werenoted in all types of alopecia, without a significantdifference in frequency. Circular hairs (Fig 1, E )and trichorrhexis nodosa (Fig 1, F ) were observedin AA or PCAs without a significant differencebetween the two groups. Hair diameter diversity (Fig 2, B ) was found in all subjects with AGA, and was significantly more common in this group thanthe others. Empty follicles (Fig 2, A), and peripilar

sign (Fig 2, A) were noted only in AGA. Absenceof follicular openings (Fig 3, A), tufted hairs (Fig3, B ), follicular hyperkeratosis (Fig 3, A), and pilitorti (Fig 3, E ) were just encountered in PCAs.The prevalence of white dots (Fig 2, C ) wassignificantly higher in PCAs, as compared with AGA.

Interfollicular featuresRed dots (Fig 3, D ), honeycomb pigment pattern

(Fig 2, C ), and crust formation (Fig 3, E ) weresignificantly associated with PCAs. There was no

significant difference between the alopecia types

CAPSULE SUMMARY

d Several investigations have confirmed

the usefulness of videodermatoscopy in

the clinical evaluation of alopecias.

d In this study, we determined the benefit

of a handheld dermatoscope in the

clinical diagnosis of various alopecias.

d A handheld dermatoscope attached to a

digital camera is a practical and useful

tool to improve the clinical diagnosis of

alopecias.

J A M A CAD DERMATOL V OLUME 67, NUMBER 2

Karada g Kö se and Gü lec ¸ 207


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regarding arborizing red lines (Fig 1, C ) and dirty dots (Fig 2, D ). Pink-white appearance (Fig 3, C ) wasnoted only in PCAs.

Follicular and interfollicular featuresEpidermal scale (Fig 3, C ) was encountered in all

types of alopecia, whereas pustules (Fig 3, B ) weresignificantly prominent in PCAs.

The frequency of dermatoscopic findings in pa-tients and control subjects are presented in Table IV .There was no significant difference between them

regarding the dermatoscopic features of circularhairs, dirty dots, crust formation, epidermal scale,and pustule. The rest of the findings were eithersignificantly more common or noted only in thealopecia group. There was no feature confined tocontrol subjects.

Peripilar sign, white dots, honeycomb pigmentpattern, and dirty dots were more prominently viewed at 30-fold magnification, whereas pili tortiand red dots could only be appreciated at thismagnification. Interfollicular simple red loops andinterfollicular twisted red loops could not be

noticed at 30-fold magnification; the rest of thefindings were easily observed at magnifications of 10- to 30-fold.

DISCUSSIONLacarrubba et al5 were the first to establish that

videodermatoscopy enhanced diagnostic capability in some forms of hair loss. Videodermatoscopicfindings of various scalp and hair disorders weredescribed by Ross et al,1 who classified them aseither follicular or interfollicular in origin.Subsequently, a growing number of reports1,3-9

have defined the use of videodermatoscopy in this

field. Studies performed with a handheld dermato-scope are still few in number, and limited to alope-cias such as AA, AGA, and frontal fibrosingalopecia.10-14

In this study of dermatoscopic findings, we addeda third class entitled ‘‘follicular 1 interfollicularfeatures’’ because of the fact that scales and pustules

are observed in both areas.

Table II. Scalp diagnosis and demographics inpatients with alopecia

Clinical diagnosis

Patients,

n = 144 (%)

F/M,

n = 80/64

Biopsy-proven

diagnosis,

n = 37

Androgenetic

alopecia

59 (41) 27/32 4

Alopecia areata 49 (34) 26/23 8

Chronic telogen

effluvium

19 (13.2) 18/1 4

Acute telogen

effluvium

6 (4.2) 6/0 0

Primary cicatricialalopecia

21 (14.6) 7/14 21

Lichen planopilaris 7 (4.9) 1/6 7

Folliculitis

decalvans

5 (3.5) 0/5 5

Frontal fibrosing

alopecia

2 (1.4) 2/0 2

Discoid lupus

erythematosus

1 (0.7) 1/0 1

Dissecting cellulitis 1 (0.7) 0/1 1

Pseudopelade of

Brocq

1 (0.7) 1/0 1

Erosive pustular

dermatosis

1 (0.7) 0/1 1

Nonspecific 3 (2.1) 2/1 3

F , Female; M , male.

Table I. Evaluation checklist of dermatoscopic features of alopecias in this study

Follicular features Interfollicular features Follicular and interfollicular features

Yellow dots Red dots Epidermal scale

Black dots (cadaverized hairs) Interfollicular simple red loops Pustule

Tapering (exclamation mark) hairs Interfollicular twisted red loops

Broken hairs Arborizing red linesShort vellus hairs Honeycomb pigment pattern

Hair diameter diversity Dirty dots

Empty follicles Crust formation

Peripilar sign

Absence of follicular openings

Tufted hairs

White dots

Follicular hyperkeratosis

Pili torti

Trichorrhexis nodosa

J A M A CAD DERMATOL A UGUST 2012

208 Karada g Kö se and Gü lec ¸


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Follicular features Yellow dots are millimetric points that arise as a

result of keratin and sebum accumulation within thefollicular infundibulum.1 They are reported mostcommonly in AA, and to a lesser extent in AGA, CTE,and healthy controls.1,8,9 Similarly, this study revealed a higher prevalence of yellow dots in AA (83.7%) than in AGA (30.5%). We also documentedthem in patients with PCA and CTE, and in controlsubjects. We suggest that yellow dots are a highly sensitive but not a specific marker for AA.

Black dots occur when the hair shaft fracturesbefore emerging from the scalp. We encounteredtheminbothAA(63.3%)andPCAs(33.3%).Inuietal 13

observed black dots in 44.3% of patients with AA, andconcluded that they are one of the most specificdiagnostic markers for AA. However, our findingsindicated that black dots are also suggestive of PCAs.

Tapering hairs were demonstrated in 31.7% of AA cases in a recent study.13 As they were also notedsolely in AA (42.9%) in this study, we think that they are diagnostic for AA.

Hairs that are fractured at different distances from

the scalp are named ‘‘broken hairs.’’

15

They were

detected in 45.7% of AA cases,13 and considered asone of the most specific markers for AA. Our resultsprovide no evidence for this conclusion because wedid not document them only in AA (57.1%), but also,albeit to a lesser extent, in patients with PCA and AGA. Thus, broken hairs are a suggestive but not anindicative feature of AA.

Short vellus hairs have been proposed to be acharacteristic feature of AA.13 However, in our study they were seen in all types of alopecia. Regrowinghairs in AA and telogen effluvium (TE) and follicle

miniaturization in AA and AGA can present as short vellus hairs. Our data indicated that they do notconstitute a helpful diagnostic feature.

To our knowledge, circular hair pattern is newly described by this study as round, velluslike, milli-metric hairs. We detected these in two patients with AA and one with PCA, so this pattern seems torepresent a rare nondiagnostic finding.

Hair diameter diversity is characterized by the variety of hair diameters involving more than 20% of hair, and corresponds to vellus transformation of thefollicles.16 It was observed in all patients with AGA,

and in some patients with AA and PCA, confirming

Table III. Dermatoscopic features observed by handheld dermatoscope in patients with alopecia

Dermatoscopic features

Alopecia type

AGA, n = 59 (%) AA, n = 49 (%) CTE, n = 19 (%) ATE, n = 6 (%) PCA, n = 21 (%) P value

Follicular features

Yellow dots 18 (30.5) 41 (83.7) 4 (21.1) e 4 (19.0) \.001

Black dots 1 (1.7) 31 (63.3) e e

7 (33.3) \.001Tapering hairs e 21 (42.9) e e e \.001

Broken hairs 1 (1.7) 28 (57.1) e e 6 (28.6) \.001

Short vellus hairs 26 (44.0) 23 (46.9) 9 (47.4) 2 (33.3) 10 (47.6) .972

Circular hairs e 2 (4.1) e e 1 (4.8) .447

Hair diameter diversity 59 (100) 16 (32.7) 2 (10.5) e 4 (19.0) \.001

Empty follicles 31 (52.5) e e e e \.001

Peripilar sign 35 (59,3) e e e e \.001

Absence of follicular openings e e e e 21 (100) \.001

Tufted hairs e e e e 10 (47.6) \.001

White dots 9 (15.3) e e e 11 (52.4) \.001

Follicular hyperkeratosis e e e e 10 (47.6) \.001

Pili torti e e e e 12 (57.1) \.001

Trichorrhexis nodosa e

8 (16.3) e e

3 (14.3) .006Interfollicular features

Red dots 11 (18.6) 8 (16.3) 1 (5.3) e 14 (66.7) \.001

Arborizing red lines 36 (61.0) 31 (63.3) 9 (47.4) 4 (66.7) 15 (71.4) .624

Honeycomb pigment pattern 22 (37.3) 3 (6.1) 1 (5.3) e 13 (61.9) \.001

Pink-white appearance e e e e 20 (95.2) \.001

Dirty dots 13 (22.0) 2 (4.1) 3 (15.8) e 2 (9.5) .062

Crust formation e 1 (2.0) e e 6 (28.6) \.001

Follicular and interfollicular features

Epidermal scale 22 (37.3) 14 (28.6) 14 (73.7) 5 (83.3) 13 (61.9) .001

Pustule e 1 (2.0) e e 6 (28.6) \.001

AA, Alopecia areata; AGA, androgenetic alopecia; ATE , acute telogen effluvium; CTE , chronic telogen effluvium; PCA, primary cicatricial

alopecia.




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the findings of earlier studies.1,5,14 Although AGA and CTE are commonly confused, they rarely coex-ist. However, our two patients with CTE had both AGA and CTE, and displayed hair diameter diversity probably as a result of AGA. Accordingly, though this

feature is not indicative of any particular alopecia, itis an indispensable finding for AGA.

Empty follicles leading to focal atrichia are de-scribed in AGA.17 Yet, kenogen hair follicles inhealthy scalps can display a similar appearance.18

Likewise, we noted them in both AGA (52.5%) andcontrols (4.9%).

Peripilar sign defines a brown halo around thefollicular ostium.19 In our study, this was confined to AGA (59.3%), as previously noted by Inui et al.14

Thus, peripilar sign points to the diagnosis of AGA. Absence of follicular openings occurs as a result of

fibrosis.1,20-23

Our data showed that it was found inall PCAs, which matches the findings of Ross et al.1

Therefore, this feature can be accepted as a hallmarkfor PCAs.

Tufted hairs are a common clinical and dermato-scopic sign of folliculitis decalvans (FD).24,25 Weobserved them merely in patients with PCAs.

Ross et al1 reported white dots in lichen planopi-laris (LPP) and FD, always in association with thehoneycomb pigment pattern. They have been sug-gested to represent the destructed follicles leading tofocal loss of melanin.26 However, a recent study 27

indicated that they correspond to the eccrine pores

in either healthy or alopecic scalps. We observedthem in AGA (15.3%) and PCAs (52.4%), but not incontrols.

We encountered follicular hyperkeratosis in47.6% of PC As, a similar finding documented by

Ross et al,1 who detected this in discoid lupuserythematosus and LPP.20,21 Therefore, we believeit to be an indicative feature of PCAs.

Pili torti occur in PCAs, particularly in LPP, yet they rarely arise in normal scalp as well.28 We viewedthem merely in PCAs (57.1%), and considered theirpresence as another clue for PCAs.

Trichorrhexis nodosa was found in AA (16.3%) and PC As (14.3%), confirming previousobservations.15,28

Interfollicular featuresRed dots could only be observed at 30-fold

magnification in our study. They represent thecounterpart of simple red loops and twisted redloops that are appreciated at 50-fold or highermagnifications by videodermatoscopy. Their deter-mination is particularly helpful in inflammatory scalpdisorders rather than alopecias, except for discoidlupus erythematosus and acute FD.1 We noted reddots in both patients (22.2%) and control subjects(13.2%), consistent with the earlier data.1

Arborizing red lines have wider diameters than

the red loops. They were more frequent in patients

Fig 1. Dermatoscopic features of scalp in alopecia areata. A , Yellow dot (arrow ) and brokenhair (arrowhead ). B, Short vellus hair (arrow ). C, Arborizing red lines (arrow ). D, Taperinghairs (arrowhead ) and black dot (arrow ). E, Circular hair (arrow ). F, Trichorrhexis node(arrow ). ( A to F, Original magnifications: 330.)




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(61.1%) than the control subjects (25.7%), as re-ported by Ross et al.1

Honeycomb pigment pattern probably resultsfrom chronic sun exposure of the balding scalp.1 It was most common in PCAs (61.9%), yet some of ourcontrol subjects (6.9%) also presented this pattern,agreeing with an earlier study.1

We defined a second new dermatoscopic findingas pink-white appearance representing the diffusepink-red and/or milky red color of the scalp. As it was purely noted in PCAs (95.2%), we believe that itis indicative of this disease group, and most probably correlates with the atrophy and fibrosis of the scalp.Earlier studies by videodermatoscopy 20,21,29 re-ported a white color of the scalp in discoid lupuserythematosus and scalp erythema in LPP.

Dirty dots have been recently described on thescalp of healthy children, as a potential mimicker of black dots. They are variably sized black-colored

dust particles that disappear after shampooing. It has

been proposed that this finding is limited to chil-dren.7 However, we detected them in both patients with alopecia (11.8%) and control subjects (11.1%) of any age.

Crust formation was reported in patients withFD.25 Similarly, we encountered it in a third of PCAs.

Follicular and interfollicular featuresEpidermal scale is detected in patients with alo-

pecia and healthy individuals.1 Similarly, almost half of our patients and control subjects displayed thisfeature.

Pustules were noted mostlyin PCAs in our study, inaccordance with the earlier investigations,2,25 whichidentified them as a characteristic feature of FD.

Dermatoscopic features observed in normal scalp

The current study revealed no significant differ-

ence between the patients and control subjects

Fig 2. Dermatoscopic features of scalp in androgenetic alopecia. A , Peripilar sign (arrowhead )and empty follicle (arrow ). B, Hair diameter diversity (arrow ). C, White dot (arrow ) andhoneycomb pigment pattern (asterisk ). D, Dirty dot (arrow ). E, Short vellus hairs (arrowhead ).(Original magnifications: A , B, C, and E, 330; D, 310.)




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regarding the frequency of circular hairs, dirty dots,crust formation, epidermal scale, and pustule. Mostof the findings, such as yellow dots and empty follicles, were observed significantly more fre-quently in the alopecia group than in the controlgroup. Several patterns such as tapering hairs andperipilar sign were not documented in normal scalp,and no specific dermatoscopic feature confined tohealthy scalp was identified.

In an earlier study,1

simple red loops, arborizingred lines, epidermal scale, and honeycomb pigmentpattern were elicited as the dermatoscopic featuresof the normal scalp. In another study 7 with 19healthy children, dirty dots, epidermal scale, and vascular features were reported as usual findings inthis age group. Rakowska9 documented yellow dots,perifollicular discoloration, pinpointlike vessels, andarborizing vessels on the scalp of healthy controlsubjects. All these investigations were performed by videodermatoscopy.

Dermatoscopic features observed in AGA Hair diameter diversity was documented in every

patient with AGA. It was accepted as an essentialbut not a specific finding of this alopecia because it was present in AA, CTE, and PCAs as well.Nevertheless, peripilar sign and empty follicles were indicative of AGA as they were confined tothis patient group. Our results are in line with therecent data.14

Dermatoscopic features observed in AA Our study revealed a higher prevalence of yellow

dots, black dots, and broken hairs in AA, as

Fig 3. Dermatoscopic features of scalp in primary cicatricial alopecia. A , Follicular hyperker-atosis (arrow ) and absence of follicular openings (# ). B, Tufted hairs (/) and pustule ([). C,

Epidermal scale (arrow ) and pink-white appearance (asterisk ). D, Red dots (circle ). E, Crustformation ([) and pili torti (/). ( A to E, Original magnifications: 330.)

Table IV. Dermatoscopic findings in patients withalopecia and control subjects

Dermatoscopic features

Patients,

n = 144

(%)

Control

subjects,

n = 144 (%)

P

value

Follicular features

Yellow dots 67 (46.5) 8 (5.6) \.001

Black dots 39 (27.1) 1 (0.7) \.001

Tapering hairs 23 (16.0) e \.001

Broken hairs 35 (24.3) e \

.001Short vellus hairs 71 (49.3) 7 (4.9) \.001

Circular hairs 3 (2.1) 1 (0.7) .314

Hair diameter diversity 79 (54.9) e \.001

Empty follicles 31 (21.5) 7 (4.9) \.001

Peripilar sign 36 (25.0) e \.001

Absence of follicular

openings

21 (14.6) e \.001

Tufted hairs 10 (6.9) e .001

White dots 20 (13.9) e \.001

Follicular hyperkeratosis 10 (6.9) e .001

Pili torti 12 (8.3) e .001

Trichorrhexis nodosa 11 (7.6) e .001

Interfollicular features

Red dots 32 (22.2) 19 (13.2) .045

Arborizing red lines 88 (61.1) 37 (25.7) \.001

Honeycomb pigment

pattern

37 (25.7) 10 (6.9) \.001

Pink-white appearance 20 (13.9) e \.001

Dirty dots 17 (11.8) 16 (11.1) .853

Crust formation 7 (4.9) e .07

Follicular and interfollicular features

Epidermal scale 66 (45.8) 66 (45.8) 1

Pustule 7 (4.9) 1 (0.7) .061




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compared with the other types of alopecias. Yellowdots were the most sensitive marker for diagnosis, whereas tapering hairs were found to be a diagnosticfeature for AA . Our findings confirmed the results of earlier studies1,5,10,14; however, in contrast to a recentreport,13 our study provided no evidence that short vellus hairs are among the most sensitive indicatorsof AA.

Dermatoscopic features observed in TEIn TE, dermatoscopy showed several findings

such as yellow dots and short vellus hairs.However, none constituted either sensitive or spe-cific clues for the diagnosis, as already mentioned by several reports.1,13 Nevertheless, we believe that by excluding AGA and AA incognito by the absence of their characteristic findings, dermatoscopy can still

help to establish the diagnosis of TE.

Dermatoscopic features observed in PCAsThe current study, the first to our knowledge to

investigate PCAs using a handheld dermatoscope,revealed that absence of follicular ostia was notedonly in PCAs with 100% prevalence. Therefore, inaccordance with the literature,1,5 we consider thisfinding pathognomonic of PCAs. Similarly, tuftedhairs, follicular hyperkeratosis, pili torti, and pink- white appearance were accepted as specific derma-toscopic patterns of PCAs. A potential limitation of

this study is the evaluation of the wholePCA group inthe same cluster, which resulted from the limitednumber of patients in each PCA subgroup.

Videodermatoscopy ensures rapid, high-resolution viewing up to 1000-fold magnification,and helps with easy storage and monitoring of theimages.30 However, it is not available in every dermatology clinic because of its high cost.Superior portability and cheaper price constitutethe advantages of a handheld dermatoscope, whichmakes it readily accessible to dermatologists.

In conclusion, our findings illustrate the value of a

polarized-light handheld dermatoscope in the clin-ical diagnosis of alopecias, with almost comparableresults to videodermatoscopy. It is only inadequatein the identification of interfollicular simple andtwisted red loops for which diagnostic value hasbeen limited to a few types of PCAs in the context of alopecias. Keeping in mind that some of the derma-toscopic findings can only be viewed by a minimumof 330 magnification, we suggest that a handhelddermatoscope attached to a digital camera is apractical and useful aid to improve the clinicaldiagnosis of alopecias.

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ESTUDIOS CIENTIFICO DE JOURNAL DERMATOLOGY ALOPECIA