Alopecia Areata in Skin of Color: Trichoscopic Analysis in Black/African American Patients

July 2025 | Volume 24 | Issue 7 | 708 | Copyright © July 2025


Published online June 26, 2025

Josephine Pyles BSa, Victoria Palmer MD MScb, Emily Balding BSb, Jorge Larrondo MDc, Amy McMichael MDb

aIndiana University School of Medicine, Indianapolis, IN
bDepartment of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC
cDepartment of Dermatology, Clinica Alemana, Vitacura, Chile

Abstract
Importance: Alopecia areata (AA) has a higher prevalence in populations with skin of color, yet the trichoscopic features in this population remain underexplored.
Objective: To identify trichoscopic findings present in a cohort of Black patients with a diagnosis of alopecia areata.
Evidence Review: The electronic medical records system was used to retrospectively analyze the trichoscopic images and medical records of 10 Black patients with a clinical diagnosis of AA who were seen and treated at an academic hair loss clinic between 2019 and 2024. Clinical and trichoscopic images of the scalp were reviewed independently by two board-certified dermatologists. Statistical analysis using the Mann-Whitney U Test highlighted significant trends in the occurrence of these features across varying severity levels as per the Severity of Alopecia Tool (SALT) scores.
Findings: Commonly reported features such as vellus hairs, black dots, and tapering hairs, alongside novel features including peripilar hyperpigmentation, follicular hypopigmentation, diffuse erythema, uninterrupted honeycomb patterns, and perifollicular scale were observed. No statistical significance was noted between the presence of trichoscopic features and the correlated SALT score.
Conclusions and Relevance: This study underscores the need for improved understanding and documentation of AA in Black individuals. Identification of trichoscopic features in AA will aid physicians with diagnosis and decrease the threshold for diagnosis of co-existing alopecias.

INTRODUCTION

Alopecia areata (AA) is a chronic autoimmune disease that results in non-scarring, patchy hair loss on the scalp and other parts of the body.1 It affects individuals of all races; however, recent evidence suggests there is a higher prevalence in people with skin of color.2 Despite this prevalence, trichoscopic features of AA in skin of color remain underexplored,3 especially amongst cases of Black patients.4 Although there is one case series examining trichoscopic features of AA in 116 Indian patients,2 there are only two published cases of AA in the literature that include trichoscopy images of Black/African American patients.3,4 Both of these cases demonstrate normal findings of a diffuse honeycomb-pigmented network with pinpoint white dots. Considering the lack of consistent documentation of AA cases in Black patients, the variability in trichoscopic presentations makes it challenging to clinically differentiate AA from other types of alopecias.6 Thus, we analyze and document the trichoscopic features of AA in Black/African American patients to better characterize its presentation in this population.

MATERIALS AND METHODS

We retrospectively analyzed the clinical images, trichoscopic images, and medical records of 10 Black patients with a clinical diagnosis of AA who were treated at an academic hair loss clinic between 2019 and 2024. Trichoscopic features were categorized as either commonly reported features of AA (vellus hairs, black dots, tapering hairs, yellow dots) or novel features--those not typically seen in AA. The Mann-Whitney U Test was used to determine statistical significance. Baseline Severity of Alopecia Tool (SALT) scores were calculated using clinical images of the scalp.

RESULTS

Distribution of Common and Novel Trichoscopic Features:
Vellus hairs were present in all patients. Black dots and tapering hairs were also observed, appearing in 5 (50%) and 4 (40%) patients, respectively. No yellow dots were observed in this group (Figure 1).
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