Trichoscopy of Cicatricial Alopecia

June 2012 | Volume 11 | Issue 6 | Original Article | 753 | Copyright © June 2012

Adriana Rakowska MD PhD,a Monika Slowinska MD PhD,a Elzbieta Kowalska-Oledzka MD PhD,aOlga Warszawik MD,a Joanna Czuwara MD PhD,a Malgorzata Olszewska MD PhD,a and Lidia Rudnicka MD PhDa,b

aDepartment of Dermatology, Clinical Hospital of Ministry of Internal Affairs,Warsaw, PolandbFaculty of Health Sciences, Medical University of Warsaw, Warsaw, Poland

Abstract
Background: Trichoscopy is widely used in differential diagnosis of non-cicatricial alopecia.
Objective: The aim of this prospective study was to identify possible characteristic trichoscopy patterns of diseases leading to primary cicatricial alopecia.
Methods: Trichoscopy was performed in a total of 1,884 consecutive patients presenting with hair loss. In this group, 84 patients were diagnosed with cicatricial alopecia and 1,800 patients with non-cicatricial alopecia. Sixty healthy persons served as healthy controls. Trichoscopy was performed with the use of Fotofinder II videodermoscopy system. Following unique or characteristic features were identified: scattered dark-brown discoloration of the skin, large yellow dots and thick arborizing vessels in cutaneous (discoid) lupus erythematosus (n=20), tubular perifollicular scaling and elongated blood vessels in lichen planopilaris (n=28), minor perifollicular scaling in frontal fibrosing alopecia (n=19), tufted hairs with starburst pattern perifollicular hyperplasia in folliculitis decalvans (n=9) and large, "3D" yellow dots imposed over dystrophic hairs in dissecting cellulitis (n=8).
Results: All patients with cicatricial alopecia trichoscopy showed white and milky-red areas lacking follicular openings. These features were not found in patients with non-cicatricial alopecia or healthy controls.
Conclusion: These results indicate that trichoscopy may be applied as a quick and non-invasive auxiliary method in differential diagnosis of diverse diseases leading to cicatricial alopecia, such as cutaneous lupus erythematosus, classic lichen planopilaris, frontal fibrosing alopecia, folliculitis decalvans, and dissecting cellulitis.

J Drugs Dermatol. 2012;11(6):753-758

INTRODUCTION

The term “primary cicatricial alopecia” refers to a diverse group of disorders having as a common final pathway the destruction of the hair follicle unit.1 According to the North American Hair Society working classification of cicatricial alopecia, primary cicatricial alopecia may be divided into: lymphocytic [lichen planopilaris (LPP), Graham Little syndrome, frontal fibrosing alopecia (FFA), pseudopelade Brocq, central centrifugal cicatricial alopecia, chronic cutaneous lupus erythematosus (discoid lupus erythematosus, DLE), keratosis follicularis spinulosa decalvans], and neutrophilic [folliculitis decalvans (FD), tufted folliculitis] and mixed [dissecting cellulitis (DC), folliculitis keloidalis] and end-stage nonspecific group.2,3
Trichoscopy (hair and scalp dermoscopy) is a newly developed method of hair imaging and analysis, based on dermoscopy or videodermoscopy of hair and scalp.4,5 The method allows visualization of hair shafts at high magnification without the need of removing hair for diagnostic purposes and in vivo analysis of the epidermal portion of hair follicles and perifollicular epidermis.5 Several reports raise the issue of potential usefulness of this technique in diagnosing hair and scalp disorders, such as androgenic alopecia,6-8 alopecia areata,9-12 tinea capitis,13-15 inherited hair shaft abnormalities,16-22 and other hair and scalp diseases.23-25
The aim of the study was to establish usefulness of trichoscopy in diagnosing primary scarring alopecia and to analyze trichoscopy features of different diseases leading to primary cicatricial alopecia.

MATERIALS AND METHODS

Trichoscopy (hair and scalp dermoscopy) was performed in 1,884 consecutive adult patients who visited the Hair Clinic at Department of Dermatology, CSK MSWiA in Warsaw, Poland. All patients were Caucasian. In this group, 4.4% (84 of 1,884) of patients were diagnosed with primary cicatricial alopecia (20—DLE, 28—LPP, 19—FFA 8—DC and 9—FD). A proportion of 18 out of 20 (90%), 22 of 28 (78%), 19 of 19 (100%), 0 of 8 (0%) and 0 of 9 (0%) of patients, respectively, were females. In all cases, the diagnosis was based on anamnesis, clinical presentation, and histopathological examination of biopsies taken from the edge of the lesion. In all patients with DLE, direct immunofluorescence of lesional skin was positive. The control group consisted of 1,800 patients with various forms of non-cicatricial alopecia, including androgenic alopecia, telogen effluvium, and alopecia areata. Sixty healthy subjects served as an additional control group.
In patients with DLE, 15 active lesions and 17 inactive lesions were examined by trichoscopy and evaluated separately. Active lesions were defined as lesions that developed or enlarged within 3 months preceding trichoscopy examination.
Trichoscopy was performed with Fotofinder II videodermoscope. Images of the scalp were taken at a 20-fold magnification, which allows high quality enlargement of 1 cm2 of scalp area to the size of a computer screen and at a 70-fold magnification, which magnifies in a similar manner an area of 9 mm.2 In each case the examination was performed with immersion fluid (70% ethanol) and without