Fernanda Torres

Hair casts are a dermoscopic clue for the diagnosis of traction alopecia.

FCAS was infiltrated with IL-17-positive cells, which appeared to be neutrophils. This is the first report of IL-17 expression in an urticarial lesion of a patient with FCAS. In conclusion, we hypothesize that the urticarial rash in FCAS is induced by IL-1b as a result of NLRP3 activation; IL-1b activates Th17 cells leading to IL-17-associated neutrophil recruitment into the dermis. In addition, the neutrophil infiltrate might secrete more IL-17, and cause further inflammation. The blockage of IL-1b by anakinra provides therapeutic benefit for patients with CAPS; however, long-term benefit and safety data are needed. We speculate that IL-17 might be a potential therapeutic target.

Pistas dermatoscópicas para diferenciar a tricotilomania da alopecia areata em placa

BACKGROUND Trichotillomania and patchy alopecia areata have similar clinical and dermoscopic features. OBSERVATIONS In trichotillomania, dermoscopy shows decreased hair density, short vellus hair, broken hairs with different shaft lengths, coiled hairs, short vellus hair, trichoptilosis, sparse yellow dots, which may or may not contain black dots and no exclamation mark hairs. CONCLUSIONS In the case of patchy alopecia and broken hairs, the absence of exclamation mark hairs suggests a diagnosis of trichotillomania. On the other hand, the finding of yellow dots without black dots does not exclude it.

Lonely Hair: A Clue to the Diagnosis of Frontal Fibrosing Alopecia

F RONTAL FIBROSING ALOPECIA (FFA) IS A VARIant of lichen planopilaris that mostly affects postmenopausal women and is characterized by progressive bandlike scarring alopecia involving the frontal hairline and the eyebrows. A 45-year-old white woman presented with a 2-year history of progressive hair loss. Clinical examination revealed a band of alopecia with regression of the frontal hairline. A few single terminal hairs were present in the midfrontal area (Figure1). Her eyebrows were sparse, and she had no hair on her upper and lower limbs. The diagnosis of FFA was confirmed by the findings of pathologic examination (Figure 1, inset), which showed a lichenoid infiltrate at the level of the upper follicle. The infiltrate was seen within the outer root sheaths surrounded by layers of perifollicular fibrosis. There were a few apoptotic keratinocytes in the outer root sheaths and a prominent cleft between the follicular epithelium and the stroma. The presence of isolated terminal hairs in the middle of the forehead, at site of the original hairline, is a clinical clue to the diagnosis of FFA. A retrospective review of pictures of biopsy-proved FFA showed that the isolated hairs were present in 30 of 39 patients (Figure 2) and (Figure 3). The solitary hairs are 3 to 7 cm long and may or may not be accompanied by perifollicular erythema and scaling. They may be localized in the central or lateral aspect of the forehead. This distinctive clue is useful in the clinical differential diagnosis of FFA, which includes traction alopecia, alopecia areata, and androgenetic alopecia, and it can improve the ability of dermatologists to diagnose FFA in their daily practice.

Frontal fibrosing alopecia occurring on scalp vitiligo: report of four cases.

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Management of contact dermatitis due to nickel allergy: an update

Nickel is the major cause of allergic contact dermatitis in the general population, both among children and adults, as well as in large occupational groups. This metal is used in numerous industrial and consumer products, including stainless steel, magnets, metal plating, coinage, and special alloys, and is therefore almost impossible to completely avoid in daily life. Nickel contact dermatitis can represent an important morbidity, particularly in patients with chronic hand eczema, which can lead to inability to work, a decrease in quality of life and significant healthcare expenses. Therefore, its management is of great importance. This article reviews diagnostic, preventive and therapeutic strategies in this field.

Dermoscopy features for the diagnosis of furuncular myiasis

We describe a 56-year-old Brazilian woman presenting three nodular lesions on the scalp. Dermoscopy of all lesions showed a creamy-white body with central birds feet-like structures surrounded by a thorn crown, corresponding to the posterior segment of the Dermatobia hominis larvae. These novel dermoscopic features allowed us to easily diagnose furuncular myiasis.

Trichoscopy as a clue to the diagnosis of scalp sarcoidosis

Background  Sarcoidosis is an idiopathic systemic granulomatous disease, in which non‐caseating granulomas formations can occur in any organ. Although rare, involvement of the scalp can occur, which might lead to cicatricial alopecia. Dermoscopic features of scalp sarcoidosis had not been reported.

Female pattern alopecia and telogen effluvium: figuring out diffuse alopecia.

Diffuse hair loss in women causes a significant impact on quality of life, reduces self-esteem, and increases stress. One of the major challenges when evaluating patients with diffuse hair loss is to determine whether you are dealing with either female pattern alopecia, telogen effluvium, or both, as they can coexist. Establishing the correct diagnosis is mandatory for optimal patient care. This article will highlight how to distinguish between and properly manage these 2 conditions.

The 'eyes' or 'goggles' as a clue to the histopathological diagnosis of primary lymphocytic cicatricial alopecia.

MADAM, Hair pathology is an essential tool in distinguishing cicatricial from noncicatricial alopecia and in diagnosing the different cicatricial disorders. Horizontal sections are very important as they allow for visualization of all hair follicles in a 4-mm punch biopsy and for detection of focal disease. However, dermatopathologists who are not specifically trained are generally reluctant to evaluate horizontal sections due to the complexity of scalp anatomy and the necessity to evaluate multiple sections. We present here a new simple method to diagnose lymphocytic cicatricial alopecia at low-power horizontal sections at the isthmus level. This method is based on detection of easy to memorize images that correspond to diagnostic clues. One of us (M.M.) proposed the ‘eyes’ and ‘goggles’ (Fig. 1a, b) as corresponding to two relevant histopathological clues for lymphocytic cicatricial alopecia after 2 years of examining horizontal scalp specimens. The eyes or goggles pattern is characterized by the presence of either ‘eyes’ or ‘goggles’ on a background of decreased follicular density with follicular scars (fibrous tracts replacing the pilosebaceous units). It is due to the grouping of two follicles in compound structures: the eyes resemble the eyes of an owl with big circles of feathers around the eyes; the goggles resemble aviator’s or swimmer’s eyewear (Fig. 2a, b). The histopathological clues and their associated images were agreed among the authors and validated with 23 physicians: one dermatopathologist, six dermatology residents and 16 pathology residents who were asked to identify the eyes or goggles among 20 low-power horizontal sections at the isthmus level (10 cases of scarring and 10 cases of nonscarring alopecia). The participants had < 30 s per slide to decide for scarring or nonscarring alopecia based on the presence or absence of the eyes or goggles. We collected 440 answers and in 437 of them (99Æ3%) the presence or absence of the eyes or goggles sign was detected correctly. To verify the frequency of the eyes or goggles sign in biopsies of primary lymphocytic cicatricial alopecia we reviewed retrospectively 25 horizontal specimens [13 cases of lichen planopilaris (LPP) including nine cases of frontal fibrosing alopecia (FFA) and 12 cases of central centrifugal cicatricial alopecia (CCCA)] collected at our department between July 2010 and February 2011. Twenty-five horizontal specimens of nonscarring alopecias served as controls. All specimens were examined in a blinded way at the isthmus level. The sign was detected in 11 of 12 (92%) cases of CCCA and in 11 of 13 (85%) cases of LPP. The three cases in which it was not observed showed advanced scarring alopecia. The eyes or goggles sign was absent in all controls. Clues that facilitate rapid pathological diagnosis of cicatricial alopecias are needed. A recent paper suggested the number of hair shafts observed within a compound follicle as a clue to distinguish between lymphocytic and neutrophilic primary cicatricial alopecia. We suggest the eyes or goggles pattern as a reliable clue for rapid recognition of LPP ⁄FFA and CCCA at low power. We did not evaluate neutrophilic cicatricial alopecias and other causes of lymphocytic cicatricial alopecia such as discoid lupus erythematosus (DLE) due to an insufficient number of horizontal specimens. However, we were able to see the sign in books and articles on hair pathology in cases of DLE, acne keloidalis and late phase of folliculitis decalvans. Owl eye-like structures are seen when the fusion occurs between the connective tissue sheaths of the follicles. The hair shaft with its inner root sheath (if present) looks like the eye (pupil and iris), and the outer root sheath looks like the big concentric circle of feathers around each owl’s eye. The size of one ‘eye’ may be larger than the other depending on the follicular size. Goggle-like structures are strongly reminiscent of the goggles used by aviators and swimmers and occur when the fusion is between the outer root sheaths of the follicles. The histopathological differentiation between LPP and CCCA is many times impossible; however, in our experience the goggles are typical of CCCA. The premature desquamation of the inner root sheath, often considered a clue to the diagnosis of CCCA, is well represented in the goggles: the fused follicles often lack their inner root sheaths and therefore resemble goggles more than eyes because they lack ‘irises’ and ‘pupils’.

Hair Shaft Disorders

Hair shaft disorders can be congenital or acquired, which can be caused by trauma. Congenital hair defects are usually present at birth or they become evident in the first months of life. Patients can present with localized or diffuse alopecia, and some hair shaft defects can also simulate hair loss and should be considered in patients with abnormal hair growth. Many of these conditions show peculiar dermatoscopic findings, which will be described in this chapter.