Mariya Miteva

Hair and scalp dermatoscopy

Dermatoscopy is a noninvasive diagnostic tool that allows the recognition of morphologic structures not visible by the naked eye. Trichoscopy (scalp dermatoscopy and videodermatoscopy) is useful for the diagnosis and follow-up of hair and scalp disorders. However, it is not widely used in the management of hair disorders. This review provides updated information from the literature and our experience on the dermoscopic features of the most common hair and scalp disorders. This will enable dermatologists to make fast diagnoses of tinea capitis and alopecia areata, distinguish early androgenetic alopecia from telogen effluvium, and differentiate scarring from nonscarring alopecia.

Dermatoscopy of hair shaft disorders

Until a few years ago the diagnosis of hair shaft disorders was based on light microscopy or scanning electron microscopy on plucked or cut samples of hair. Dermatoscopy is a new fast, noninvasive, and cost-efficient technique for easy in-office diagnosis of all hair shaft abnormalities including conditions such as pili trianguli and canaliculi that are not recognizable by examining hair shafts under the light microscope. It can also be used to identify disease limited to the eyebrows or eyelashes. Dermatoscopy allows for fast examination of the entire scalp and is very helpful to identify the affected hair shafts when the disease is focal.

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.

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.

Permanent alopecia after systemic chemotherapy: A clinicopathological study of 10 cases

Anagen effluvium due to chemotherapy is usually reversible with complete hair regrowth. However, there is increased evidence that certain chemotherapy regimens can cause dose-dependent permanent alopecia. The histological features of this type of alopecia and the mechanisms of its origin are not known yet. We discuss the histological features of 10 cases of permanent alopecia after systematic chemotherapy with taxanes (docetaxel) for breast cancer (6 patients), busulfan for acute myelogenous leukemia (3 patients), and cisplatin and etoposide for lung cancer (1 patient). All patients had moderate to very severe hair thinning, which in 4 cases was more accentuated on androgen-dependent scalp regions. Patients complained that scalp hair did not grow longer than 10 cm and showed altered texture. Paired scalp biopsies from the affected scalp areas were obtained and evaluated in serial horizontal and vertical sections. The histology of all specimens was characterized by a nonscarring pattern with a preserved number of follicular units and lack of fibrosis. The hair count revealed decreased number of terminal hairs, increased telogen hairs, and increased miniaturized vellus-like hairs with a terminal to vellus and anagen to telogen ratios of 1:1 and 3.6:1, respectively. There was increased number of fibrous streamers (stelae) in both reticular dermis and subcutis. Arao-Perkins bodies were found in the subcutaneous portions of the streamers. The histological findings of permanent alopecia after chemotherapy are those of a nonscarring alopecia similar to androgenetic alopecia. Dermatopathologists should be aware of this condition as the absence of fibrosis and the presence of miniaturized hairs may be considered as features consistent with a diagnosis of androgenetic alopecia. Hence, these cases could easily be misdiagnosed in the absence of a good clinicopathological correlation.

Pseudoxanthoma elasticum–like papillary dermal elastolysis: A large case series with clinicopathological correlation

BACKGROUND Pseudoxanthoma elasticum (PXE)-like papillary dermal elastolysis (PDE) is a rare acquired elastic tissue disorder. To date, less than 20 cases have been reported. OBJECTIVE We report a case series of 17 patients presenting with PXE-like PDE and discuss the clinicopathological correlation. METHODS Seventeen cases of PXE-like PDE were collected prospectively and evaluated for common demographic, clinical, and histopathological features. RESULTS All patients were women with a mean age of 61.8 years. The lateral sides and back of neck were the most common sites of involvement (100%), followed by the supraclavicular region (41.2%) and the axilla (35.3%). Systemic involvement was absent in all cases, and in 7 patients the discovery of PXE-like PDE was an incidental finding. The main histopathologic features included complete loss (82.4%) or marked reduction (17.6%) of elastic fibers in the papillary dermis and the presence of melanophages in the same zone (88.2%). LIMITATIONS Our results require validation with a larger series. CONCLUSIONS Our findings help to differentiate PXE-like PDE from similar elastic tissue disorders based on the selective elastic tissue elimination in the papillary dermis and the presence of melanophages in the same zone as a possible consequence of subclinical junctional photodamage. PXE-like PDE is likely underdiagnosed rather than rare, and dermatologists should be aware of its similarity to inherited PXE to spare unnecessary investigations because of the lack of systemic involvement. Clinicopathologic correlation is critical as hematoxylin-eosin staining is nonspecific and elastic tissue stains are necessary to make the correct diagnosis.

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

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Treatment options for alopecia: an update, looking to the future

Introduction: Hair loss is a very common complaint. The diagnosis is based on clinical, dermoscopic and pathological examination. The treatment is usually continuous and requires strong compliance. Areas covered: This article aims to i) summarize current treatment options for the most common forms of hair loss; ii) update the literature on treatment options to emerge over the 3 years since the release of the first edition of this article in 2009; and iii) outline future strategies for treating alopecia. Expert opinion: There is good evidence-based information for the treatment of androgenetic alopecia. There are very few good-quality randomized studies, and no information about long-term results for most of the available treatments for alopecia areata and cicatricial alopecias. Significant research success has been achieved over the past few years through i) discovering the genetic profile of alopecia areata; ii) working on follicular neogenesis in androgenetic alopecia; and iii) discovering the PPAR-γ pathway in scarring alopecia.

Frontal fibrosing alopecia in black patients

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The follicular triad: a pathological clue to the diagnosis of early frontal fibrosing alopecia

MADAM, Frontal fibrosing alopecia (FFA) is a clinical variant of lichen planopilaris (LPP), which mostly affects postmenopausal women and frequently involves the eyebrows. It presents as a progressive symmetric band-like alopecia involving the frontal hairline, the preauricular and, less commonly, the retroauricular scalp. The partial or complete hair loss of the eyebrows without clinical inflammation is characteristic and occurs either before or after the onset of frontotemporal recession. The condition usually advances slowly (0Æ9 mm a month) and eventually stabilizes. There is current evidence that, in FFA, vellus or terminal hair follicles of the face, including the eyelashes, as well as extrafacial body sites may also be affected by hair loss. We recently reported that biopsies obtained from limb alopecia and scalp alopecia in FFA share the same histopathological features, i.e. a LPP pattern. This finding was confirmed by two recent publications. Clinical diagnosis of FFA is usually not difficult. Differential diagnosis includes the ophiasis variant of alopecia areata and marginal traction alopecia, particularly in African-American patients. Pathological diagnosis of FFA may be challenging in the early stages when the follicular density is almost normal or in the advanced stages when follicular scars are the only feature. Dermoscopy-guided biopsies can increase the diagnostic accuracy of hair disorders as the biopsy can be taken from a site of disease activity. We report here the pathology of dermoscopy-guided biopsies in early FFA (focal areas of alopecia on frontal hairline, Fig. 1a) taken from follicles showing peripilar casts (Fig. 1b). Dermoscopy-guided scalp biopsies of three cases of early FFA revealed a common pattern that can be a clue to the diagnosis of FFA: the follicular triad. The follicular triad describes the simultaneous involvement of follicles of different types: terminal, intermediate (0Æ03–0Æ06 mm) and vellus (< 0Æ03 mm) and in a different stage of cycling (anagen, catagen and telogen) (Fig. 2a). The follicular triad of FFA is better seen in horizontal sections as a lichenoid ⁄ interface lymphocytic infiltrate and perifollicular fibrosis affecting an anagen, a telogen and a vellus ⁄miniaturized follicle (Figs. 2b–d). The explanation for the concomitant involvement of hair follicles of different types and at different stages of cycling in FFA is unknown. A previous study showed increased apoptotic activity in the outer root sheaths in FFA compared with LPP. This may explain the increased number of telogen hairs as well as the persistence of the infiltrate around telogen follicles in the FFA biopsies. The reason for the more prevalent involvement of the intermediate ⁄vellus follicles in FFA is not clear, but may depend on the normal anatomy of the hairline that possibly contains more vellus and intermediate follicles. It has been suggested that FFA may selectively target androgen-dependent terminal follicles from the frontal scalp leading first to their miniaturization and then to their destruction. BJD British Journal of Dermatology