Volume 03 Issue 12-2023
39
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
12
P
AGES
:
39-43
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
ABSTRACT
We present 3 patients with hair thinning that is pronounced on the top of the head (Fig.1 a,b,c). Thinning of the vertex
region is characteristic of female-type androgenetic alopecia but is not diagnostic. Trichoscopy (dermoscopy of hair
and scalp) can provide important differential diagnostic information.
KEYWORDS
Trichoscopy, female-type androgenetic alopecia, Alopecia.
INTRODUCTION
Case #1
The 60-year-old patient clinically showed a pronounced
oval-shaped hair thinning in the area of the head with a
gap in the front hairline (Fig. 1a). The scalp, which was
clearly visible in this area, had an atrophic shiny
appearance with discrete perifollicular redness around
individual remaining hair shafts. In addition to the loss
of follicle openings, erythema with perifollicular
emphasis around residual hairs (Fig. 2a, white arrow)
and whitish areas (Fig. 2a, black arrow) were visible in
this area under reflected light microscopy.
Case #2
Clinically, the 29-year-old patient presented with an
oval, moderately pronounced hair thinning in the area
of the vertex and the adjacent scalp (Fig. 1b). In the
dermoscopic examination of the affected area, a clear
variability in the thickness of the hair shaft (Fig. 2b,
white arrows) and the predominance of follicular ostia
Research Article
DERMOSCOPY IN FEMALE ANDROGENETIC ALOPECIA
Submission Date:
December 11, 2023,
Accepted Date:
December 16, 2023,
Published Date:
December 21, 2023
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume03Issue12-08
Tashmatova N.B.
Research Institute Of Military Medicine Of The Military Medical Academy Of The Armed Forces Of The Republic
Of Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ijmscr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 03 Issue 12-2023
40
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
12
P
AGES
:
39-43
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
with only one emerging hair shaft (Fig. 2b, arrowheads)
were visible as a correlate for the clinically visible hair
thinning.
Case #3
The 26-year-old patient clinically showed diffuse hair
thinning with the greatest severity in the vertex area,
whereby the scalp was visible. Clinically, this showed
numerous follicular openings that appeared prominent
due to dilatation and occasionally had a comedo-like
appearance.
Dermoscopically, in addition to the rarefaction of the
hair shafts, short hairs, some of which tapered
proximally and had blunt ends (Fig. 2c, “exclamation
point hair”, black arrows), were also visible. Numerous
follicular openings of both hairless and hair-bearing
follicles were dilated and filled with a yellowish
material (Fig. 2c, “yellow dots”, white arrows).
DISCUSSION
Hair loss can be clinically diffuse, focal or in a so-called
pattern “Hair loss in a pattern” is typically found
in
androgenetic alopecia. Women most often show an
oval or triangular thinning of the vertex area with a
preserved frontal hairline (Ludwig and Olsen type); a
male pattern of loss is observed in individual cases
(Hamilton type) [1].
Rarely, other hair diseases can mimic the picture of
androgenetic alopecia, especially alopecia areata and
lichen planopilaris [2].
Case 1
Our first patient (Case 1; Figs. 1a and 2a) showed a
pattern of hair loss compatible with advanced
androgenetic alopecia of the Ludwig type, but the
changes in the scalp were already clinically suspicious
for a scarring process. The loss of follicle openings and
the presence of whitish fibrosed areas in reflected light
microscopy confirmed this suspicion. The perifollicular
erythema in the area of residual hair was suggestive of
lichen planopilaris (Table 1). The suspected diagnosis
was also confirmed histologically.
The so-
called “fibrosing alopecia in a pattern
distribution” represents a clinical variant of lichen
planopilaris that occurs in areas typical of androgenetic
alopecia.
Dermoscopic examination of the scalp is of great
importance for differentiating scarring and non-
scarring alopecias. The simultaneous loss of hair and
follicle openings is the main feature of primary
cicatricial alopecia. Further reflected light microscopic
findings help to differentiate the subentities; the
perifollicular emphasis of erythema, fibrosis and
scaling with a sometimes ruff-like appearance is typical
of lichen planopilaris [3]. However, because of the
common underlying inflammatory fibrosing process,
Volume 03 Issue 12-2023
41
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
12
P
AGES
:
39-43
SJIF
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MPACT
FACTOR
(2021:
5.
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)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
scarring alopecias may show overlapping reflected
light microscopic criteria.
Diagnosis case 1: Lichen planopilaris (“fibrosing
alopecia in a pattern distribution”)
With regard to therapeutic consequences, biopsy
confirmation of the diagnosis is recommended.
Case 2
In our second patient (case 2; Figs. 1b and 2b) there was
clinically hair thinning similar to the beginning of
androgenetic alopecia of the Ludwig type. The increase
in thin hairs and the decrease in follicular ostia with 2
or 3 hair shafts emerging together, which could be
detected under reflected light microscopy, reflected a
progressive miniaturization of the hair follicles in this
area and confirmed the suspected clinical diagnosis of
androgenetic alopecia (Table 1). Through the
morphological assessment of hair and scalp,
trichoscopy enables differentiated conclusions to be
drawn about the pathogenesis of hair loss diseases and
thus facilitates differential diagnostic considerations.
Fig.1a,b,c Three patients with hair thinning on the top of the head as in female-type androgenetic alopecia.
Volume 03 Issue 12-2023
42
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
12
P
AGES
:
39-43
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
Fig.2 Dermoscopic images of the patients shown in Fig.
1.a - loss of follicular openings with the presence of
whitish fibrosed areas (black arrow) and characteristic
perifollicular erythema (white arrow). b - variability of
the hair shaft thickness due to the presence of normal
terminal hairs, intermediate and thin hairs (white
arrows) as well as an increase in vellus hairs and
follicular ostia with the emergence of individual hairs
(arrowheads). c - short hair, partly tapering towards
the scalp, with blunt ends (black arrows, “exclamation
point hair”) and clearly visible follicular ostia filled with
yellowish material (white arrows, “yellow dots”)
Hair changes in androgenetic alopecia are caused by
the genetically varying degrees of sensitivity of
individual follicles to androgens [4]. Under the
influence of hormones, the affected hair follicles shrink
or even lose. Depending on the hormone status and
metabolism of sex hormones in hair and skin, affected
different areas of the scalp. The occipital region usually
shows little or no changes.
Diagnosis Case 2: Androgenetic alopecia (Ludwig type)
The topographically varying severity of dermoscopic
changes of central diagnostic importance and enables
the recognition of early forms without a clinically
pronounced pattern of failure.
The examination using a hand dermatoscope is a
method for diagnosing androgenetic alopecia that is at
least equivalent to the trichogram and is also time-
saving and painless. Most videodermatoscopes use
special computer programs to carry out a digital
trichogram, which, in addition to determining the
anagen/telogen ratio, also allows the vellus/terminal
hair ratio as well as the hair density and thickness to be
measured. The possibility of digital storage is of great
advantage for monitoring progress and objectively
evaluating the success of therapy.
Table 1. Characteristic reflected light microscopic findings of the patients shown
Fall 1: Lichen planopilaris
Fall 2: Androgenetic alopecia
Fall 3: Alopecia areata incognita
Loss of follicle openings
Variability of hair shaft thickness
(increase in thin and vellus hairs)
Dystrophic hair shafts: short hairs
that partly taper proximally and
have blunt ends
Volume 03 Issue 12-2023
43
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
12
P
AGES
:
39-43
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
Perifollicular erythema
Increase in follicular ostia with only
one emerging hair shaft
Numerous “yellow dots”
Whitish areas
*in androgen-dependent areas
Case 3
The patient clinically showed an emphasis on the
vertex region that is characteristic of androgenetic
alopecia of the female type. The severe degree of hair
loss was mainly as unusual given the patient's age, as
were the dilated follicle openings in the severely
affected area. The presence of numerous “yellow
dots” and characteris
tic dystrophic hair shafts in
reflected light microscopy led us to the diagnosis of
alopecia areata incognita (Table 1).
Diagnosis Case 3: Alopecia areata incognita (Alopecia
areata diffusa)
Clinically, alopecia areata incognita often shows a hair
loss pattern similar to androgenetic alopecia. In the
case of hair loss caused by inflammation, disease
activity can often be determined using a reflected light
microscope. Alopecia areata shows a disorder of hair
growth in active stages due to the inflammatory
infiltration of the bulb region. There are typically
broken hairs, hairs that taper towards the scalp and so-
called hairs that are cadaverized at the scalp level
(“black dots”) [5]. The accumulation of unpigmented
hair residues and sebum leads to dilatation and
yellowish coloration of follicle openings. The
appearance of short, regrowing hair can be seen as a
prognostically favorable sign.
REFERENCES
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Assouly P, Reygagne P (2009) Lichen planopilaris:
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10
2.
Rakowska A, Slowinska M, Kowalska-Oledzka E,
Olszewska M, Rudnicka L (2009) Dermoscopy in
female
androgenic
alopecia:
method
standardization and diagnostic criteria. Int J
Trichology 1(2):123
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130
3.
Tosti A, Whiting D, Iorizzo M, Pazzaglia M, Misciali
C, Vincenzi C, Micali G (2008) The role of scalp
dermoscopy in the diagnosis of alopecia areata
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