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Trichoscopy of Cicatricial Alopecia
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June 2012 753 Volume 11 • Issue 6

Copyright © 2012 ORIGINAL ARTICLES Journal of Drugs in Dermatology
SPECIAL TOPIC
Trichoscopy of Cicatricial Alopecia
Adriana Rakowska MD PhD,a Monika Slowinska MD PhD,a Elzbieta Kowalska-Oledzka MD PhD,a
Olga Warszawik MD,a Joanna Czuwara MD PhD,a Malgorzata Olszewska MD PhD,a and Lidia Rudnicka MD PhDa,b
a
Department of Dermatology, Clinical Hospital of Ministry of Internal Affairs,Warsaw, Poland
b
Faculty 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 diag-
nosed 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 MATERIALS AND METHODS
T
he term “primary cicatricial alopecia” refers to a diverse Trichoscopy (hair and scalp dermoscopy) was performed in 1,884
group of disorders having as a common final pathway consecutive adult patients who visited the Hair Clinic at Depart-
the destruction of the hair follicle unit.1 According to the ment of Dermatology, CSK MSWiA in Warsaw, Poland. All patients
North American Hair Society working classification of cicatri- were Caucasian. In this group, 4.4% (84 of 1,884) of patients were
Do Not Copy
cial alopecia, primary cicatricial alopecia may be divided into:
lymphocytic [lichen planopilaris (LPP), Graham Little syndrome,
frontal fibrosing alopecia (FFA), pseudopelade Brocq, central
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,
Penalties Apply
centrifugal cicatricial alopecia, chronic cutaneous lupus erythe- respectively, were females. In all cases, the diagnosis was based
matosus (discoid lupus erythematosus, DLE), keratosis follicu- on anamnesis, clinical presentation, and histopathological exami-
laris spinulosa decalvans], and neutrophilic [folliculitis decalvans nation of biopsies taken from the edge of the lesion. In all patients
(FD), tufted folliculitis] and mixed [dissecting cellulitis (DC), fol- with DLE, direct immunofluorescence of lesional skin was posi-
liculitis keloidalis] and end-stage nonspecific group.2,3 tive. The control group consisted of 1,800 patients with various
forms of non-cicatricial alopecia, including androgenic alopecia,
Trichoscopy (hair and scalp dermoscopy) is a newly developed telogen effluvium, and alopecia areata. Sixty healthy subjects
method of hair imaging and analysis, based on dermoscopy or served as an additional control group.
videodermoscopy of hair and scalp.4,5 The method allows visual-
ization of hair shafts at high magnification without the need of In patients with DLE, 15 active lesions and 17 inactive lesions
removing hair for diagnostic purposes and in vivo analysis of the were examined by trichoscopy and evaluated separately. Active
epidermal portion of hair follicles and perifollicular epidermis.5 lesions were defined as lesions that developed or enlarged within
Several reports raise the issue of potential usefulness of this tech- 3 months preceding trichoscopy examination.
nique in diagnosing hair and scalp disorders, such as androgenic
alopecia,6-8 alopecia areata,9-12 tinea capitis,13-15 inherited hair shaft Trichoscopy was performed with Fotofinder II videodermoscope.
abnormalities,16-22 and other hair and scalp diseases.23-25 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
The aim of the study was to establish usefulness of trichoscopy in a computer screen and at a 70-fold magnification, which magnifies
diagnosing primary scarring alopecia and to analyze trichoscopy in a similar manner an area of 9 mm.2 In each case the examination
features of different diseases leading to primary cicatricial alopecia. was performed with immersion fluid (70% ethanol) and without
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754
Journal of Drugs in Dermatology A. Rakowska, M. Slowinska, E. Kowalska-Oledzka, et al.
June 2012 • Volume 11 • Issue 6
immersion fluid (dry trichoscopy). A total number of 20 images FIGURE 1. Characteristic trichoscopy features of discoid lupus erythe-
were taken from each cicatricial alopecia lesion and its periphery. matosus: thick arborizing vessels (a), large yellow dots (b), and scattered
In the control group of patients with non-cicatricial alopecia, one brown discoloration of the skin (c). Magnification: 70x (a,b) and 20x (c)
image at 20-fold magnification and 4 images at 70-fold magnifica-
a) b) c)
tion were taken each of following four areas: frontal, occipital, right
temporal, and left temporal according to the method described by
Rakowska.25 Trichoscopy features in these images (type of vessels,
the appearance of skin surface, follicular openings and number of
hair shafts emerging from one perifollicular unit) were evaluated by
three independent examiners. The final results were the effect of a
consensus meeting. In patients with cicatricial alopecia 1 to 2 diag-
nostic punch biopsies were taken from areas previously evaluated
by trichoscopy and histology evaluation was performed. Statistical
analysis was performed with the use of BioStat 2008 5.1.4 software.
FIGURE 2. Characteristic trichoscopy features of lichen planopilaris:
The study was approved by the CSK MSWiA Ethical Committee. tubular perifollicular scaling (a), elongated vascular loops (b), and “clas-
sic” white dots with a tendency to merge into white fibrotic areas (c).
RESULTS Magnification: 70x
The following trichoscopy features were observed in discoid
a) b) c)
lupus erythematosus (Figure 1), lichen planopilaris (Figure 2),
folliculitis decalvans (Figure 3), dissecting cellulitis (Figure 4),
and frontal fibrosing alopecia (Figure 5):
Blood vessels
Three different types of vessels were seen in patients with cica-
tricial alopecia. Large, arborizing vessels (Figure 1A) were found
in all patients with DLE and in two patients with LPP. They re-
assembled arborizing vessels observed in dermoscopy of basal
cell carcinoma, but appeared slightly thicker and more irregular. FIGURE 3. Characteristic trichoscopy features of folliculitis decalvans:
This vascular pattern was not seen in trichoscopy of FD and DC starburst pattern epidermal hyperplasia (a), follicular pustule with emerg-
or in patients in the control groups. The average thickness of the ing hair shafts (b), and tubular perifollicular scaling and hair tufts (c)
Do Not Copy
widest vessel in one lesion was 114 mm + 28 mm (mean +/- SD)
and was significantly wider than arborizing vessels seen in nor-
mal scalp, or seborrheic dermatitis (36 +/- 17, P<0.05).
a) b) c)
Penalties Apply
Elongated vascular loops (Figure 2B), were observed in 15 of 28
(53.6%) patients with LPP. These vessels were located in close
proximity to hair shaft openings. They were not seen in other
types of cicatricial alopecia nor in control groups and they were
not associated with any specific histopathology finding.
A total of 6 out of 8 (75%) patients with DC had pinpoint vessels FIGURE 4. Characteristic trichoscopy features of dissecting folliculitis:
with whitish halo (Figure 4A). This finding was characteristic, but large “3D” yellow dots imposed over dystrophic hairs (“soap bubble”
not specific for DC. Pinpoint vessels with whitish halo were ob- structures) and pinpoint vessels with whitish halo (a), yellow, structure-
served in 2 of 9 (22.2%) patients with folliculitis decalvans and less areas adjacent to empty follicular openings (b), and black dots (c).
Magnification: 70x (a, b) and 20x (c)
in less than 1% of patients with non-cicatricial alopecia. Detailed
results are presented in Table 1. a) b) c)
Skin surface appearance

White and milky-red areas lacking follicular openings were seen
in all types of primary cicatricial alopecia, except DC. White and
milky-red areas were present in 8 of 20 (40.0%) patients with
DLE, 23 of 28 (82.1%) patients with LPP, 19 of 19 (100%) patients
with FFA, and 8 of 9 (88.8%) patients with FD.
755
TABLE 1.
FIGURE 5. Characteristic trichoscopy features of frontal fibrosing
alopecia: mild perifollicular scaling, seen best in dry trichoscopy (without Blood Vessels in Trichoscopy of Cicatricial Alopecia
immersion fluid). Magnification: 20x P-value
DLE LPP FFA DC FD (statistical
(n=20) (n=28) (n=19) (n=8) (n=9) significance)
Thick
arborizing 18 2
0 0 0 P<0.05
vessels. (90.0%) (7.1%)
No (%)
Elongated
blood 15
0 0 0 0 P<0.05
vessels. (53.6%)
No (%)
Pinpoint-
like vessels
with 6 2
0 0 0 NS
whitish (75.0%) (22.2%)
halo.
No (%)
DLE = discoid lupus erythematosus; LPP = lichen planopilaris; FFA = frontal
fibrosing alopecia; DC = dissecting cellulitis; FD = folliculitis decalvans; NS
= not statistically significant
Brown scattered discoloration of the skin (Figure 1C) was ob- Thin arborizing vessels emerging from large yellow dots were
served in DLE (9 of 20 patients, 45.0%) and was not seen in observed in patients with DLE and no patient in any other group.
any other disease. This trichoscopy feature corresponded to
incontinence of pigment with concomitant atrophy seen in his- Large yellow dots (Figure 1B) were observed only in DLE lesions.
topathology. Pigment incontinence with epidermal acanthosis These large yellow dots had a mean diameter of 653 mm +/- 125
appeared as bluish-gray, bluntly demarcated areas, which were mm (mean +/- SD) and were significantly (P<0.05) bigger compared
most common in LPP. to yellow dots observed in alopecia areata (212 mm +/- 66 mm) or
female androgenic alopecia (190 mm +/- 71mm). They correspond-
Structureless yellow areas (Figure 4B) were seen in all patients ed to follicular plugging and hyperkeratosis in histopathology.
with DC and corresponded to dense, predominantly neutrophilic
dermal infiltrates in histopathology. Detailed results are present- Hyperplasia forming a starburst pattern around the hair follicle
ed in Table 2.
Follicular openings
Do Not Copy opening (Figure 3A) was found only in patients with FD. This
corresponded in histopathology to hyperkeratosis, with para-
keratosis, overlying a hyperplastic epidermis.
Penalties Apply
Perifollicular scaling was seen in all patients with LPP and 6 of 9
(66.6%) patients with FD. In LPP perifollicular scaling formed a White dots (Figure 2C) were found most commonly in patients
silver-white tubular structure around the emerging hair shafts, with LPP, but were a rather rare and non-specific finding. They
reaching usually about 1 mm to 3 mm above scalp surface (Fig- differed from pinpoint white dots observed commonly in pa-
ure 2A). In one patient the tubular scaly structures surrounding tients with dark skin phototypes by a bigger size, blunt boarders
the hair shaft reached up to 3 cm above scalp surface. This fea- and tendency to become confluent.
ture could be better appreciated by dry trichoscopy, as compared
to trichoscopy with immersion fluid. Perifollicular scaling seen in Follicular red dots were found in only one patient with DLE, but a
trichoscopy of LPP corresponded to perifollicular hyperkeratosis similarly appearing structure was common in the eyebrow area
and vacuolar changes with presence of necrotic keratinocytes of patients with FFA. Detailed results are presented in Table 3.
in the basal layer of the outer hair follicle root sheath. Tubular
perifollicular scaling in FD (Figure 3C) differed by a yellowish Black dots (Figure 4C) were observed in two patients with DC, and
hue, which was absent in LPP. Mild perifollicular scaling with no in no other patient with cicatricial alopecia. In the non-scarring con-
tendency to form tubular structures around hair shafts was ob- trol group black dots were a common finding in alopecia areata and
served in FFA (Figure 5). in trichotillomania. They were not observed in healthy individuals.
Large 3D yellow dots with dystrophic hair inside (Figure 4A) Large follicular pustules with an emerging hair shaft (Figure 3B)
were found to be specific for DC. These structures were not seen were a hallmark of folliculitis decalvans. This feature was present
in cicatricial alopecia of other origin, non-cicatricial alopecia or in all patients with FD and in two patients (0.1%) in the control
healthy individuals. group with non-cicatricial alopecia.
756
TABLE 2.
Skin Surface in Trichoscopy of Cicatricial Alopecia
DLE LPP FFA DC FD P-value
(n=20) (n=28) (n=19) (n=8) (n=9) (statistical significance)
White and milky-red homogenous areas. No (%) 8 (40.0%) 23 (82.1%) 19 (100.0%) 0 8 (88.8%) NS
Dark-brown scattered discoloration. No(%) 9 (45.0%) 0 0 0 0 P<0.05
Bluish deep discoloration. No (%) 3 (15.0%) 15 (53.5%) 0 0 0 P<0.05
Structureless yellow areas. No(%) 0 0 0 8 (100%) 0 P<0.05
Pinpoint-like vessels with whitish halo. No (%) 0 0 0 6 (75.0%) 2 (22.2%) NS
DLE = discoid lupus erythematosus; LPP = lichen planopilaris; FFA = frontal fibrosing alopecia; DC = dissecting cellulitis; FD = folliculitis decalvans; NS =
not statistically significant
TABLE 3.
Follicular Openings in Trichoscopy of Cicatricial Alopecia
DLE LPP FFA DC FD P-value
(n=20) (n=28) (n=19) (n=8) (n=9) (statistical significance)
Perifollicular scaling. No (%) 0 28 (100.%) 15 (78.9%) 0 6 (66.0%) NS
Perifollicular hyperplasia with starburst pattern. No(%) 0 0 0 0 6 (66.7%) P<0.05
Yellow dots with 3D structure and dystrophic hair
0 0 0 8 (100%) 0 P<0.05
inside. No(%)
Yellow dots with radial, thin arborizing vessels. No (%). 7 (35.0%) 0 0 0 0 P<0.05
Large yellow dots. No(%) 11 (55.0%) 0 0 0 0 P<0.05
White dots. No(%) 1 (5.0%) 11 (39.0%) 1 (5.2%) 0 1 (16.0%) NS
Follicular red dots. No(%) 1 (5.0%) 0 6* (31.6%) 0 0 P<0.05
*Eyebrow area only; DLE = discoid lupus erythematosus; LPP = lichen planopilaris; FFA = frontal fibrosing alopecia; DC = dissecting cellulitis; FD =
folliculitis decalvans; NS = not statistically significant
TABLE 4.
Trichoscopy Features of Active vs Inactive Discoid Lupus of alopecia in the course of DLE. Features visible only in inactive
Erythematosus Lesions lesions were porcelain-white areas, white dots, and lack of fol-
licular openings. In active lesions, the most prominent features
Active Inactive P-value
Patches Patches (statistical were “large yellow dots” visibly bulging beyond skin surface
(n=15) (n=17) significance) and dark-brown scattered discoloration of the skin. These re-
Thick arborizing vessels.
No(%)
Milky-red areas. No(%)
15
(100.0%)
0
Do Not Copy
17
(100.0%)
10
(58.8%)
NS
P<0.05
sults are summarized in Table 4.
DISCUSSION
Penalties Apply
Dark-brown scattered 7 Dermoscopy is most commonly used for early melanoma detec-
0 P<0.05
discoloration. No(%) (46.6%) tion and differential diagnosis of pigmented skin lesions and skin
14 tumors.26,27 The method is now applied with increasing frequency
Large yellow dots. No(%) 0 P<0.05
(93.3%)
in inflammatory skin diseases (inflammoscopy),28 insect infesta-
Yellow dots with radial, thin 15
0 P<0.05 tions (entomodermoscopy)27 nail diseases (onychoscopy) and hair
arborizing vessels. No(%) (88.2%)
2 and scalp diseases (trichoscopy).5,29-32 There is a growing body of
White dots. No(%) 0 NS
(11.7%) evidence related to characteristic trichoscopy features of non-cic-
Lack of follicular orfices. 17 atricial alopecia, however, usefulness of trichoscopy in differential
0 P<0.05
No(%) (100%) diagnosis of cicatricial alopecia has only partly been explored.6,8-23,31
1
Follicular red dots. No(%) 0 NS
(6.6%)
In discoid (cutaneous) lupus erythematosus, our study revealed
NS = not statistically significant
the following characteristic trichoscopy features: scattered
Tufted hairs dark-brown discoloration of the skin, bluish-gray, bluntly de-
Tufted hairs (more than 5 emerging from one follicular open- marcated areas, large yellow dots and thick arborizing vessels.
ing) were observed in all patients with FD and 1 of 28 (3.5%)
patients with LPP. Dark-brown discoloration of the skin, giving a “dirty” appearance,
was observed in active DLE lesions. This finding corresponds in
Trichoscopy of active and inactive DLE lesions histopathology to pigment incontinence in lesions with epider-
Large arborizing vessels, of average thickness being 114 mm + mal atrophy and may be similar to blue-grey dots forming a
28 mm (mean +/- SD) were seen at the periphery of all patches speckled pattern in DLE lesions, as described in patients with dark
757
skin phototypes by Duque-Estrada et al.33 Blue-grey dots were py, as compared to trichoscopy with immersion fluid. Our study
not observed in our study, which included patients with skin pho- indicates that tubular perifollicular scaling is highly characteris-
totype II and III. We have, however, observed bluish-gray, bluntly tic for LPP. It was rarely observed in patients with FD, but in no
demarcated interfollicular areas, reassembling dermoscopy ap- other group of patients. Tubular perifollicular scales tended to be
pearance of a blue-whitish veil, seen in melanocytic lesions.34,35 silver-white in LPP, while in FD they had a yellowish hue. Tubular
perifollicular scaling was previously not described in literature.
Large yellow dots seen in DLE significantly differed from yellow
dots observed in alopecia areata30,36,37 and androgenic alopecia.8,38 White dots were observed in patients with LPP, as described pre-
Their mean diameter was 653 mm +/- 125 mm (mean +/- SD), viously by Ross et al.30 There is some confusion in the literature
while yellow dots observed in alopecia areata had a diameter of regarding white dots.The “classic” white dots of LPP,30,42 which cor-
212 mm +/- 66 mm and those in androgenic alopecia were 190 mm respond to vertically-oriented fibrotic tracts in histopathology, may
+/- 71 mm. They also appeared darker and were dark-yellow to yel- be observed in most primary cicatricial folliculocentric alopecias.
low-brown in color. Large yellow dots with radial, thin arborizing They are irregular in shape, have blunt borders, and a tendency to
vessels emerging from the dot were found to be specific of DLE. We merge and form white areas devoted of follicular openings. The
refer to this feature as “red spider in yellow dot.” To the best of our smaller “pinpoint” white dots, first described by Brazilian doc-
knowledge, this finding has not yet been reported in the literature. tors,43,44 may be observed in patients with dark skin phototype (IV
to VI according to Fitzpatrick's scale) and correspond to empty hair
Another feature characteristic for DLE was the presence of thick ar- follicle openings or eccrine sweat duct openings.44,45 These “pin-
borizing vessels, predominantly at the periphery of the lesion. The point” white dots are small, regularly oval, or circularly shaped,
average thickness of the widest vessel in a lesion was 114 mm + sharply demarcated from the brown surrounding skin. Often the
28 mm (mean +/- SD) and was significantly larger, compared to ar- border of these “pinpoint” white dots is marked by a hyperpig-
borizing vessels seen in normal scalp, or seborrheic dermatitis (36 mented halo.This is a non-specific finding, observed in individuals
+/- 17, P<0.05).Thick arborizing vessels were observed in almost all with phototype IV-VI, including patients with cicatricial or non-cica-
patients with DLE, in a small proportion of patients with LPP, but tricial alopecia, but possible also in healthy indviduals.43-45
not in patients with other cicatricial or non-cicatricial alopecias.
Thick arborizing vessels observed in DLE are practically indistin- Our study also showed elongated, parallel-oriented blood ves-
guishable from arborizing vessels seen commonly in basal cell sels at the margin of some active LPP lesions. This finding does
carcinoma,39 although they might appear slightly more irregular not mirror any known histopathology feature of classic lichen
with variable thickness in the course of a vessel. planopilaris of the scalp.
Do Not Copy
Active DLE lesions, defined as lesions that appeared or enlarged 3
months prior to examination, were characterized by scattered dark-
brown discoloration and presence of large yellow dots. We found
In patients with frontal fibrosing alopecia trichoscopy showed
ivory-white areas devoted of follicular openings and mild peri-
follicular scaling, as shown previously by other authors.46-48
Penalties Apply
follicular red dots, as described by Tosti et al.,40 in only one patient
with active DLE lesions. According to the study by Tosti et al.40 In folliculitis decalvans, trichoscopy showed tufted hairs sur-
follicular red dots are present in active DLE and their presence cor- rounded by perifollicular hyperplasia arranged in a starburst
relates with dilated infundibula surrounded by dilated vessels with pattern. This novel observation, considered by us to be specific
pronounced red blood cell extravasation. According to authors of for FD, was not observed in any other type of alopecia, cicatricial
this report, the presence of follicular red dots in DLE lesions is a or non-cicatricial. Other observations in FD included presence
good prognostic and indicates high probability of hair regrowth. of large follicular pustules with an emerging hair shaft.
Evaluation of patients with lichen planopilaris showed that In dissecting cellulitis, trichoscopy revealed yellow, structureless
most characteristic trichoscopy features of the disease are: tu- areas and yellow dots with “3D” structure imposed over dys-
bular perifollicular scaling, white dots merging to form white trophic hair shafts as the most characteristic findings. This “3D”
areas lacking follicular openings, and elongated, parallel-ori- trichoscopy structure is called the “soap bubble” by Dr. Sami Ab-
ented blood vessels. This is partly in agreement with literature dennader (personal communication). Pinpoint-like vessels with
data, which indicate perifollicular scaling, white dots, reduced whitish halo, observed in DC, were not found in patients with
number of follicular ostia, and round perifollicular blue-grey other causes of hair loss but are not uncommon in other scalp
dots in a “target pattern” as characteristic features of LPP.30,33,41 and skin diseases, especially skin tumors.39,49
Our study confirmed the presence of perifollicular scaling in LPP.33 CONCLUSION

Scales formed a tubular structure surrounding the emerging hair The results of our study indicate that trichoscopy may be ap-
shaft. This feature could be better appreciated with dry trichosco- plied as quick and non-invasive auxiliary method in differential
758
25. Rakowska A. Trichoscopy (hair and scalp videodermoscopy) in the healthy

diagnosis of diseases leading to primary cicatricial alopecia, in- female. Method standardization and norms for measurable parameters. J
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Kittler H, Rosendahl C, Minas S, Zalaudek I. Dermoscopy and entomology
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ska M. Trichoscopy. Arch Dermatol. 2008;144:1007.
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E-mail:...…..........………..………..........lidia.rudnicka@euderm.eu
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Trichoscopy of Cicatricial Alopecia

Article in Journal of drugs in dermatology: JDD · June 2012

Adriana Rakowska Monika Słowińska

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Elzbieta Kowalska-Oledzka Olga Warszawik

histopathology of pemphigus on the scalp View project

pemphigus View project

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June 2012 753 Volume 11 • Issue 6

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

INTRODUCTION MATERIALS AND METHODS

Skin surface appearance

Our study confirmed the presence of perifollicular scaling in LPP.33 CONCLUSION

25. Rakowska A. Trichoscopy (hair and scalp videodermoscopy) in the healthy

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