Tr i c h o s c o p y T i p s

Rodrigo Pirmez, MDa,*, Antonella Tosti, MDb

KEYWORDS
 Trichoscopy  Dermoscopy  Alopecia  Hair  Lupus  Lichen planopilaris  Eyebrows  Scalp

KEY POINTS
 Trichoscopy is useful to diagnose early scarring alopecias and to select the optimal biopsy site in
these patients.
 Trichoscopy can easily distinguish hair loss from hair breakage and provides good information on
hair shaft damage.
 The pigmented scalp has unique trichoscopic features that make diagnosis of scarring alopecia
more difficult.
 Be aware of possible pitfalls, including scalp staining and scalp and hair shaft deposits.

INTRODUCTION patchy, or marginal alopecia. Examination of the

scalp will depend on the type of hair loss pre-
Dermoscopy has only recently been introduced in sented by the patient.4 In addition, examination
the assessment of hair and scalp disorders. How- of hair shafts and eyebrows may be decisive in
ever, in the past few years, much attention has some individuals.
been given to the method, with many studies
focusing on its applications in the field being pub-
Diffuse alopecia
lished; to the point that many hair specialists now
In patients with diffuse hair loss, it is important to
consider dermoscopy as an essential part of their
part the hair in the midline and to examine at least
dermatologic consultation. Dermoscopy allows
3 sites: frontal and middle scalp and vertex. We
visualization of morphologic structures that are
recommend evaluating each one of the sites with
not readily visible by the naked eye, including peri-
at least 2 magnifications: first with a lower one
follicular and interfollicular features, as well as
(10–20) and then with a higher magnification
changes to hair shaft thickness and shape.1 In
(40–50). Hair diameter variability, a hallmark of
2006, the name trichoscopy was first proposed
androgenetic alopecia (AGA), may be better
for the use of dermoscopy in the diagnosis of
appreciated at higher magnifications (Fig. 1).
hair and scalp disorders2 and is now widely adop-
Because the occipital scalp is commonly spared
ted.3 The aim of this article was not to make an
in patients with AGA, control pictures can be taken
extensive and overdetailed review of all tricho-
from this site for comparison.
scopic signs, but rather to discuss topics that
may be a source of doubt and to give tips that
Patchy alopecia
will help clinicians to better perform trichoscopy.
When patients present with patchy alopecia, both
the center and the periphery of the alopecic patch
PERFORMING TRICHOSCOPY: THE BASICS
should be checked. When examining the center of
How to Evaluate My Patient
the lesion, it is important to establish whether hair fol-
First, it is important to determine in which general licle openings are present or not. Loss of follicular
group of hair loss your patient best fits: diffuse, openings will guide the diagnosis toward a scarring

Disclosure Statement: None declared.

a
Dermatology Department, Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa de Miseri-
derm.theclinics.com

córdia do Rio de Janeiro, Rua Visconde de Pirajá 330, sala 1001 22410-000, Rio de Janeiro, RJ, Brazil;
b
Department of Dermatology and Cutaneous Surgery, Miami Miller School of Medicine, University of
Miami, 1295 NW 14th Street South Building Suites K-M, Miami, FL 33125, USA
* Corresponding author.
E-mail address: rodrigopirmez@gmail.com

Dermatol Clin - (2018) -–-

https://doi.org/10.1016/j.det.2018.05.008
0733-8635/18/Ó 2018 Elsevier Inc. All rights reserved.
2 Pirmez & Tosti

magnifications are needed (at least 70). Clini-

cians should look for causes of hair breakage,
such as trichorrhexis nodosa (Fig. 3), commonly
seen in hair weathering; or hair shaft defects that
may signal a congenital condition, such as the
typical constrictions of monilethrix (Fig. 4).5,6

Eyebrows
Hair disorders, such as alopecia areata (AA) and
FFA, may also affect the eyebrows (Fig. 5). Tricho-
scopy may be quite useful, particularly in cases of
atypical presentation or when the disease is
limited to this area.7 Of note, disorders or hair shaft
formation, such as trichorrhexis invaginata, might
Fig. 1. Hair shaft variability: presence of more than be detectable only in the eyebrows.
20% diversity in the hair shaft diameter is suggestive
for a diagnosis of androgenetic alopecia. Immersion Fluid: When to Use It
A few variables will determine whether immersion
condition. Signs of disease activity may be present fluid should be used or not, when performing tri-
either at the center or at the periphery of lesions, choscopy. A few simple points should be taken
depending on the etiology. So, the latter should al- into account:
ways be examined, as well. In addition, it is important
to evaluate apparently normal scalp surrounding 1. Contact dermoscopy always will be necessary
alopecic patches because early signs of disease ac- if an immersion fluid is being used.
tivity may already be present in trichoscopy, even 2. Devices with nonpolarized light will require the
before hair loss becomes clinically evident. use of an immersion fluid to cancel out reflec-
tions from the stratum corneum.
Marginal alopecia 3. Immersion fluids may hamper evaluation of
An important tip when evaluating a patient with scaling conditions and visualization of vellus
marginal alopecia is to check if vellus hairs are pre- and white hairs (as they “disappear” when a
sent. Loss of vellus hairs in the hairline is a typical fluid is used).
sign of frontal fibrosing alopecia (FFA) (Fig. 2). 4. “Elimination” of scaling with immersion fluid is
sometimes desirable, as excessive scaling
“My hair does not grow” may interfere with visualization of underlying tri-
This is a common complaint of patients with either choscopic features.
congenital or acquired hair shaft disorders. In
these cases, shafts should be directly examined As a general rule, we start the examination with
and trichoscopy has satisfactorily replaced optical dry dermoscopy and then use an immersion fluid if
microscopy in most scenarios. For hair shafts, it’s we judge necessary. The choice of the immersion
interesting to use polarized light, and higher fluid (eg, water, gel, alcohol) is a matter of personal
choice.

Fig. 2. Frontal fibrosing alopecia: the hairline has no

vellus hair. Fig. 3. Trichorrhexis nodosa.
 Trichoscopy Tips 3

of 10 to 20. Recently, cheaper videodermato-

scopes that can be connected to any computer via
USB also became available. According to some in-
vestigators, these cheaper devices may have image
quality drawbacks, when compared with the more
expensive digital dermoscopes.9

IDENTIFYING BASIC STRUCTURES IN

TRICHOSCOPY
A didactic way to learn the trichoscopic structures
is to organize them in groups, according to their
distribution on the scalp. In this regard, tricho-
scopic features could be divided into (1) follicular,
Fig. 4. Monilethrix. (2) perifollicular and interfollicular; (3) vascular, and
(4) hair shaft.10 The following examples are not a
comprehensive review of all trichoscopic struc-
Which Dermoscope Should I Use? tures, but illustrative of this classification. Hair
shafts are discussed in the article by Lidia Rud-
Each device has its advantages and drawbacks, and
nicka and colleagues, “Trichoscopy in Hair Shaft
the clinician should opt for the one that will best fit his
Disorders,” elsewhere in this issue.
or her practice profile. Handheld portable dermo-
scopes usually allow a 10-fold magnification; which Follicular Structures
is quite satisfactory in daily practice. In addition,
lower magnifications provide a better overview of a Because in trichoscopy we observe a 3-dimen-
large scalp area.8 Such dermoscopes are generally sional structure such as the skin as a 2-dimen-
considered to be reasonably cost-effective. On the sional image, follicular structures will be seen as
other hand, higher magnifications (20-fold to 100- dots by the observer. A few examples include yel-
fold and higher) provided by digital dermoscopes low, black, red, and white dots.
allow better visualization of fine details, specially In case shafts break before scalp emergence, they
hair shaft defects and changes in scalp vessels. will be perceived as black dots (Fig. 6). This may be
Another advantage of this more expensive group of due to weakening of shafts secondary to inflamma-
devices is that they are usually equipped with photo tion, such as seen in AA, or to mechanical trauma, as
storage software, allowing comparison of “before provoked by patients with trichotillomania.11–13
and after” pictures, among other resources. Person- If a hair follicle loses its shaft, it becomes filled with
ally, we feel that showing patients their trichoscopic sebum and keratin debris. This material gives a yel-
pictures helps them to understand their condition low hue to hair follicle openings and can be observed
and to better appreciate the results of the treatment as a yellow dot (Fig. 7) under trichoscopy of patients
being used. A somewhat in-between and practical with AGA or long-standing AA, for example.14
option are the mobile-connected dermoscopes, Follicular red dots (FRD) were described in
which allow photography usually at a magnification active discoid lupus (DLE). They are a positive
prognostic factor, representing a greater chance

Fig. 5. Eyebrows from a patient with alopecia areata:

note exclamation mark hairs. Fig. 6. Alopecia areata: black dots.
4 Pirmez & Tosti

Vascular Structures
Thin arborizing vessels are a normal finding in the
scalp and frequently seen in the temporal and occip-
ital regions (Fig. 8). Simple red loops may also be
seen in the normal scalp.10 On the other hand,
some vascular structures may be indicative of a
scalp disorder. Thick arborizing vessels, for
example, are typically present in connective tissue
diseases such as DLE and dermatomyositis20 or as
a side-effect in areas of steroid-induced atrophy.21

AM I FACING A SCARRING CONDITION?

As a general rule, alopecias may be divided into non-
scarring, a group in which patients retain the possibil-
ity of presenting hair regrowth; and scarring, when
hair loss is irreversible. The trichoscopic hallmark of
scarring alopecias is loss of follicular openings
(Fig. 9). Therefore, when first approaching a patient
with hair loss, clinicians should look for this
variable to start considering possible differential
diagnoses. Pitfalls do exist, as seen in patients with
long-standing AA. In these cases, follicular openings
may not be clearly visible, misleading one’s diag-
Fig. 7. Alopecia areata totalis: yellow dots. nosis. Another clue for potentially scarring conditions
is the presence of inflammatory signs, such as
of hair regrowth.15 Because of vasodilation and erythema and scaling or the presence of exudative
skin atrophy present in DLE lesions, the vascular lesions.18,22 Even though this is not a strict rule, overt
network that surrounds hair follicles becomes inflammation is usually part of the trichoscopic picture
visible and is perceived as FRD through tricho- of potentially scarring conditions, whereas nonscar-
scopy.16 The presence of such a vascular network ring conditions, such as AGA, AA, and telogen efflu-
suggests that the follicular structure is still viable vium do not present obvious inflammatory features.
and patients should be aggressively treated.
White dots are more easily perceived in patients MY PATIENT HAS A RECEDING HAIRLINE:
with dark scalp. They represent follicular and HOW TRICHOSCOPY MAY HELP?
eccrine gland openings and are known as pinpoint
white dots.17 The list of possible diagnoses of patients presenting
a receding hair line includes AGA, AA in a sisaipho
Perifollicular and Interfollicular Patterns pattern, traction alopecia, and FFA. Differential diag-
nosis between them may not be trivial, particularly in
The differential diagnosis between scalp DLE and early cases or in nonactive disease, in which typical
lichen planopilaris (LPP) is a good example of
how characterization of trichoscopic features
such as having a perifollicular versus interfollicular
pattern of distribution may help the clinician when
using trichoscopy. Lichenoid inflammation in LPP
is mainly folliculocentric and this will result in peri-
follicular inflammatory signs, like scaling. On the
other hand, the diffuse lichenoid inflammation
typical of DLE means that the interfollicular area
also will be affected, and patients will present
with diffuse scaling.18 Likewise, pigment inconti-
nence also will have distinct patterns. In LPP,
pigment incontinence will be perceived as blue-
gray dots in a target pattern (surrounding hair folli-
cles), whereas in DLE blue-gray dots are diffusely
spread, arranged in a speckled pattern.19 Fig. 8. Arborizing vessels.
 Trichoscopy Tips 5

what other trichoscopic features are also there?

What is the patient history? What is the clinical pic-
ture? These are simple questions that should al-
ways be in the clinician’s mind. Black dots, for
example, may be found in a number of condi-
tions.26 Weakening and breakage of hair shafts
forming black dots may result from either the cyto-
toxic insult of chemotherapeutic agents,13,27
inflammation in AA, hypoxemia in pressure-
induced alopecia,13 or even traumatic pulling in
trichotillomania. Focusing on a single trichoscopic
feature, instead of looking at the bigger picture,
may lead the clinician to the wrong diagnosis.

Fig. 9. Lichen planopilaris: absence of follicular open-

ings; also note peripilar casts around hair shaft
FEATURES UNIQUE TO THE DARK SCALP
emergence. Early articles discussing trichoscopy reported fea-
tures mainly in the context of light-skinned patients.
clinical features may not be present. A useful clue is Only a few years ago publications started to focus
to check for the presence of vellus hairs in the hair- on the particularities of the dark scalp, and this field
line. In the normal hairline, there is a progressive still remains to be fully explored.10,19,28
“transition” from very thin vellus hairs present in A remarkable normal finding of the dark scalp is
the forehead to the thick terminal hairs of the scalp. the visualization of a pigmented network (Fig. 10).
In FFA, this “transition” is affected: the loss of vellus This feature is present in the dark scalp due to the
hairs in the hairline is a typical sign of the disease greater amount of pigment in the skin and reflects
(see Fig. 2).23 For such, when approaching a patient normal cutaneous architecture with rete ridges
with a receding hairline, clinicians should bear in forming the darker network, whereas the thinner
mind this decisive trichoscopic feature. When pa- epidermis overlying the dermal papilla forms the
tients have active ongoing conditions, other tricho- lighter areas in-between. Assessing this pattern is
scopic features may help the diagnosis, such as particularly useful in the differential diagnosis of
the presence of exclamation marks and coudability some forms of scarring alopecia. Although the pig-
hairs in AA,24 perifollicular erythema, and scaling in mented network remains unaffected in folliculocen-
FFA or hair casts in traction alopecia.25 tric conditions such as LPP, DLE presents with a
lichenoid dermatitis that affects the whole dermal-
DON’T FORGET THE BIGGER PICTURE epidermal junction in addition to hair follicles. For
such, in DLE, the skin architecture is affected and
When clinicians and students are first introduced to loss of the pigmented network pattern is an ex-
trichoscopy, attempting to memorize lists of tricho- pected trichoscopic feature of the disease in
scopic features for each disease is a common (but dark-skinned patient. Damage to the basal layer
deceptive) reaction. Trichoscopy is a recent diag- leads to pigment incontinence, which in turn results
nostic tool and, as expected, new trichoscopic fea- in the visualization of blue-gray dots in trichoscopy.
tures are being continuously described. But, to
understand trichoscopy, it is important to make cor-
relation with disease pathogenesis. Many different
trichoscopic features represent, in fact, the same
pathogenic process. A good example of that is
trichotillomania. In this compulsive disorder, we
may find, among others, flame hairs, tulip hairs,
hair powder, or the v-sign, but all these findings
result from a common cause: hair shafts that were
broken by the patient by traumatic pulling. Depend-
ing on the shape shafts assume after breakage, they
receive a different name. To establish diagnosis,
more important than knowing all these names, is
to understand that they represent broken hair shafts.
In trichoscopy, it is also important to analyze the
context in which a trichoscopic feature is present: Fig. 10. Pigmented network.
6 Pirmez & Tosti

Blue-gray dots, either in a target or speckled casts consist of the pulled out inner and/or outer
pattern as previously discussed, are also more root sheath and are not characterized by prominent
commonly seen in patients with darker skin types. parakeratosis.25
When facing a potentially inflammatory condi-
tion of the scalp, clinicians should be aware that CHILDREN! WHAT TO EXPECT IN
the severity of the process may be underestimated TRICHOSCOPY?
in one’s evaluation, for the visualization of ery-
thema may be hampered by the overlying A variety of conditions are more frequently seen
intensely pigmented skin. in children, ranging from infections and infesta-
A trichoscopic feature described in the same tions to hair shaft formation disorders. The fact
population is the “starry sky” pattern, the presence that trichoscopy is noninvasive and painless
of multiple pinpoint white dots on the darker skin makes this diagnostic method particularly inter-
background. This is a normal finding caused by esting in the evaluation of hair and scalp disor-
the visualization of the eccrine grand openings. ders in children.31 Even so, few studies
Peripilar white gray halos have been described in regarding the use of trichoscopy have been
the trichoscopy of central centrifugal cicatricial alope- done exclusively in children and much of the cur-
cia,29 the most common cause of scarring alopecia in rent knowledge derives from studies in adults.
African American women.30 They correspond on pa- However, some features that are inherent to this
thology to the lamellar fibrosis surrounding the outer group should be observed.
root sheath. In our experience, they also may be In our experience, follicular units in children usu-
seen in dark-skinned patients with other forms of fol- ally consist of 1 or 2 hairs and often have shafts of
liculocentric scarring alopecias, such as FFA. different diameters, which may mislead to the
Traumatic hair styling makes some populations diagnosis of AGA by an unwary clinician.
and ethnicities, such as Africans and African de- A normal trichoscopic feature commonly seen in
scendants particularly prone to traction alopecia. children is dirty dots. Dirty dots appear as brown,
Hair casts are a useful trichoscopic sign of ongoing black, and occasionally red, yellow, and blue par-
traction. On trichoscopy, hair casts appear as white ticulate dots and loose fibers and likely represent
to brown cylindrical structures that encircle the environmental particles.32 This finding possibly re-
proximal hair shafts (Fig. 11). Traction-induced hair sults from the inability of the scalp to repel partic-
ulate debris from exogenous environmental
sources due to low activity of the sebaceous
glands in patients of early age. The involution of
sebaceous glands with age may also explain the
presence of dirty dots in the elderly.33
The low activity of sebaceous glands is also
responsible for the lower incidence of yellow
dots in children. Clinicians should keep this infor-
mation in mind. Long-standing patches of AA
may not reveal yellow dots, and visualization of
follicular openings may be hampered. For this
reason, cases of AA may end up being misdiag-
nosed as scarring alopecia, which in reality is quite
uncommon in children.

PITFALLS IN TRICHOSCOPY: BE AWARE!

Pitfalls in trichoscopy are artifacts that may
simulate hair disorders. It is important to identify
such artifacts to avoid misdiagnosing a hair con-
dition. The most important pitfalls are secondary
to scalp deposits, scalp staining, and hair shaft
deposits.

Scalp Deposits
Scalp deposits may be either due to deposition of
Fig. 11. Traction alopecia: casts surrounding the shafts environmental particles, like dust, or camouflage
at the margins of the patch indicate ongoing traction. products. Environmental particles are the
 Trichoscopy Tips 7

previously discussed “dirty dots.” To the untrained

eye, dirty dots may simulate a few trichoscopic
features, depending on the shape and color of
the particle. Some deposits are commonly misin-
terpreted as black dots, a sign of ongoing hair fol-
licle damage observed in a few conditions, such as
AA. Importantly, dirty dots can be completely
removed after intense shampooing.
Another type of scalp deposit is camouflage
products used by patients to conceal areas of
decreased hair density. They can be present as a
powder on the scalp surface or, more commonly,
as fibers. In this later case, it is important not to
confuse them with broken hair shafts.
Fig. 13. Pseudocasts due to hair spray.
Scalp Staining
Common causes of scalp staining include hair dye, SUMMARY
topical medication, such as anthralin, or scalp tat-
The aim of this article was to bring selected infor-
toos, which is an increasingly popular method to
mation from the literature and our clinical experi-
camouflage decreased hair density.
ence that may help dermatologists to use
Hair dye may be present on the scalp surface and
trichoscopy in their everyday practice. Clinicians
within follicular openings simulating both interfollicu-
should keep in mind that trichoscopy is a recently
lar hyperpigmentation and dots (Fig. 12).34 Anthralin
described and evolving technique; many new con-
also may stain follicular openings and resemble
cepts are constantly arising and constant update
black dots. Because anthralin is used in the treat-
is required.
ment of alopecia areata, identification of this pitfall
is essential to not misclassify your patients as having
active AA. Finally, ink deposition in scalp tattoos REFERENCES
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