Hair Loss and Trichoscopy

Trichoptilosis by Hair Styling Procedure
It is a symptom of hair shaft damage (“hair weathering”) that may be caused
by hair-damaging environmental factors and cosmetic procedures
A long longitudinal break

Trichoptilosis
Longitudinal splitting of the distal hair shafts producing 2 m or multiple frayed ends of
different length

Trichoclasis
A clean transverse fracture across the hair shaft bounded only by intact
cuticle develop secondary to conditions that weaken the hair

Trichoschisis
A complete clean transverse fractures across the hair shaft with Localized
Absence of the Cuticle commonly associated with trichothiodystrophy

Note cuticular damage, which leads to transverse fractures in the hair shaft. Polarized
light would help to differentiate trichoschisis from trichothiodystrophy
Trichoschisis

Irregular, ragged distal end in trichotillomania
Broken Hairs
Hairs are broken
at different levels
above the scalp

Golf tee hairs
Golf tee hairs
Golf tee hairs
the distal end of the
broken hair will have a
concave, cupped
appearance
Netherton’s
syndrome

Netherton syndrome
the expanded proximal end of an invaginate node after abreak has occurred
Golf tee hair’ appearance

SPLINT ENDS AND PAINT BRUSH APPEARANCEN

Tightly curled, with knots and breakage and in cross section, it is flattened or
Hair Shaft in African American

Trichorrhexis nodosa and trichoptilosis in a broken shaft

Trichonodosis (Hair Knotting)
observed in patients with short curly hair either spontaneously or in response to
scratching with little clinical signifcance

An acquired, transient condition as an effect of scratching or hair styling
procedures
TRICHONODOSIS(HAIR KNOTTING)

Trichonodosis
an incidental finding of little clinical significance in short curly hair

Hair cast (Peripilar kerating cast)
firm, white, freely movable tubular masses that encircle the hair shafts

Cylindrical and hyaline mass involving the hair shaft
Hair cast (peripilar cast)
Hair casts may be a
secondary phenomenon in
the course of psoriasis,
seborrheic dermatitis, or
lichen planopilaris.
Idiopathic hair
casts may be
observed in healthy
individuals

White nodules along
affected hair shafts results
from hair weathering at
free ends of long hair
Acquired Trichorrhexis nodosa
Causes of TN include mechanical,
chemical, and thermal damage,
mainly as a result of hairstyling and
processing.

Trichorrhexis Nodosa
At the site of these nodular thickenings, hairs bend with a rounded edge

Trichorrhexis Nodosa
Polarizing microscope

Broken hairs leave brush-like ends with numerous small fibers at the distal end of
the hair shaft

Acquired Trichorrhexis Nodosa
Brush like tip

Light microscopy of trichorrhexis nodosa
A broken, tapered end
The characteristic findings of
light microscopy are
sometimes obscured at the
distal end of the hair shaft.

Trichorrhexis nodosa
The disruption of the cuticle and the splaying out of the cortical cells.

Trichorrhexis Invaginata)
Hair shaft invaginates at several points
along the shaft irregularly and appears as
multiple small nodules spaced along the
shaft at irregular intervals.
Bamboo Hairs

Netherton syndrome.
bamboo, matchstick, and golf-tee hairs
‘‘regularly bended ribbon sign

bamboo-like appearance at
site of invagination
Trichorrhexis invaginata

Trichorrhexis Invaginata
Pathognomonic of Netherton syndrome
High-magnification
trichoscopy shows an
invagination of the
distal portion of the
hair shaft into its
proximal portion
forming a ball-in-cup
appearance

Trichorrhexis invaginata
a tulip-like appearance at the site of invagination.

Upright Re-growing Hairs in Telogen effluvium
Short (3-5mm), thin
(>50um), normally
pigmented, with
upright firm
appearance, with
pointed distal end
characteristic of the
hair regrowth phase
of telogen effluvium
and other non
cicatricial alopecica

Very short < 3mm, Very thin
< (30um), hypopigmented,
non medullated, weak
appearance with blurred
distal ends
Vellus hairs

Hair blocks are very short hair
with horizontal distal end
i-Hairs are hair
blocks with dark
distal end
TINEA CAPITIES

Tulip hairs in trichotillomania at low Magnifications
light-colored hair shafts with dark distal ends

Broken hairs with a
diagonal fracture surface
and a cuticle detached at
the distal end
Slightly thinner
at the base than
at the distal end
Tulip hairs at higher Magnifications

both cicatricial and non cicatricial alopecia reflecting
different pathologic mechanisms and histopathology
Broom fibers

Broom hairs in non cicatricial alopecia
Multiple short full-thickness hairs emerging from one follicular unit in a patient who

Flame hairs in in active trichotillomania
residues from recently pulled hairs

Typical monilethrix hairs with
regularly distributed nodes
and internodes
the defect is in the
internodes (constricted
sections)
Nodosities
correspond to the
normal hair caliber

Monilethrix
Regular nodes correspond to
normal hair shaft thickness,
contain medulla whereas the
internodes are narrowing
with no medulla

Monilethrix
Hairs are bent regularly at
multiple locations and have a
tendency to fracture at
constriction sites

Monilethrix of Eyebrows
Regular spaced elliptical nodes

Pseudo-monilethrix
Irregularly spaced nodes
wider than the
normal shaft,
occurring near
the site of
overlap of the
hairs
Some authors consider it an optical illusions

Denting of the hair at the site of pressure from an overlapping hair
Pseudo-monilethrix

Pseudomonilethrix .
Rectangular indentations on one side of the hair shaft must be differentiated from
irregular fusiform narrowins of Pohl Pinkus constrictions

These constrictions occur most commonly when the metabolic and mitotic activity of the follicle are
rapidly and repeatedly suppressed by an external or internal factor
Pohl-Pinkus Constrictions
Monilethrix like hairs

Monilethrix like hairs
Pohl-Pinkus constrictions
• Alopecia areata
• Chemotherapy
• Blood loss
• Severe nutritional
deficiencies
• Cicatricial alopecia
• Locoalized hereditary
hypotrichosis

Pohl-Pinkus constrictions or monilethrix like, the nodules appear wider
and the internodes has the same width as the hair shaft
Regularly distributed constrictions in monilethrix where the
nodes are same as hair shaft and internodes are contrictions
Differentiate monilethrix from monilethrix like

Monilethrix – like congenital hypotrichosis
spaces between narrowing are significantly
shorter and more superficial compared with
true monilethrix
almost invisible in
thicker hairs

Exclamation and Micro-exclamation Mark Hairs
Short hairs that are thin and hypopigmented at the proximal end and thicker and
darker at the distal end sometimes shorter than 1-2mm

Exclamation and Micro-exclamation Mark Hairs
• Alopecia areata
• chemotherapy
• anagen effluvium
• Trichotillomania

Tapered hairs (Hair Coudability)
hairs that are thin at the proximal end and become normal distally are called tapered
hairs when the hair is longer than one dermoscopic field of view (×70)
Not pathognomonic for alopecia areata

Tapered hairs (Hair coudability)
Very long exclamation mark or Pohl-Pinkus constrictions

Re-growing Pigtail hair
Short, regularly twisted hairs (circular or oval) with tapered ends

result from rapid hair
regrowth, before full
recovery of the hair
follicle. .
Re-growing pigtail hairs
Although most characteristic for alopecia areata, regrowing pigtail hairs also may be
present in cicatricial alopecia

Comma Hair and Corkscrew
Comma hairs with multiple
twists form corkscrew- like
structures.
characterized by
homogeneous thickness and
pigmentation of the hair shaft
and a sharp diagonal end
short comma-like hairs

are a hallmark of tinea capitis in patients of all skin phototypes
corkscrew hairs
Comma hairs often coexist
with corkscrew hairs.

Comma Hairs
the presence of multiple comma hairs in focal alopecia is
pathognomonic for tinea capitis

Coiled hairs in trichotillomania
After fracturing, the remaining part of the hair coils
irregularly at the fracture site giving different
appearance

Coiled or Hook like hair
differ from re-growing pigtail hairs in their irregular, oval appearance and blunt end.
Occasionally, they may have a hook-like
appearance

Zigzag or Z hairs
Any disease that cause focal weakening of the hair shaft

Pili torti
Twists of hair shafts along the long axis, usually through an angle of180

Pili torti has numerous causes, both inherited and acquired
Pili Torti in low magnification
Hair shafts slightly bent at
different angles at irregular
intervals

PILIT TORTI HAIR
A common, nonspecific symptom associated with many types of hair loss, both
inherited and acquired.

Monilethrix / Pili Torti
repeated dilations and constrictions of
the hair shaft
relatively flat shape of the
hair fiber with regular twists
Monilethrix
Pili Torti

a cyclical short, wavy hair that recalls a characteristic “moving snake” image;
Woolly hair

Woolly hair
Tightly coiled curls often thin and
hypopigmented hair shaft
resembling a crawling snake with
short wave cycles with increased
fragility

Hairs are flat, thinner, curly twisted, elliptical or oval in cross section some
hairs may have trichorrhexis nodos
Woolly hair

Pili Annulati
Bands are nearly the width of a hair and their borders are not clear-cut,

Air spaces in the cortexof the hair appear darker in light microscopy.
Pili Annulati

Pili Annulati with reflected light
Banded appearance of hair

Tinea capitis caused by Microsporum canis
Hairs with thin transverse bands (Morse code hairs)

Acquired hair shaft dystrophy in cicatricial alopecia
The most common reason for this condition is perifollicular fibrosis. Before a
follicle is destroyed, it produces various types of dystrophic hair shafts usually in
whitish or milky red areas with decrease of hair follicles number

Acquired hair shaft dystrophy in cicatricial alopecia .
it produces various types of dystrophic hair shafts.
emerge in whitish or milky red areas with a
decreased number of hair follicles
perifollicular fibrosis

Acquired hair shaft dystrophy in cicatricial alopecia .
The hair is short and very thick compared with other hairs in this patient with dissecting
cellulitis

Braiding damages hair shaft cuticle.

The gas-filled bubbles are caused by excess physical stress on the hair shaft, appear
as white oval spaces with swiss chees structure
Light microscopy of Bubble Hair

Cross-sectional microscopy demonstrating reniform and other abnormal shapes.
Un-combable Hair

Many cross-sections of hair fibers show typical triangular shapes
Uncombable hair syndrome
Shrinking tube technique

Pili trianguli et canaliculi on light microscopy
canal-like longitudinal depressions along the hair shaft

Triangular cross-section and canalicular depression or gutter along one side
Uncombable hair syndrome

Uncombable Hair Pili trianguli et canaliculi
Canal-like longitudinal depressions along the hair shaft

Bubble hair
Bubbles form within the hair cortex and medulla as a result of high temperatures from

Flattened hair shafts, one twisting like a ribbon.
Tricho-thiodystrophy
Several areas of trichoschisis.

Flattened shaft twisted through 360°
Trichothiodystrophy

Trichoschisis
Trichothiodystrophy Light Microscopy

Trichothiodystrophy (TTD)
under polarizing microscopy, it displays a diagnostic alternating light and dark
banding pattern, called ‘‘tiger tail banding

Trichothiodystrophy TTD
Trichoschisis
Trichorrhexis nodosa-like fraying

showing absence of root sheaths and ruffled cuticle.
Loose Anagen Syndrome

Loose anagen hair with misshapen darkly pigmented bulb, short twisted segment
immediately distal to the bulb, absent inner root sheath, and“ ruffled” cuticle
Loose Anagen Syndrome

Mitotic arrest narrows the shafts and hair breaks when they reach
the scalp surface
Anagen arrest with chemotherapy

Examination of the hair shaft under polarized light microscopy
Normal hair

Minimal weathering of the cuticle with chipped cuticle cells.

Weathering of the cuticle with lifting of the cuticle cells.

severe weathering and loss of the cuticle.

Irregular ridging and fluting and disordered cuticle scale pattern
Trichothiodystrophy.

Infestations
(Pediculus Humanus Capitis

The head louse egg or nit is 0.8 mm in length
Head Louse Egg or Nit

able to differentiate lice nits containing nymphs from empty nits of hatched parasites
and from amorphous pseudonits and hair casts.
Empty nits

Incomplete Nit Attached to a Hair

Dermatoscopy of pediculosis pubis

White Piedra
Nodules measure 1 to 1.5 mm in diameter; they are fusiform and of soft
consistency, mainly attached to the distal portions of the hair
Hair shafts appear coated by yellow or beige sheaths.

Occasionally red, green or light brown, soft, loose
White Piedra (Trichosporon beigelii)

Hard brown to black nodules, firmly attached
Black piedra (Piedra Hortae)

Trichomycosis Axillaris
concretions on the shafts of axillary and (less often) pubic hairs. The hair shafts develop
adherent yellow, red or black nodules or cylindrical sheaths that can be seen with the
naked eye
Superficial Corynebacterial Infection

Dirty scalp : prepuberal children Use

Use of scalp camouflage products Scalp staining

Perifollicular Evaluation of hair follicle opening
• Normal
• Empty
• Fibrotic
• Biologic Material

Normal hair and scalp findings on trichoscopy

Number of hairs emerging from one follicular unit

One hair per follicular unit in androgenetic alopecia usually less than 30/% but
decreased in telogen effluvium and androgenic alopecia

Two hairs per follicular unit in
a healthy individual .
The number of hairs in a follicular unit
varies from one to three in healthy
persons

Some authors may consider this number borderline normal
Small hair tufts in
lichen planopilaris
tufts of five to seven hairs
The number of hairs in one follicular unit is increased in
tufted folliculitis

Large Tufted hairs is charachterisitic folliculitis decalvans
a tuft containing more than 20 hairs walled by a widened, hyperkeratotic, scaly
hair follicle opening

Broom hairs in non cicatricial alopecia
Multiple short full-thickness hairs emerging from one follicular unit
in a patient who otherwise has long hair
Multiple hair shafts emerging from the
same follicular ostium in a brush-like
pattern can differentiate pili multigemini
from compound follicles

Black dots
Black dots are residues of pigmented hairs that have
been broken or destroyed at the level of the scalp.
• Alopecia areata
• Tinea capitis
• Dissecting Cellulitis
• Tinea capitis
• Trichotillomania

Black dots and short vellus hairs
Alopecia areata in dark skinned individuals
Black dots are not
present in healthy
individuals or in
patients with PHL or
telogen effluvium

Yellow dots are hair follicle openings that contain keratosebaceous material. They may
be present in alopecia areata, DLE, and female PHL

Yellow dots, appearing as large 3-D soap bubbles imposed over dark dystrophic hairs,
are specific
Dissecting cellulitis

Large yellow dots (follicular keratotic plugs) are characteristic.
Discoid lupus erythematosus.

Dermoscopy guided biopsy, the area shows numerous yellow keratotic plugs
Chronic Cutaneous Lupus Erythematosus (CCLE)

White Dots
Pinpoint white dots correspond to hair follicle openings and eccrine gland openings,
regardless of hair loss seen on the normal scalp of dark skin phenotype

White Dots
White dots may appear as fibrotic white dots or pinpoint white dots

Chronic Cutaneous Lupus Erythematosus (CCLE)
Branching capillaries
White patches
Keratin plugs White dots
Blue grey dots

White Dots
Classic white dots represent areas of perifollicular fibrosis and are observed most
commonly in lichen planopilaris
Lichen Planopilaris
White Dots

Lichen Planopilaris
perifollicular scaleswhite dots
blue-grey dots
"target" pattern

Central, Centrifugal, cicatricial (CCCA)
single hairs or group of two hairs surrounded by a peripilar gray-white halo
shows reduced hair density
small pinpoint white dots

Red dots have been described in DLE and in individuals with vitiligo. Pink-grey and
grey dots have been observed in the eyebrow area of patients with frontal fibrosing
alopecia
Red. Pink, Grey

Dyschromia due to pigment incontinence secondary to interface dermatitis
and prominent follicular red dots; a good prognostic for possible hair regrowth

EPIDERMAL SCALING
Normal
psoriasis
Seborrheic
dermatitis
Diffuse
Lichen
plano-pilaris
Frontal
fibrosing
Alopecia
FOLLICULITI
S
DECALVANS
Peri
follicular

Epidermal scaling is a common finding in healthy individuals or associated with use of
hair cosmetic
Psoriasis

Discoid Lupus Erythematosus
multiple thick arborizing vessels
large yellow dots
fine scaling

Perifollicular scaling with some scales forming tubular structures around the emerging
hair shaft.
Lichen Planopilari (LPP) or
Frontal fibrosing alopecia (FFA)

TRACTION ALOPECIA
Dermatoscopy is very helpful to establish if hair style causing traction. It shows
small casts, mobile, cylindrical structures enveloping the proximal hair shaft and
may be mistaken for nits.

Tufted hairs in Folliculitis Decalvans .
Perifollicular scaling with the formation of tubular scaly structures around hair shafts is
observed in LPP (white) and in folliculitis decalvans (yellow)

NORMAL SCALP
Scalp color in dark-skinned individuals can vary from light brown to dark black
Another typical feature is
a perifollicular pigmented
network or honeycomb
pattern
A characteristic feature of the
pigmented scalp is the
presence of pin point white
dots corresponds to acro-
syringeal and follicular
openings

Androgenic Alopecia
Peripilar sign
A brown halo, roughly 1 mm in diameter, around the emergence of the hair shaft

Ludwig type I hair loss patient
Brown peripilar signs

The presence of a pigmented network in a honeycomb pattern is an important feature
to distinguish from DLE because inflammatory process in the former is restricted to the
hair follicles
Lichen Planopilaris

Dyschromia due to pigment incontinence secondary to interface dermatitis
and prominent follicular red dots.

FRD was proposed as a normal trichoscopic feature, appearing to be related to the
rich vasculature that naturally envelops the normal hair follicle.
Follicular Red Dots (FRD)

The red dots are erythematous polycyclic, concentric structures, regularly
distributed around the follicular ostia and denotes good prognostic for hair
regrowth

markedly reduced follicular ostia, scale, erythema, and perifollicular blue-gray dots.
Frontal fibrosing alopecia

Discoid lupus erythematosus
The absence of pigmented network indicates destruction of the interfollicular
Speckled blue-gray dots
milky red areas and follicular plugging

The milky-red (strawberry ice cream) color is
indicative of fibrosis of recent onset
Absence of follicular openings manifesting as
empty yellow or black dots
Cicatricial alopecia

Evaluation of Blood Vessels
Appearance of cutaneous microvessels may vary in type, arrangement, and
number,is of special importance in differential diagnosis of inflammatory scalp
disease such as psoriasis, seborrheic dermatitis, lichen planopilaris and DLE

Several inflammatory scalp disorders are characterized by a
specific pattern of blood vessel arrangement on trichoscopy
Blood vessels

are C-shaped or slightly curved vessels with no branching. They are common in in
flammatory scalp diseases, such as seborrheic dermatitis and psoriasis, but also may be
observed in healthy individuals
Comma vessels or Linear Vessels

Hairpin elongated vessels are characteristic of cicatricial alopecia and are
observed most frequently in classic lichen planopilaris and folliculitis decalvans. This
vessel type typically is found in the perifollicular area, especially adjacent to tufted hairs
Hairpin ( linear looped ) Elongated vessels

Thin arborizing vessels usually are thinner than the average hair on the trichoscopic image. They are a
normal finding in the scalp, especially in the occipital and temporal areas . They are distributed regularly
between follicular units. Some authors suggest that thin arborizing vessels are characteristic of seborrheic
dermatitis; however, thus far, studies have not compared patients with seborrheic dermatitis with healthy
controls
Thin arborizing vessels

SEBORRHEIC DERMATITIS
the most common patterns are arborizing vessels and atypical red
vessels in the absence of red Dots and globules.

Lace-like vessels ( arrow ) are a combination of serpentine and looped vessels. These capillaries have a
serpentine shape and open ends that usually are spaced widely. These vessels are most characteristic of
psoriasis and correspond to the tortuous and dilated blood vessels within the elongated dermal papillae
seen on histopathology
Lace - like vessels

Glomerular (i.e., coiled or twisted) vessels ( arrows ), are most characteristic of psoriasis.
They usually are regularly arranged in lines or circles ( rings ). At lower magnification,
these circles appear as “red globular rings”
Glomerular ( coiled ) vessels

. Helical (corkscrew) vessels ( arrows ) are linear vessels twisted along a central axis. They are observed
rarely in scalp skin and never in healthy individuals. In noncancerous lesions, linear helical vessels are a
marker of severe inflammation and are observed in severe scalp psoriasis, pemphigus, and cutaneous T-
cell lymphoma.
Helical vessels or Corkscrew Vessels

A psoriatic plaque: dilated, elongated, “bushy” capillaries, homogeneously distributed
(twisted loop in 100% help to differentiate it from seborrheic dermatitis
PSORIASIS

multiple thick arborizing vessels
large yellow dots
fine scaling
Yellow dots with radial, thin arborizing
vessels emerging from the dot are
considered characteristic

Characteristic large yellow dots and arborizing vessels

large erythematous nodules on the occipital area with few remaining hairs.
DISCHARGE
BACTERIAL
INFECTIONS
TINEA
CAPITIS
FOLLICULITIES
DECALVAN
DISSECTINH
CELLULITIS
Dissecting folliculitis

Cultures from the pustules usually reveal Staphylococcus aureus
Folliculitisdecalvans
Perifollicular pustules are seen in active lesions.
DISCHARGE

HAIR SHAFT DISORDERS WITHOUT
INCREASED FRAGILITY
Scanning electron micrograph of hair surface

Eyebrows, eyelashes, and other body hair also may be evaluated
with trichoscopy with 0.9% NaCl as an immersion fluid

Hair Loss and Trichoscopy

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