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◦ Cicatricial alopecia also known as
scarring alopecia.
◦ It is a type of hair loss-
◦ Hair follicles replaced by fibrous
tissue.
◦ Leads to permanent hair loss.
◦ Caused by a disease-
◦ affecting the hair follicles.
◦ by an external process.
INTRODUCTION
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◦ has a significant impact on
◦ a patient's emotional
◦ psychological well-being.
◦ Role of trichoscopy:
◦ Early detection and management.
◦ Prevents further damage.
INTRODUCTION
4. TYPES OF CICATRICIAL ALOPECIA
PRIMARY CICATRICIAL ALOPECIA
LYMPHOCYTIC
1. Chronic cutaneous lupus
erythematosus
2. Lichen planopilaris (LPP):
i. Classic LPP
ii. Graham–Little
syndrome
iii. Frontal fibrosing
alopecia
3. Pseudopelade of Brocq
4. Central centrifugal cicatricial
alopecia
5. Alopecia mucinosa
6. Keratosis pilaris spinulosa
decalvans
NEUTROPHILIC
1. Folliculitis decalvans
(including tufted folliculitis)
2. Dissecting
cellulitis/folliculitis
MIXED
1. Acne keloidalis
2. Acne necrotica
3. Erosive pustular dermatosis
NON SPECIFIC
1. Non‐specific or end‐stage
cicatricial
alopecia
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6. TRICHOSCOPY BASICS
◦ Any handheld dermoscope may be used to perform trichoscopy.
◦ A dermatoscope usually consists of a
◦ light source
◦ achromatic lens
◦ contact plate
◦ power supply.
◦ Three types of dermoscopes:
◦ Polarised contact dermatoscopy
◦ Polarised noncontact dermatoscopy
◦ Nonpolarised contact dermatoscopy
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7. ◦ Non polarised light is useful as-
◦ Allows the evaluation of scales.
◦ Features that are associated with disease activity-
◦ peripilar casts
◦ keratotic plugs.
◦ Non contact polarised light dermoscopes-
◦ visualisation of vascular patterns in inflammatory scalp diseases.
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TRICHOSCOPY BASICS
13. NORMAL TRICHOSCOPIC PATTERNS
◦ Familiarity with normal features aids in the
recognition of abnormalities of the
◦ Follicular ostia,
◦ Perifollicular skin,
◦ Cutaneous blood vessels,
◦ Hair shafts.
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14. FOLLICULAR OSTIA
◦ Normal follicular ostia as
◦ small, circular, regularly spaced
structures
◦ commonly referred to as "dots.“
◦ Normal follicular units-
◦ Two or three hair shafts
◦ from the same follicular ostium.
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15. PERIFOLLICULAR
SKIN
◦ Mild diffuse scaling-
◦ common
◦ Incidental
◦ associated with use of hair products, gels.
◦ skin phototypes IV to V,
◦ normal scalp - honeycomb-like
pigment network.
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In moderately to highly pigmented skin, the normal scalp shows a honeycomb-like
pigment network characterized by pigmented lines surrounding round, hypo chromic
areas that resemble pinpoint, white dots.
16. BLOOD VESSELS
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(A) Inter follicular red loops; (B) Arborizing red lines corresponding to
subpapillary plexus of vessels.
A.
B.
Normal scalp vessels
Interfollicular
simple red loops
Vessels of dermal
papilla
Arborizing red lines
subpapillary vascular
plexus.
17. HAIR SHAFTS
◦ In the normal scalp, vellus hairs account
for less than 20 percent of all scalp
hairs.
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Vellus hairs are shorter and thinner than terminal hairs
TERMINAL HAIR VELLUS HAIR
• Consistent
diameter
• Consistent color
• Shorter
• narrower than
terminal hairs.
20. ABNORMAL TRICHOSCOPIC FINDINGS
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WHITE PATCHES
Dermoscopic findings –
• Irregularly distributed white patches
• different sizes and shapes
• interspersed with pinpoint white dots,
• highly pigmented skin (phototypes IV to VI)
Pathologic correlation –
Fibrosis
Associated disorders –
Cicatricial alopecias
21. ABNORMAL TRICHOSCOPIC FINDINGS
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Black dots (arrow) and follicular keratotic
plug (arrowhead)
BLACK DOTS
Dermoscopic findings –
Round, black dots within ostia
Pathologic correlation –
Broken hair shafts
Associated disorders –
Alopecia areata,
dissecting cellulitis,
tinea capitis,
trichotillomania
22. ABNORMAL TRICHOSCOPIC FINDINGS
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Multiple blue gray dots (arrow) in a speckled pattern
BLUE- GRAY DOTS
Dermoscopic findings –
Blue-gray dots in speckled or target pattern
within ostia
Pathologic correlation –
Melanophages in papillary dermis
Associated disorders –
• Discoid lupus erythematosus
(speckled pattern),
• lichen planopilaris (target pattern)
23. ABNORMAL TRICHOSCOPIC FINDINGS
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Diffuse scaling, loss of pigment network and
follicular keratotic plugs
FOLLICULAR KERATOTIC PLUGGING
Dermoscopic findings –
Keratin within follicular ostia
Pathologic correlation –
Hyperkeratosis resulting in keratin plugs
within follicular ostia
Associated disorders –
• Discoid lupus erythematosus
• dissecting cellulitis of the scalp
24. ABNORMAL TRICHOSCOPIC FINDINGS
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Tufts of hair surrounded by thick peripilar casts
HAIR TUFTING
Dermoscopic findings –
More than five hairs emerging from
a single ostium
Pathologic correlation –
Fusion of outer root sheaths of
adjacent follicles
Associated disorders –
• Acne keloidalis
• Folliculitis decalvans
25. ABNORMAL TRICHOSCOPIC FINDINGS
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Follicular red dots
RED DOTS
Dermoscopic findings –
Erythematous, polygonal or
concentric structures within or
around follicular ostia
Pathologic correlation –
Dilated infundibula with peripheral
dilated vessels and red blood cell
extravasation
Associated disorders –
• Discoid lupus erythematosus
26. ABNORMAL TRICHOSCOPIC FINDINGS
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PERIPILAR WHITE HALO
Dermoscopic findings –
Gray-white halo around follicular
ostia
Pathologic correlation –
Concentric fibrosis
Associated disorders –
• Central centrifugal cicatricial
alopecia Gray-white halos (arrow) around follicular ostia and
irregular distribution of pinpoint white dots(arrowhead)
43. SHORTCOMINGS OF TRICHOSCOPY
◦ Technical difficulties, software dependant.
◦ Sensitivity affected by multiple factors-
◦ shampooing habits of the local population
◦ racial skin types.
◦ Yellow dots- not visible over freshly cleansed scalp.
◦ Vascular patterns- not visualized in darker populations.
◦ Not very specific - overlap of findings.
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44. RECENT ADVANCES
◦ TRICHOSCOPIC ACTIVITY SCALE FOR FOLLICULITIS
DECALVANS
◦ predict the severity of disease.
◦ assessed by investigators global assessment (IGA)
◦ 10-point scale.
◦ Final scores range 0 to 3
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DISEASE WORSENING
• perifollicular erythema
• follicular pustules
• follicular extravasation,
• Yellow tubular scaling
• yellow crusts
DISEASE IMPROVEMENT
• Well-defined thin arborizing vessels
45. CONCLUSION
◦ In the absence of a definitive, non-invasive and reliable diagnostic technique for hair and scalp disorders,
a trichoscope comes in as a handy and reliable tool.
◦ It is relatively easy to acquire the skill and expertise needed for trichoscopy as it can be mastered by all
those with a keen eye to observe.
◦ Easy record keeping, documentation and comparison with pre-treatment images help to evaluate
therapeutic response and satisfy anxious patients.
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