Scaling around hair follicles

Perifollicular Scale

The appearance of white colored scale around hair follicles is common. This can either be concerning - or not concerning. The white scale in the right picture is not concerning and represents a mild scale from normal epidermal turnover. The patient also has androgenetic alopecia. There is only one follicle affected and the scale is not tightly adherent to the hair follicle. When I see this, it catches my attention for just a second and then I move on to assess other scalp features.

The picture on the left shows a pattern of scale which is concerning. When I see hair follicles that look like this I am immediately concerned. This scale is tightly adherent to the follicle and forms a circular shape all around the follicle. It is important to note the underlying redness and it is also important to note that all of the follicles in the photo are just single hairs. Scale that tightly encircles the hair follicle in this manner is known as "perifollicular scale." In this left sided picture, the patient has an underlying scarring alopecia known as lichen planopilaris. Perifollicular scale and perifollicular redness are common in lichen planopilaris (as well as frontal fibrosing alopecia). Scale patterns can change if a patient washes his or her hair within 12 hours of their appointment. Sometimes, in order to better appreciate scaling in patients with challenging diagnoses - I will ask them to refrain from washing the scalp for 24-72 hours. I don't commonly do this but it can be helpful.