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Vellus Hairs in Alopecia Areata: Sensitivity, Activity, Severity

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Vellus hairs are short, thin hairs are commonly seen in patients with alopecia areata. These hairs tend to be seen in patients with more severe and active disease. 
This photo shows vellus hairs in a patient with advanced alopecia areata involving 85 % of the scalp.
 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Alopecia Areata: Broken Hairs

Hair Breakage

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Alopecia areata is an autoimmune disease that affects hairs and nails. Inflammation deep under the skin in a region of the hair follicle known as the bulb leads to the production of weak hair follicles that break easily. Hair breakage is commonly seen in active alopecia areata. The photograph here shows a hair follicle that is about to break. Within hours the hair will likely break off at the site demarcated by the arrow. Treatment of alopecia areata can reduce inflammation and lead to the production of stronger hairs that do not break. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Secondary Hair Casts: Psoriasis

What are hair casts?

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Hair casts are thin, elongated, cylindrical concretions that encircle the hair shaft. Hair casts range in size from 2-7 mm and can be easily dislodged. The term was coined by Kligman in 1957.

Hair casts (sometimes called “pseudonits”) can be easily differentiated from true “knits" because they slide along hairs when grabbed with the fingers. They are usually asymptomatic and particularly common in young women.

Hair casts are said to be "primary" in nature when not associated with an underlying scalp disorder and "secondary" when associated with an underlying disorder. Common secondary causes include psoriasis, seborrheic dermatitis, pemphigus and traction alopecia and scarring alopecia. Many other causes are possible too including hair sprays and deodorants.

Hair casts are thought to represent material from both the internal root sheath and the external root sheath.

The photo here shows casts in a patient with psoriasis.
 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Scalp Psoriasis: Many Variations

Many Variations

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Dermoscopy of Scalp psoriasis. There are many variations in how scalp psoriasis appear. It can be red to pink and scaly white to scaly silver. Psoriasis needs to be differentiated from a range of inflammatory conditions such as seborrheic dermatitis, dandruff, scarring alopecia and various infectious causes.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Perifollicular erythema in FFA

Redness around hair follicles: Perifollicular eythema

Frontal fibrosing alopecia or "FFA" is a scarring alopecia (scarring hair loss condition) that most commonly develops in women 45-65. It causes permanent hair loss. The cause is not know although a mix of immune based mechanisms and hormonal mechanics are likely to contribute. The condition can be asymptomatic - and many patients have no itching, burning or pain.



FFA Disease Activity: How do we know it's' active or not

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How do we know whether a given patient's FFA is active? Undoubtedly, the absolute best way is with a photo. If a patient's photo changes over a period of monitoring (6 months or 12 months) the FFA is active by definition.

However, photographs don't capture subtle changes in activity. To accomplish this examination by "dermoscopy" is helpful. In this photo, slight redness around the hairs can be seen. We call this "perifollicular" erythema. (note peri means "around"). In 2013, Spanish researchers Toledo- Pastrana and colleagues published an article in the International Journal of Trichology examining dematoscopic features of FFA. Of 79 patients examined, 66 % showed perifollicular erythema. In patients with active disease, perifollicular erythema was present in 95 % of patients.


Conclusion


Perifollicular erythema is an important sign to look for in FFA. It indicates disease activity and a high likelihood of further hair loss in the patient.

 


Reference


Toledo- Pastrana et al. Perifollicular erythema as a trichoscopy sign of progression in frontal fibrosing alopecia. Int J Trichoscopy 2013; 5: 151-3.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Dissecting Cellulitis: Early Features

Early Stages of DSC

Dissecting Cellulitis (DSC) is a relatively rare scarring alopecia. Men are affected much more than women and affected patients are frequently young males in their 20s.

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The condition beings with discharge of pus and sometimes blood from the scalp. It can also be quite itchy. The beard, underarm (axilla) and groin can be affected with similar discharge. A key feature of diagnosis is the presence of sinus tracts or "tunnels" underneath the skin. Small thin vellus hairs are also seen in the affect area.

The primary treatment of DSC is isotretinoin although antibiotics, zinc, dapsone, colchicine, and TNF inhibitors can be used.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Pseudopelade of Brocq

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Pseudopelade of Brocq

Pseudopelade of Brocq (PPB) is a scarring alopecia. It causes permanent hair loss. The cause is unknown.

In contrast to lichen planopilaris, there is little to no scale around hair follicles. The areas may be pink-colored when active. Treatment is similar to lichen planopilaris including use of topical steroids, steroid injections, topical calcineurin inhibitors, oral methotrexate, oral doxycycline, oral hydroxychloroquine and others.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Alopecia Areata

Shaved scalp: Exclamation mark hairs

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Many patients with advanced alopecia areata shave their scalp. For some, this allows a wig to fit better. For others, especially men, the shaving is done to reduce the appearance of hair loss. 
Even with a shaved scalp, it is sometimes possible to tell if a patient's alopecia areata is active or not. This is especially true if exclamation mark hairs can be seen. "Exclamation mark" (arrow) hairs are easy to identify with a magnifying device. They are 3-5 mm in size and wide at the top and narrow at the bottom. They signal disease activity and the need for more aggressive treatment if hair loss is to be stopped.

Other features can also be seen on a shaved scalp including yellow dots (and hair follicles lacking a hair follicle) and hair follicles with just a single hair coming out (rather than in groups of 2 and 3 haired follicles).


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Eccrine Glands: White Dots

White Dots

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The eccrine glands are a type of sweat gland. They are abundant on the scalp (and even more abundant on the palms and soles). The eccrine gland openings can be more readily seen via trichoscopy (dermoscopy) in darker colored skin than lighter colored skin. This photo shows an arrow pointing to an eccrine gland opening. The variation in the thickness of hairs that can be seen in this image indicates an underlying diagnosis of androgenetic alopecia as well. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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EXCLAMATION MARK HAIRS IN ALOPECIA AREATA

 Variations In Size

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Exclamation mark hairs are hairs that are quite short. Most exclamation mark hairs are 4-6 mm in length but rarely they can be longer depending on the amount of inflammation under the scalp beneath that specific hair. Here in this photo, we can see two exclamation mark hairs of different lengths - one is 3 mm and the other is nearly 15 mm in length. Exclamation mark hairs are seen in alopecia areata, trichotillomania and a few other conditions as well. They are important signs in alopecia areata as they indicate disease activity


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Female Pattern Hair Loss

 

Major and Minor Criteria

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Female androgenetic alopecia is common. By the age of 50, well over 1/3 of women will have androgenetic alopecia (AGA)- also known as female pattern hair loss (FPHL). This type of hair loss causes thinning in the frontal and mid scalp. The sides and back may also be affected but generally to lesser degrees than the front for most women. Traditionally, the diagnosis of androgenetic alopecia has been made based on the finding of reduced density in the frontal scalp compared to the back of the scalp and the clear demonstration via dermoscopy that there is a variation in the diameter if more than 20% of hair follicles. This is known as anisotrichosis.

In 2009, Dr Rudnicka and colleagues proposed a series of major and minor criteria for diagnosing FPHL.

 

FPHL MAJOR CRITERIA

(1) ratio of more than four empty follicles in four images (at 70-fold magnification) in the frontal area

(2) lower average thickness in the frontal area compared to the occiput

(3) more than 10% of thin hairs (<0.03 mm in diameter) in the frontal area.

 

FPHL MINOR CRITERIA

(1) increased frontal to occipital ratio of single-hair pilosebaceous units

(2) vellus hairs

(3) peripilar signs.

 

Remarkably, the presence of two major criteria or of one major and two minor criteria allow diagnosis FPHL with 98% specificity.

 

Reference

Rakowska A et al. Int J Trichol. 2009;1:123–30.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Trichoscopy of Hair Dyes

Hair Dye Colors the Openings of Hair Follicles

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Hair dye can sometimes alter the up close appearance of the scalp. Hair dyes can deposit on the scalp given the appearance of hyperpigmentation. In addition, the hair follicle openings or “pores” can take up pigment simulating the appearance of “dots.”

Hair dye is generally safe for most patients with hair loss. However one must be aware that freshly dyed hair may take on a slightly altered appearance. This photos shows brown dots coating hair follicles in a patient with frontal fibrosing alopecia (FFA).

 

See also

Trichoscopy of Hair Dyes

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Trichoscopy of Late DLE

Late DLE: Features

 

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Discoid lupus (DLE) is an autoimmune condition affecting the scalp and skin. It can cause permanent hair loss in affected individuals. About 5% develop systemic lupus erythematosus, an autoimmune condition with the potential to affect many organs of the body. Late scalp lesions of DLE show hyperpigmentation, white structureless areas and telangiectatic vessels,


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Trichoscopy of Early DLE

DLE - Early Features

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Discoid lupus (DLE) is an autoimmune condition affecting the scalp and skin. It can cause permanent hair loss in affected individuals. About 5% develop systemic lupus erythematosus, an autoimmune condition with the potential to affect many organs of the body. Early scalp lesions show whitish scale, follicular plugging and a perifollicular white halo. Aggressive treatment of early DLE can prompt hair growth in some individuals


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Telogen Effluvium: What are upright regrowing hairs (URH)?

URH in TE

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Telogen effluvium refers to a type of hair loss whereby the patient experiences increased daily shedding. Shedding typically occurs 2-3 months after a "trigger" such as weight loss, surgery, illness, low iron, crash diet, medication initiation or development of some internal illness.

Dermoscopy (shown here) does not have many specific findings in patients with telogen effluvium although many upright regrowing hairs (URH) may be seem along with hair follicles containing only a single hair follicle.  


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Alopecia areata: Yellow dots

Yellow dots in AA

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Alopecia areata is an autoimmune disease affecting nearly 2% of the world’s population.

This condition is potentially regrowable although some patients have more challenging types of alopecia areata to regrow than others.

The photo shows typical “yellow dots” by dermoscopy. The yellow dots represent hair follicle openings that are filled with keratin. 
Yellow dots are very common in patients with AA. Together with black dots and short vellus hairs, yellow dots are associated with disease severity.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Differentiating between Short 1 cm Hairs by Dermoscopy: Many Possibilities !

How can we tell apart the various causes of short hairs?

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I'm frequently asked by patients and physicians how to determine the identify of a short 1 cm or so hair that is seen on the scalp. Looking at the scalp with dermoscopy, one often want to know "Is this a vellus hair I'm seeing or is it an upright regrowing hair as part of a telogen effluvium? ... or is it simply a normal regrowing hair ?"

This chart below helps summarize the main things I think about when I see a short hair. The answer does not necessarily come immediately but rather it comes by asking 4 questions:

1) Is the hair reasonably thick (i.e. 40-50 um or more) or is it very thin (less than 30 um)?

2) Are the ends pointy or blunt?

3) Are these short hairs found all over the scalp or just one area?

4) Are there just a few of these short hairs or lots and lots of them?

 

By working through these 4 questions, I can generally determine the cause of the short hair I'm seeing on the scalp. 

shorthairs

Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Sinus tracts in Dissecting Cellulitis

Dissecting Cellulitis (DSC)

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DSC is a rare scarring alopecia. It often affects young men. A key feature is boggy tender nodules that develop in the scalp, some of which drain pus. "Sinus tracts" are another feature and this refers to the presence of small tunnels that interconnect under the scalp.

This photo shows the appearance of one such "sinus tract" after it has entered a healing phase. This area will be permanently scarred with some degree of permanent hair loss in this area.

Treatment for DSC includes isotretinoin, antibiotics, TNF inhibitors. Second line agents include zinc, dapsone, colchicine. Surgical excision and laser therapies are also considerations. Some forms are challenging to treat.

For more information on DSC, see our Dissecting Cellulitis Handout for Patients


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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"Miniaturization" and "Anisotrichosis" in Androgenetic Alopecia

Terms in AGA: Miniaturization and Anisotrichosis

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Androgenetic alopecia is common in men and women. By 50 years, about 50 % of men and 30 % of women have some evidence of androgenetic alopecia. The early features of AGA include hair shedding in some and hair loss in specific areas (temples and crown in men and central scalp in women).

When examined up close as in this photo, one can see "miniaturization" of hairs whereby some thicker hairs undergo a change to thinner hairs. Most hairs we have on our scalp as teenagers range in around 70-90 micrometers in diameter. During the process of androgenetic alopecia, the follicles become thinner and thinner and over time reduce slowly to 50 micrometers then 20 then 10 etc. Finally the fibers are so thin and short that they fail to reemerge from the scalp.

Not all hairs become thin and not all hairs thin at the same speed (rate). There is great variation in the thickness of hairs. We call this variation in hair shaft thickness "anisotrichosis." Two finding of miniaturization and anisotrichosis is a typical feature of androgenetic alopecia in both men and women. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Single Hairs in Androgenetic Alopecia (AGA)

Isolated 'single' hairs in Androgenetic Alopecia

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Androgenetic alopecia is often referred to as "thinning" and certainly the progessive miniaturization of hairs is a feature of AGA.

However, another important feature is the disruption of the normal architecture of how follicles are grouped. Instead of finding follicles in groups of 1, 2 or 3 hair units hairs are often seen all by themselves in more advanced stages of AGA.

The accompanying photos shows numerous single hairs in a patient with moderately advanced AGA.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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