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 Table of Contents  
ORIGINAL ARTICLES
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 43-56

Trichoscopy as an essential diagnostic technique for hair and scalp disorders in skin of color: A case-control study


Postgraduate Department of Dermatology, Venereology, and Leprosy, Government Medical College, Srinagar, University of Kashmir, Jammu and Kashmir, India

Date of Submission05-Oct-2020
Date of Decision20-Feb-2021
Date of Acceptance08-Jun-2021
Date of Web Publication06-Oct-2022

Correspondence Address:
Yasmeen Jabeen Bhat
Postgraduate Department of Dermatology, Venereology, and Leprosy, Government Medical College, Srinagar, University of Kashmir, Jammu and Kashmir 190010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdpdd.ijdpdd_112_20

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  Abstract 

Background: Hair and scalp disorders cause significant morbidity, warranting an early diagnosis and treatment. Trichoscopy has shown great promise in the diagnosis and assessment of these disorders. Aims: The aim of this study was to determine the trichoscopic findings in cases of alopecia and scalp disorders and to determine their statistical significance. Materials and Methods: This was a case–control study in which trichoscopy using a hand-held dermoscope was done in 605 patients and 200 controls. Results: The trichoscopic findings that showed statistical significance in 405 alopecia cases when compared with controls were broken hair, exclamation hair, black dots, yellow dots, vellus hair and pigtail hair in alopecia areata, hair diameter variability, single hair predominance, brown and white peripilar sign in androgenetic alopecia, corkscrew hair, comma hair, morse-code hair and interfollicular scale in tinea capitis, and white dots and peripilar erythema in primary cicatricial alopecia. The findings which had a statistical relevance among scalp disorders included light red background, dots and globules and dermoscopic Auspitz’s sign for psoriasis, dark red background and arborizing vessels for eczemas and yellowish background for verrucae, comedo-like openings, milia-like cysts and moth-eaten borders for seborrheic keratosis, and viable nits for pediculosis capitis. Conclusion: Our study documented many trichoscopic features which were statistically significant among cases of alopecia and scalp disorders when compared with controls. Limitations: Histopathological confirmation of diagnosis was not done in most of the cases. The patients were not subjected to follow-up trichoscopy after treatment.

Keywords: Alopecia, cicatricial, scalp disorders, trichoscopy


How to cite this article:
Bhat YJ, Shah FY, Saqib Nu, Shah AA, Latif I, Zeerak S, Dar UK, Bashir Y, Hassan I, Rather SP. Trichoscopy as an essential diagnostic technique for hair and scalp disorders in skin of color: A case-control study. Indian J Dermatopathol Diagn Dermatol 2021;8:43-56

How to cite this URL:
Bhat YJ, Shah FY, Saqib Nu, Shah AA, Latif I, Zeerak S, Dar UK, Bashir Y, Hassan I, Rather SP. Trichoscopy as an essential diagnostic technique for hair and scalp disorders in skin of color: A case-control study. Indian J Dermatopathol Diagn Dermatol [serial online] 2021 [cited 2023 Jan 27];8:43-56. Available from: https://www.ijdpdd.com/text.asp?2021/8/2/43/357930




  Introduction Top


Hair and scalp disorders are a common affliction which arises from problems within the hair or scalp skin and may be congenital or acquired. The most common presentation of scalp and hair disorders is in the form of alopecia, although some disorders of the scalp may not have associated hair loss. Scalp disorders such as seborrheic dermatitis, psoriasis, scalp folliculitis, etc. do not lead to alopecia, whereas others such as telogen effluvium, discoid lupus erythematosus (DLE), tinea capitis, etc. are associated with hair loss. Hair loss from the scalp can be localized or generalized, cicatricial or non-cicatricial.

Analysis of cases of hair loss involves invasive as well as non-invasive procedures with scalp biopsy and trichogram belonging to the former group, whereas potassium hydroxide mounts and dermoscopy concur with the latter. Dermoscopy, also known as epiluminescence microscopy or skin surface microscopy, is a non-invasive diagnostic modality used extensively in the diagnosis of skin disorders.[1] Kossard and Zagarella[2] in 1993 described spotted pale dots in cicatricial alopecia in a dark-skinned patient, as first dermoscopic feature in hair disorders. The term “trichoscopy” was coined by Rudnicka et al.[3] in 2006 to refer to the dermoscopy of scalp and hair. Trichoscopy has shown great promise in the diagnosis, assessment, and follow-up of various disorders of scalp and hair. It allows for visualization of hair shafts at high magnification without the need for plucking out hair, along with analysis of epidermal portion of hair and interfollicular epidermis. Trichoscopy can be performed using a hand-held dermoscope or videodermoscope. In recent years, the hand-held dermoscope has proved to be a reliable and consistent device with results comparable to those of a videodermoscope.[4]

There is paucity of literature with reference to trichoscopy from this part of the world. This study was conducted to assess the utility of trichoscopy and to identify the trichoscopic features of various types of alopecias and scalp disorders in our population.

Aims and objectives

This study was designed to determine the trichoscopic findings in patients with different types of alopecia as well as scalp disorders and to determine statistical significance of such findings, if any.


  Materials and Methods Top


This was a case–control study conducted in the trichology clinic of dermatology outpatient department (OPD) in a tertiary care hospital over a period of 4 years from July 2015 to June 2019. Ethical clearance was obtained from the Institutional Ethical Committee before enrolling study participants. Patients presenting with hair and scalp disorders who were referred to the trichology clinic for evaluation were recruited after obtaining an informed consent. Two hundred cases who did not have any scalp or hair disorder were enrolled as controls.

Inclusion criteria

Patients presenting to the dermatology OPD with hair or scalp disorders were included in the study after obtaining an informed consent from the patient or the guardian. Those who presented to the OPD for cosmetic indications or problems unrelated to the scalp and hair were included as controls.

Exclusion criteria

Patients who did not consent to be a part of the study, children less than 12 years age, pregnant and lactating females, those suffering from other systemic disorders, and those taking drugs which could cause alopecia were excluded from the study.

All the patients were subjected to clinical and dermoscopic examination. A detailed history was taken followed by a thorough clinical examination. Pull test was done in all the patients. Relevant laboratory investigations such as hemoglobin, serum ferritin levels, thyroid-stimulating hormone, hormone profile and ultrasonography pelvis, potassium hydroxide mount (KOH) and culture of hair, and biopsy were carried out in selected patients with diagnostic difficulty. Trichoscopy was done using a hand-held dermoscope (DermLite 3Gen DL3N, CA, USA), with a magnification of 10–20×. Images were recorded using I-phone 6 attached to the dermoscope. Trichoscopic evaluation was done using both non-polarized and polarized modes, with and without a fluid interface. Spirit (70% isopropyl alcohol) was used as the linkage fluid. Structures analyzed with trichoscope included hair shafts, follicular openings, perifollicular areas, inter-follicular epidermis, and cutaneous vasculature, in that order in all cases. For diffuse hair loss, both frontal and occipital areas were compared for hair shaft thickness (evaluation of at least 50 hairs from each area).

All the data were tabulated in the form of a master chart and subjected to statistical analysis using OpenEpi software. The findings in cases and controls were analyzed for significance using χ2 test, and P-value less than 0.05 was taken as significant.


  Results Top


The study included a total of 605 cases of scalp and hair disorders. This included 405 patients presenting with alopecias of various etiologies, constituted by 245 females and 160 males. Additionally, there were 200 patients presenting exclusively with scalp disorders without any evidence of hair loss. These included 105 males and 95 females presenting with disorders such as psoriasis, seborrheic dermatitis, etc. Two hundred healthy individuals, 100 males and 100 females, were also enrolled to act as controls. The age of the patients ranged from 13 to 65 years with a mean age of 24.89 ± 11.73 years, whereas that of controls varied from 13 to 69 years with a mean age of 25.64 ± 12.35 years. Majority of our cases were from a rural background (54%) and the remaining were from urban areas (46%). The patients were divided into two broad groups based on pattern and extent of hair loss: localized (35.3%, n = 143/405) and diffuse (64.7%, n = 262/405). Further classification was done based on distinctive clinical findings, trichogram, KOH, fungal culture, and biopsy, and the same is tabulated in [Table 1] and [Table 2].
Table 1: Classification of alopecia patients encountered in our study

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Table 2: Classification of scalp disorders encountered in our study

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The trichoscopic features in alopecia patients and controls were compared and are listed in [Table 3], along with findings of statistical significance indicated by a P-value of ≤0.05. The most common trichoscopic findings in control subjects were arborizing vessels (21%), dirty dots (12.5%), dotted vessels (12%), and perifollicular scaling (8.5%). Out of all the trichoscopic findings, dirty dots were encountered more frequently among controls when compared with alopecia cases.
Table 3: Comparison of trichoscopic findings in alopecia cases and controls

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Trichoscopic findings in diffuse alopecias

The findings that were encountered during trichoscopy of cases of diffuse alopecias are enumerated in [Table 4]. In diffuse alopecia areata (AA), black dots (84%), yellow dots (64%), broken hair (60%), and vellus hairs (56%) were commonly encountered findings. Exclamation mark hairs, pigtail hairs, comma hairs, and alternate coloured hairs (flag hair sign) were seen exclusively in cases of diffuse AA and not in other diffuse alopecias [Figure 1]. In androgenetic alopecia (AGA), hair diameter variability of ≥20% was the single most common finding. Vellus hair and single hair predominance were among commonly encountered findings. Peripilar sign was also observed more frequently than in other causes of diffuse alopecias [Figure 2]. In chronic telogen effluvium, a number of findings such as perifollicular and interfollicular scaling, comma, hairpin, and arborizing vessels were encountered more frequently [Figure 3].
Table 4: Comparison of trichoscopic findings in cases of diffuse alopecias

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Figure 1: Trichoscopy of diffuse AA showing short broken hairs (green arrows), black dots (blue arrows), and pig tail hairs (yellow arrows) (DermLite DL3N, polarized, 10×)

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Figure 2: Trichoscopy of AGA showing brown peripilar sign (yellow arrow), hair shaft diameter diversity shown by vellus hair (green arrows), intermediate hair (blue arrows), terminal hair (purple arrows), and single hair in most of the follicles (DermLite DL3N, polarized, 10×)

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Figure 3: Trichoscopy of chronic telogen effluvium showing absence of hair shaft diameter diversity, predominantly single terminal hairs (purple arrows) and upright regrowing hairs (blue arrows) (DermLite DL3N, polarized, 10×)

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Trichoscopic findings in localized alopecias

The trichoscopic findings encountered in cases of localized alopecias along with their frequencies are listed in [Table 5]. In AA, the most common dermoscopic finding was black dots (71.7%). Yellow dots, red dots, peripilar erythema, and vellus hair were encountered more commonly in AA when compared with other forms of localized alopecia [Figure 4]. Dotted vessels and hairpin vessels were encountered exclusively in cases of AA. Pigtail hairs were exclusive to this type of localized alopecias. In trichotillomania (TTM), the most common findings included broken hairs (100%) and black dots (93.7%). Tulip hairs, mace hairs, flame hair, V sign, and burnt matchstick sign were seen exclusively in cases of TTM [Figure 5]A & [Figure 5]B. In tinea capitis, findings such as interfollicular scales (100%), broken hairs (91.2%), perifollicular scaling (83.3%), and black dots (79.2%) were commonly encountered. Corkscrew hairs and morse-code hairs were found exclusively in cases of tinea capitis [Figure 6].
Table 5: Comparison of trichoscopic findings in cases of localized alopecias

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Figure 4: Trichoscopy of focal AA showing yellow dots (blue arrows), exclamation hairs (green arrows), and black dots (yellow arrows) (DermLite DL3N, polarized, 10×)

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Figure 5: Trichoscopy of TTM showing (A) broken hair shafts of different lengths (green arrows), hair powder (yellow stars), flame hair (blue arrow), burnt matchstick sign (purple arrow). (B) Trichoptilosis (green arrow), V-sign (yellow arrows), tulip hair (blue arrow), burnt matchstick sign (purple arrow), short-coiled hair (orange arrow) (DermLite DL3N, polarized, 10×)

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Figure 6: Trichoscopy of tinea capitis showing corkscrew hair (green arrows), zig-zag hair (yellow arrows), comma hair (orange arrows) (DermLite DL3N, polarized, 10×)

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In traction alopecia, fringe sign and peripilar cast were seen exclusively. Also vellus hair, black dots, focal atrichia, and white areas were seen [Figure 7].
Figure 7: Trichoscopy of traction alopecia showing peripilar casts (blue arrows), vellus hairs (green arrows), follicular plugs (orange arrows), black dots (yellow arrow), atrichia (purple stars) (DermLite DL3N, polarized, 10×)

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In primary cicatricial alopecias (PCAs), the most common dermoscopic findings seen were white dots (88.9%), broken hairs (44.4%), and perifollicular scaling (44.4%). Tufted hairs, collar sign, and pseudo-fringe sign were seen in some cases [Figure 8][Figure 9][Figure 10][Figure 11][Figure 12].
Figure 8: Trichoscopy of lichen planopilaris showing peripilar collar of scales (yellow arrows) and absence of follicular openings (blue stars) (DermLite DL3N, polarized, 10×)

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Figure 9: Trichoscopy of folliculitis decalvans showing polytrichia (yellow arrows) and absence of follicular openings (green stars) (DermLite DL3N, polarized, 10×)

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Figure 10: Trichoscopy of DLE showing follicular red dots (blue arrows), yellow dots (green arrows), speckled pigmentation (blue star) (DermLite DL3N, polarized, 10×)

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Figure 11: Trichoscopy of frontal fibrosing alopecia showing lonely hairs (green arrows), absence of vellus hairs, and atrophy with absence of follicular openings (blue stars) (DermLite DL3N, polarized, 10×)

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Figure 12: Trichoscopy of dissecting cellulitis of scalp showing 3-D yellow dots (green arrow), scales (yellow arrow), and absence of follicular openings (blue stars) (DermLite DL3N, polarized, 10×)

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Trichoscopic findings in scalp disorders

The trichoscopic findings encountered in various scalp disorders were compared with controls and subjected to inter-disease comparison as well [Table 6] and [Table 7]. In case of scalp psoriasis, dots and globules and white scales were found to be statistically significant findings. The dermoscopic Auspitz sign could be picked up more easily than the clinical Auspitz sign [Figure 13]. Features like dull red background, yellow scales, and arborizing vessels were found to be significant markers for the diagnosis of seborrheic dermatitis [Figure 14]. Yellowish white papillomatous globules with looped vessels and punctate hemorrhages at the tips were a commonly encountered finding in verrucae [Figure 15]. Presence of a brownish black background, comedo-like openings, milia-like cysts, and moth-eaten border was limited to cases of seborrheic keratosis [Figure 16]. Nevus sebaceous cases were characterized by the presence of yellowish globules and less commonly a yellowish background [Figure 17]. Polymorphic vessels and white structureless areas were encountered in both cases of squamous cell carcinoma, whereas rosettes were seen in one of them [Figure 18].
Table 6: Comparison of trichoscopic findings in scalp ­disorders and controls

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Table 7: Comparison of trichoscopic findings in different scalp disorders

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Figure 13: Trichoscopy of scalp psoriasis showing white scales (blue arrows) and regular red dots and globules (green arrows) on a dull red background (blue stars) (DermLite DL3N, polarized, 10×)

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Figure 14: Trichoscopy of seborrheic dermatitis showing arborizing vessels (green arrows) on a yellowish background (blue stars) (DermLite DL3N, polarized, 10×)

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Figure 15: Trichoscopy of verruca showing pin-point hemorrhagic red dots (green arrows), looped vessels surrounded by the hyperkeratotic whitish halo (yellow arrows) (DermLite DL3N, polarized, 10×)

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Figure 16: Trichoscopy of seborrheic keratosis showing comedo-like opening (yellow arrow) and ridges and grooves in cerebriform pattern (green stars) (DermLite DL3N, polarized, 10×)

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Figure 17: Trichoscopy of nevus sebaceous showing yellowish clods and globules aggregated in clusters (green arrows) with pinkish erythematous papillary appearance at places (blue arrow) (DermLite DL3N, polarized, 10×)

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Figure 18: Trichoscopy of squamous cell carcinoma of the scalp showing polymorphous vessels (yellow star), hemorrhagic areas (green star), milky white structureless areas (blue star), rosettes (blue arrows), and whitish scales (red arrows) (DermLite DL3N, polarized, 10×)

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Presence of nits was confirmed in 100% cases of pediculosis capitis when observed with the help of a dermoscope [Figure 19]. A ‘wrangled mesh of wire” appearance on trichoscopy characterized all cases which were historically and clinically consistent with a diagnosis of plica polonica [Figure 20]. Vascular blotches and brown homogeneous and whitish structureless areas were the trichoscopic findings in the limited cases of Langerhans cell histiocytosis (LCH) encountered in our study [Figure 21].
Figure 19: Trichoscopy of pediculosis capitis showing viable nits as brownish opaque globules adherent to the hair shaft and convexity of outer side (green arrows) (DermLite DL3N, polarized, 10×)

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Figure 20: Trichoscopy of plica polonica showing intertwined mesh of wires of brownish hair and concretions (blue arrows) (DermLite DL3N, polarized, 10×)

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Figure 21: Trichoscopy of LCH showing vascular blotches (green arrows), brownish homogeneous areas (blue arrows), and whitish structureless areas (yellow arrows) (DermLite DL3N, polarized, 10×)

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  Discussion Top


Trichoscopy has demonstrated great potential in the diagnosis of various scalp and hair disorders.[4],[5],[6],[7],[8] In this study, we used 35 distinctive trichoscopic features and determined their significance in the diagnosis of localized and diffuse alopecias and compared the findings with those in normal individuals. Findings such as red dots, peripilar erythema, and hemorrhages and vasculature (dotted, comma, hairpin, arborizing vessels) were commonly seen in controls and did not show any statistically significant relation to either cases or controls and can be considered non-specific features.

Trichoscopic features in diffuse alopecias have been studied previously, though not as passionately as for localized alopecias. In diffuse AA, features like black dots, yellow dots, broken hairs, exclamation hairs, and vellus hairs have been reported as common findings.[9],[10] This was similar to the findings in our study. In addition, we found cadaverized hair in a significant proportion of our patients, which has mostly been reported as a classical finding in tinea capitis.[7] AGAs demonstrate hair shaft diameter variability (>20%) and peripilar sign, and these have been considered as significant diagnostic features on trichoscopy.[11],[12] In addition to these features, predominance of single hair follicles was found to be a significant finding of AGA in our study. The prevalence of brown peripilar sign and white peripilar sign was found to be much less common than that reported in other studies.[11] No specific trichoscopic features provide a clue to the diagnosis of telogen effluvium, but we found single and upright hairs to be more common in this group when compared with other causes of diffuse alopecias. Yellow dots have been reported in a previous study as the most important trichoscopic feature to distinguish telogen effluvium from AGA.[13] However, we could not document any such findings, and the prevalence of yellow dots in telogen effluvium was found to be quite low in our study.

The role of trichoscopy in the diagnosis of localized alopecias has been studied extensively. Black dots, yellow dots, vellus hair, broken hairs, and exclamation hairs have been reported as common dermoscopic findings in previous studies on localized AA.[14],[15] Although similar findings were encountered in our study, only yellow dots, vellus hairs, and exclamation hairs were encountered more frequently in AA in comparison to other localized alopecias. Black dots and broken hair, although seen in AA, were confronted more commonly in alopecias due to other causes. In cases of TTM, detection of broken hairs with variable length has been documented as a specific finding on trichoscopy.[16] We found a similar trend to all cases of TTM showing broken hairs with variable length on trichoscopy. Trichoscopic signs such as hair powder, tulip hair, mace hair, flame hair, V sign, and burnt matchstick sign have been reported previously in literature and were appreciated as less common findings in our study.[17],[18],[19] Cadaverized hairs and coudability hairs, which are otherwise regarded as features specific to AA, were also encountered in some cases of TTM in our study.

Corkscrew hairs, comma hairs, and morse-code hairs are regarded as findings specific to the diagnosis of tinea capitis,[20],[21] and the same was corroborated in our study. Other findings like interfollicular and perifollicular scaling were also observed frequently but are considered to be non-specific. However, the frequent occurrence of interfollicular and perifollicular scaling in tinea capitis merits consideration as a trichoscopic feature of tinea capitis. The findings in traction alopecia were non-specific in our study. Peripilar casts and fringe sign were seen only in cases of traction alopecia, and this was consistent with previous reports.[5],[22] The predominance of single hairs in cases of traction alopecia was seen in a few cases but has not been reported extensively in literature. Owing to the low number of cases of traction alopecia, it was difficult to comment on the specificity of these findings.

In cases of PCAs, white dots and single hair follicles were found to be significantly common when compared with other causes of localized alopecias. This was in line with previous studies in which white dots and white areas, corresponding to areas of scarring, have been reported as prominent features of PCA. Additionally, tufted hairs and pseudo-fringe sign were found to be limited to cases of PCA in our study as found in previous studies.[23],[24]

In scalp psoriasis, regular distribution of red dots and globules was found to be a consistent feature. These dots correspond to the presence of dilated and tortuous capillaries arranged vertically in elongated dermal papillae. Although this feature can be observed in other inflammatory disorders as well, the uniform distribution of red dots and globules is a hallmark of psoriasis and has been reported consistently in previous studies.[25] A light or dull red background with overlying whitish scale was also found to be a regular feature, whereas yellow scales were not encountered in any case. The background color in psoriasis has been described as various shades of pink and red previously, whereas yellow scales are believed to be a negative predictor for psoriasis and the same was corroborated in our study.[26],[27] A dull red background with arborizing vessels and yellowish scales has been described as features representative of eczema on dermoscopy.[28] The same was validated in our study as well.

Punctate hemorrhages and a yellow-to-brown background have been consistently demonstrated as dermoscopic features of verrucae,[29] and the same was confirmed in our study. The most common dermoscopy findings in cases of seborrheic keratosis reported previously include comedo-like openings, milia-like cysts, and moth-eaten borders and our study confirmed the same.[30],[31] Presence of yellowish globules, which may be aggregated at times, over a yellowish background is a consistently reported dermoscopic feature of nevus sebaceous,[32] and the similar findings were concurred in our study. Squamous cell carcinoma is characterized by features such as polymorphic vessels and white structureless areas on dermoscopy.[33] Rosettes are seen less frequently.[34] A similar set of findings was seen in the few cases we came across during this study.

The diagnosis of pediculosis capitis is greatly improved with the help of dermoscopy as it helps to visualize the nits at high magnification and allows for differentiation from pseudonits.[35]

Trichoscopic examination in cases of plica polonica revealed “wrangled mesh of wire” appearance which occurs due to interlacing of hair shafts with matting and presence of honey-colored concretions. The trichoscopic findings correspond to the clinical appearance of dense-matted hair which looks like a “bird’s nest.”[36] The presence of vascular blotches in LCH is believed to correspond to dermal hemorrhage and has been found useful in differentiating it from seborrheic dermatitis along with other trichoscopic findings such as brown homogeneous areas, white structureless areas, and absence of dotted and non-dotted vessels.[37]


  Conclusion Top


In this study, we documented some typical trichoscopic patterns which can aid in the diagnosis and differential diagnosis of various localized and diffuse alopecias. Although most of the findings are consistent with those reported extensively by various authors, we report our experience and some new trichoscopic findings specific to different alopecias which have not been emphasized previously in the literature. Trichoscopy is an easy and reliable tool which can help in quick and non-invasive assessment of the scalp and thus direct therapy and management. This study will act as a stepping stone in this direction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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