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Evaluation of Clinical Significance of Dermoscopy in Alopecia Areata

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Evaluation of Clinical Significance of Dermoscopy in Alopecia Areata DERMOSCOPY ROUND Evaluation of Clinical Significance of Dermoscopy in Alopecia Areata Akhila Sai Guttikonda, Chintaginjala Aruna, D V S B Ramamurthy, K Sridevi, Senthil Kumar L Alagappan Abstract From the Department of Background: Alopecia areata (AA) is a common, chronic inflammatory disease characterized Dermatology, Venereology, by nonscarring hair loss on the scalp or any hair-bearing area of the body. Recently, Leprology, Katuri Medical dermoscopy, a noninvasive diagnostic procedure, has been employed for the diagnosis of AA. College and Hospital, Guntur, Andhra Pradesh, India Aim: To evaluate various dermoscopic patterns in AA and correlate these patterns with the disease activity and severity. Materials and Methods: Dermoscopy was performed on AA patients using DL1 dermoscope (magnification ×10 was used). The dermoscopic patterns Address for correspondence: recorded were analyzed to identify any correlation with the disease activity and severity. Dr. Chintaginjala Aruna, Results: A total of fifty patients of AA were recruited in the study. Female outnumbered Department of Dermatology, males with the ratio being 1.173:1. Mean age of the patients was 25.06 years. Mean duration Venereology, Leprology, of disease was 14 months. The most common site involved was scalp (80%) and type noted Katuri Medical College and Hospital, Guntur - 522 019, was patchy (84%). Various dermoscopic patterns noted were yellow dots (YD) (88%), short Andhra Pradesh, India. vellus hair (66%), black dots (BD) (58%), broken hairs (BHs) (56%), tapering hair (TH) (26%), E-mail: [email protected] Coudability hairs (14%), pigtail hair (14%), and Pohl-Pinkus constrictions (2%). Statistically significant correlation was observed between BD, BHs, THs, and disease activity. No significant correlation was found between severity and any of the dermoscopic features. Conclusion: The most common dermoscopic pattern in our study was YD. Presence of BDs, BHs, and THs indicate active disease. Dermoscopic patterns were not affected by severity of the disease. Key Words: Alopecia areata, black dots, dermoscopy, micro exclamation mark hair, yellow dots What was known? Various dermoscopic features in alopecia areata are black dots (cadaverous hairs), yellow dots, tapering hairs (exclamation mark hairs), and broken hairs. Introduction smooth surface and characteristic exclamation mark hair. Alopecia areata (AA) is a common, chronic inflammatory In the past, doubtful cases were confirmed by invasive disease characterized by nonscarring hair loss on procedures such as punch biopsy, which at times can the scalp or any hair-bearing area of the body. It be troublesome in pediatric age group. This problem accounts for 25% of all alopecia cases presenting to has been overcome by dermoscopy, a noninvasive the dermatologists and 2–3% of all new outpatient diagnostic procedure, which magnifies subtle clinical dermatology services in the USA and the UK, 3.8% in surface features of skin lesions as well as unveils some China, and 0.7% in India.[1-4] Although AA may occur at subsurface skin structures normally not visible even [6] any age, incidence is high among younger age group; in with a magnifying lens. Various dermoscopic features fact, it is the most common form of alopecia seen in in AA that are already described in the literature are children. Various patterns of alopecia described clinically black dots (BD) (cadaverous hairs), yellow dots (YD), are patchy, diffuse, reticulate, ophiasis, ophiasis inversus, tapering hairs (THs) (exclamation mark hairs), broken [7] and depending on the extent of hair loss, alopecia hairs (BHs), etc. With this background, we conducted subtotalis, alopecia totalis (complete loss of scalp hair), a study to evaluate various dermoscopic patterns in AA and alopecia universalis (complete loss of body hair) are that help in diagnosis and to correlate these patterns described.[5] with disease activity and severity so that ideal treatment can be planned. AA is diagnosed clinically by the presence of well-circumscribed, round, or oval bald patches with This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows Access this article online others to remix, tweak, and build upon the work non‑commercially, as long as the Quick Response Code: author is credited and the new creations are licensed under the identical terms. Website: www.e‑ijd.org For reprints contact: [email protected] How to cite this article: Guttikonda AS, Aruna C, Ramamurthy D, Sridevi K, Alagappan SL. Evaluation of clinical significance of dermoscopy DOI: 10.4103/0019‑5154.193668 in alopecia areata. Indian J Dermatol 2016;61:628‑33. Received: May, 2015. Accepted: August, 2016. 628 © 2016 Indian Journal of Dermatology | Published by Wolters Kluwer - Medknow Guttikonda, et al.: Dermoscopy in alopecia areata Materials and Methods and severity of scalp hair loss. The dermoscopic patterns We conducted a cross-sectional study on all AA patients recorded were analyzed to identify a correlation between attending to the outpatient department of our hospital any of the specific dermoscopic features and the disease from January 2013 to September 2014 after obtaining activity and severity by Spearman rank-order correlation Institutional Ethical Committee clearance. All the patients coefficient by rank test and their statistically significant with AA irrespective of age and sex who were willing was determined by calculating P value. to undergo the protocol were included in the study. An Results informed consent was obtained from the patient or parent or guardian in case of a child. Cases of AA were clinically Fifty patients of AA were recruited in the study. Most of diagnosed, and biopsy was done in ambiguous cases. the patients (86%) were younger than 40 years. There Epidemiological data (name, age, sex, and occupation), was an extreme variation in the duration of the disease, relevant history (age of onset, duration of the disease, ranging from 10 days to 8 years. The alopecia remained history of atopy, association with other autoimmune confined to the scalp in 72% (36/50) of the cases, only diseases, and family history), and clinical examination body hair was involved in 20% (10/50), and both were including general, systemic, and cutaneous examinations involved in 8% (4/50) of the cases. Most common type were documented. Biopsy was done in two cases to confirm of AA in our study was patch type. Localized patches the diagnosis. A number of patches, distribution, pattern, (1–3) were seen in 70% (35/50) of the cases and morphology, and characteristic features if any were noted. multiple patches (>3 patches) were seen in 14% (7/50) of the cases. Demographic and clinical details were given Dermoscopic patterns of the patches were noted with the in Table 1. In the present study of fifty patients, there help of DL1 dermoscope (DermLite, 3 Gen LLC, San Juan Capistrano, CA, USA) (magnification × 10) that can be used without immersion oil because of the presence of Table 1: Demographic and clinical characters of study polarized filters. Dermoscope was attached to Samsung population Galaxy S3 smartphone with an adaptor [Figures 1 and 2]. Character Values Dermoscopic features were observed, and the photographs Sex (female to male ratio) 1.173:1 were taken with the help of camera of mobile device. Age (mean±SD), years 25.06±12.08 Later, they were transferred to the laptop and were Disease duration (mean±SD), months 14±20 stored for further comparison and analysis. Assessment Positive family history of the disease, % 10 (5/50) of disease activity was based on the subjective history Association with atopy, % 32 (16/50) of progression and an objective evaluation of hair pull History of associated thyroid 8 (4/50) test at the margins of each individual patch. Severity of abnormalities, % disease was assessed by severity of alopecia tool (SALT) Various patterns of alopecia, % score calculated based on the combination of extent Patchy 84 (42/50) Reticulate 6 (3/50) Ophiasis 6 (3/50) Diffuse 4 (2/50) Site of involvement, % Scalp 80 (40/50) a Beard area 18 (9/50) Eye brow 2 (1/50) SD: Standard deviation b c Figure 1: (a) Cross-polarized spacer unit (b) DL1-dermacope (c) Samsung Galaxy S3 mobile phone, attached to DermLite mobile device case Figure 2: DermLite DL1 - dermoscope attached to mobile phone 629 Indian Journal of Dermatology 2016; 61(6) Guttikonda, et al.: Dermoscopy in alopecia areata were a total of 109 patches and hair pull test was done in 2004. Since then, it was widely used in this field at the margins of each individual patch to assess the because of its ease and noninvasiveness. activity. It was positive in 35% (38) of the patches and Table 2 depicts the comparison of dermoscopic features negative in 65% (71) of the patches. Grade S1 severity of our study with other Indian studies and with the was found in 58% of the study population as determined study done in Japan. by SALT score, the details were represented in Figure 3. Dermoscopic evaluation of the scalp in the current Yellow dots study revealed different hair shaft abnormalities and They represent distended follicular orifices of the various patterns at hair follicle openings against the affected follicles, filled with sebum and keratinous background of honeycomb pigment network. The most material. They appear as round or polycyclic, yellow to common finding was YDs followed by short vellus yellow-pink dots devoid of hairs or contain miniaturized hair (SVH) [Table 2 and Figures 4-9]. Micro-exclamation or cadaverized or dystrophic hairs. In our study, YDs mark hair was seen in 16% (8/50) of the cases. were seen in 88% (44/50) of cases, similar to the Statistically significant correlation was observed between other studies.[9-11] However, some studies reported BD, BHs, TH, and disease activity. SVHs correlated lesser incidence.[7,12,13] This variation in results can be negatively with the disease activity, but this was attributed to the difference in skin types (yellowish not statistically significant [Table 3].
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