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Ultrasound Characteristics of the Hair Follicles and Tracts, Sebaceous Glands, Montgomery Glands, Apocrine Glands, and Arrector Pili Muscles

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Ultrasound Characteristics of the Hair Follicles and Tracts, Sebaceous Glands, Montgomery Glands, Apocrine Glands, and Arrector Pili Muscles ORIGINAL RESEARCH Ultrasound Characteristics of the Hair Follicles and Tracts, Sebaceous Glands, Montgomery Glands, Apocrine Glands, and Arrector Pili Muscles Ximena Wortsman, MD , Laura Carreño, MD, Camila Ferreira-Wortsman, MS, Rafael Poniachik, MS, Kharla Pizarro, MD, Claudia Morales, MD, Perla Calderon, MD, Ariel Castro, MSc Video online at jultrasoundmed.org Objectives—To explore the capability of very high-frequency ultrasound (US; 50–71 MHz) to detect the normal morphologic characteristics of the hair follicles and tracts, sebaceous glands, Montgomery glands, apocrine glands, and arrector pili muscles. Methods—A retrospective study, approved by the Institutional Review Board, evaluated the normal US morphologic characteristics of the hair and adnexal structures in a database of very high-frequency US images extracted from the perilesional or contralateral healthy skin of 1117 consecutive patients who underwent US examinations for localized lesions of the skin and 10 healthy Received September 26, 2018, from the individuals from December 2017 to June 2018. These images were matched with Institute for Diagnostic Imaging and Research their counterparts from the database of normal histologic images according to for the Skin and Soft Tissues, Santiago, the corporal region. The Cohen concordance test and regional mean diameters Chile (X.W.); Departments of Dermatol- of the hair follicles and adnexal structures were analyzed. ogy (X.W., P.C.) and Pathology, Dermo- Results—The normal hair follicles and tracts, sebaceous glands, Montgomery pathology Section (L.C., K.P., C.M.), Faculty glands, apocrine glands, and arrector pili muscles were observed on US images of Medicine (R.P.), and Office for Clinical and matched their histological counterparts in all the corporal regions. There Research Support, Hospital Clínico Universi- was significant US concordance (κ = 0.82; P = .0001) among observers. dad de Chile (A.C.), University of Chile, Regional mean diameters (millimeters) of the hair follicles, sebaceous glands, Santiago, Chile; and Faculty of Medicine, and apocrine glands are provided. University Finis Terrae, Santiago, Chile Conclusions— (C.F.-W.). Manuscript accepted for publica- The hair follicles and tracts, sebaceous glands, Montgomery tion November 11, 2018. glands, apocrine glands, and arrector pili muscles are detectable with very high- frequency US, including some regional and anatomic variants. Knowledge of Address correspondence to: Ximena their normal US appearances is a requisite for detecting subclinical changes, Wortsman, MD, Institute for Diagnostic understanding the physiopathologic characteristics, and supporting the early Imaging and Research of the Skin and Soft diagnosis and management of common dermatologic diseases. Tissues, Department of Dermatology, Faculty of Medicine, University of Chile, Lo Fontecilla Key Words—apocrine gland ultrasound; arrector pili muscle ultrasound; 201, Of 734, Las Condes, Santiago, Chile. dermatologic ultrasound; hair ultrasound; Montgomery gland ultrasound; E-mail: [email protected] sebaceous gland ultrasound; skin ultrasound; ultrasound dermatology Abbreviation kin conditions are among the leading causes of the global US, ultrasound burden of disease.1 However, to date, common dermatologic disorders still present unclear points in their physiopathologic S 2 doi:10.1002/jum.14888 characteristics and management. The ability to noninvasively © 2018 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2018; 9999:1–10 | 0278-4297 | www.aium.org Wortsman et al.—Ultrasound Characteristics of the Hair and Adnexal Structures detect the normal morphologic characteristics of the Review Board (approval number 055-2018) was per- hair and adnexal glands can allow identification of formed from December 2017 to June 2018. Before early subclinical abnormalities in many dermatologic the US examinations, all patients signed an informed conditions that affect millions of people worldwide, consent form following the standardized protocol for such as alopecia and acne.3,4 education and research of our center, and all of the Hair is a complex and dynamic structure that is examinations and images were analyzed under the one of the main hallmarks of mammals and a distinc- Helsinki principles of medical ethics. In the case of tive characteristic of an individual.5 The presence of children, the parents or guardians signed the an excessive amount or its loss can strongly affect informed consent, and all images were deidentified. self-esteem.6 The database was composed of 1127 examinations; Sebaceous glands contribute to the lubrication of 1117 of them were consecutive patients examined by the skin and hair.7 Variants of these glands are located dermatologists. The rest were 10 healthy adults. in some parts of the body, such as Montgomery In patients’ examinations, the dermatologic US glands in the areola.8 protocol typically includes a comparison with the Apocrine sweat glands provide support to the healthy skin located in the perilesional area or the thermoregulation and supposedly influence the scent contralateral side. The patients underwent very high- of an individual.9 These are located in some parts of frequency US studies of the healthy skin after examina- the body, such as the scalp, ciliary glands of the eyelids tions with another US device (LOGIQ E9 XD Clear; (Moll glands), external meatus (ceruminous glands), GE Healthcare, Waukesha, WI) equipped with a trans- and axillary and perineal regions, among others.10 ducer working at a maximum frequency of 18 MHz. Currently, ultrasound (US) is a suitable and rap- The healthy individuals underwent very high-frequency idly growing imaging modality for studying skin and US examinations of the face (right cheek), right axillary nail disorders because of the development of high- region (middle third), and right thigh (upper and inner frequency transducers (≥15 MHz).11 Although the third) region, and the diameters (millimeters) of the US characteristics of the hair follicles and tracts have hair follicles, sebaceous glands, and apocrine glands been reported at 15 MHz,12,13 this frequency does were measured. All cases were studied with the same not allow distinction of the internal part of the hair very high-frequency transducer that operates at a range tract located inside the hair follicle or the adjacent of frequencies from 29 to 71 MHz (Vevo MD, UHF adnexal structures, such as sebaceous glands, apocrine 70; VisualSonics, Toronto, Ontario, Canada). This glands, and the arrector pili muscle. transducer had an axial resolution of 30 μm and a Besides a few attempts to describe the morpho- lateral resolution of 65 μm. An automatic setting for logic characteristics of the hair and sebaceous glands superficial structures that comprises a range from – using experimental US devices in small series,14 16 to 50 MHz (center) to 71 MHz (maximum), a minimum date, there are no reports on the US morphologic gain of 43 dB, low persistence, and a dynamic range of characteristics of the rest of the adnexal structures 65 dB was used. Automatic adjustment of the fre- such as the apocrine glands and the arrector pili mus- quency of the transducer according to the depth of the cle on devices that are available worldwide. This study observation was enabled. Since the targets were com- aimed to explore the capability of very high-frequency posed of very superficial structures located in the first (≥50 MHz) US for detecting the normal morpho- 5 mm; the transducer automatically set the frequency logic characteristics of the hair follicles and tracts, at the higher values of the bandwidth. The maximum sebaceous glands, apocrine glands, Montgomery depth for this transducer is 10 mm; the focal depth is glands, and arrector pili muscles. 5 mm; and the view was adjusted by using a copious amount of gel, according to the diameter and depth of the structure and the thickness of the skin in each cor- Materials and Methods poral region. The spatial resolution was 0.05 mm (50 μm). There were 2 more transducers available for A retrospective study of the database of dermatologic use with the very high-frequency device (Vevo MD; US examinations approved by the Institutional VisualSonics): UHF 48 (range, 20–46 MHz) and 2 J Ultrasound Med 2018; 9999:1–10 Wortsman et al.—Ultrasound Characteristics of the Hair and Adnexal Structures UHF 22 (range, 10–22 MHz). However, neither of A tutorial with comparative histologic and US these very high-frequency transducers nor the available images of the same cutaneous structures was devel- 18-MHz transducer (maximum frequency) working on oped. Then a questionnaire with US images that were the LOGIQ E9 XD Clear machine was used in the different from the ones used in the tutorial was built. study for detecting or identifying structures. Both the tutorial and questionnaire were sent to 5 med- The inclusion criteria were patients with localized ical observers from different medical backgrounds and skin lesions on one side of a corporal segment who levels of training who were not involved in the genera- were otherwise healthy and healthy adults with no tion of the data. These observers included a dermato- history of cutaneous procedures or surgery in the pathologist, a resident of pathology (second year), a examination regions. The exclusion criteria were a dermatologist, and 2 medical students (second year). history of systemic dermatologic diseases and a his- These observers blindly and separately answered tory of cosmetic or plastic surgery
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