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CME ARTICLE
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 93-101

Trichoscopy in pediatric age group


1 Medical Director, Department of Dermatology, Rita Skin Foundation, Kolkata, West Bengal, India
2 Consultant Dermatologist, Department of Dermatology, Rita Skin Foundation, Kolkata, West Bengal, India

Date of Web Publication26-Mar-2018

Correspondence Address:
Purva R Mehta
15, Lovely Rose Apartments, Juhu Road, Juhu, Mumbai - 400 049, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_109_17

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  Abstract 


Approach to trichology in the pediatric age group is based on the clinical expertise of the dermatologist and investigative techniques. Currently, the trichoscope is an indispensible, noninvasive tool in the diagnosis of trichological disorders. It not only highlights the subtle tricoscopic points invisible to the naked eye but also serves as a prognostic and monitoring tool in therapeutic management. Trichoscopy goes a long way in improving the diagnostic and clinical acumen of the physician. In the pediatric age group, trichoscopy deals with pattern analysis ranging from hair shaft patterns to follicular, perifollicular, and interfollicular patterns. It not only describes the key trichoscopic features of noncicatricial alopecias, cicatricial alopecias, and genetic hair shaft defects but also helps to delineate various trichological mimics from each other. For compiling data, all trichology cases presenting to a tertiary care center were examined and photographed with a Fotofinder, DermLite Foto II Pro, and DermLite DL 3N. All trichological data were analyzed, and interpretations were based on the literature available.

Keywords: Cicatricial alopecia, genetic hair shaft defects, noncicatricial alopecia, pediatric age group, trichoscopic pattern analysis, trichoscopy


How to cite this article:
Malakar S, Mehta PR, Mukherjee SS. Trichoscopy in pediatric age group. Indian J Paediatr Dermatol 2018;19:93-101

How to cite this URL:
Malakar S, Mehta PR, Mukherjee SS. Trichoscopy in pediatric age group. Indian J Paediatr Dermatol [serial online] 2018 [cited 2018 Apr 23];19:93-101. Available from: http://www.ijpd.in/text.asp?2018/19/2/93/228345




  Introduction Top


Pediatric trichology is a two-pronged approach, based on clinical knowledge and investigative techniques. The investigative techniques are either invasive or noninvasive. Since invasive procedures in the pediatric age group are cumbersome, trichoscope serves as a simple yet effective, noninvasive device to aid clinical diagnosis and monitor therapeutic response. Pediatric trichoscopy can be performed by nonpolarized trichoscopy, polarized contact, or polarized noncontact trichoscopy. Polarized trichoscopy has the advantage of cross-polarized filters, which eliminate light reflected off the skin surface and allow light reflected from the deeper structures to reach the physician's eye. This review summarizes basic trichoscopic patterns and describes key trichoscopic features of common trichological conditions encountered in day-to-day practice. The first author (SM) was an invited speaker on 'Trichoscopy' in 2018 AAD Annual Meeting at San Diego, California.


  Methods Top


For data selection, all trichology patients presenting to the outpatient department of a tertiary care center were analyzed with a trichoscope. A DermLite DL3N, Fotofinder, and a DermLite Foto II Pro were used to study all trichological cases and capture images. Images were analyzed by 3 dermatologists, and trichoscopic findings were recorded. Interpretation of data was done on the basis of trichoscopic literature available.


  Trichoscopy Tool Top


A dermatoscope used on the scalp to diagnose hair and scalp disorders is called a trichoscope. Trichoscopic tool could be handheld or digital. Magnification provided by a trichoscope is 10–100 fold or even higher. Digital trichoscopes are preferred as they allow higher magnification of images and also enable photography of trichoscopic images. Fotofinder is an excellent system serving a dual purpose of digital trichoscopy and providing for trichoscopic evaluations. Trichological parameters such as hair count, hair shaft diameter, and follicular unit count are easily obtained through Fotofinder without indulging in invasive biopsies or painful practices of plucking of hair.[1]


  Trichoscopic Pattern Analysis Top


To understand and decipher trichoscopic images, it is essential to first study the trichoscopic patterns that signify various trichological conditions.

Hair shaft

  • Vellus hair is hypopigmented and nonmedullated, and comprises of 10% of normal scalp hair. Its length is <3 mm
  • Terminal hair is uniform in color and thickness along its entire length [2]
  • Tapering hair include exclamation mark hair and coudability hair, commonly seen in alopecia areata. Exclamation mark hair is a short broken hair with a hypopigmented, tapering proximal portion and a darker, thicker distal portion. Coudability hair, on the other hand, is hair of normal length with narrowing at the proximal part [Figure 1]a[3],[4],[5]
  • Circle hair or pigtail hair is a short, vellus hair that is thinned and coiled. Large number of circle hair on trichoscopy is almost diagnostic of alopecia areata [4]
  • Pohl–Pinkus constrictions are constrictions on the hair shaft placed at irregular intervals. They are commonly seen in alopecia areata [Figure 1]b[6]
  • Short regrowing hair or upright regrowing hair has a tapered distal end, the thickness of the shaft increases toward the proximal end. The thickness of a short regrowing hair is normal or <0.03 micrometer and is seen in telogen effluvium and the recovery phase of alopecia areata.[7] Short regrowing hair needs to be distinguished from vellus hair. Vellus hair is short, thin, and hypopigmented, whereas a short regrowing hair is upright, uniformly pigmented, and has a pointed distal end [Figure 1]c[8]
  • Comma hair is a short, curved “c”-shaped hair resembling a comma. It is seen in tinea capitis, both in endothrix and ectothrix infections [9]
  • Corkscrew hair is also seen both in ectothrix and endothrix infections of tinea capitis. It is a short hair, spirally shaped, and resembles a corkscrew [10]
  • Z hair is a zigzag-shaped hair with sharp bends at multiple points of the hair shaft as a result of focal weakening. Z hair is found in tinea capitis, alopecia areata, trichorrhexis nodosa, etc.[11],[12]
  • Broken hairs are formed as a result of breakage of hair shafts at various levels from the scalp surface and are seen in trichotillomania, alopecia areata, tinea capitis, etc.[13],[14]
  • Flame hair is a cone-shaped, wavy hair resembling a flame and is characteristic of trichotillomania. Flame hair corresponds to a pigmented cast on histopathology [15]
  • Block hair is a short hair with a horizontal distal tip and is found in tinea capitis [15]
  • i hair is defined as a short, broken hair with an accentuated distal end resembling the letter “i.” It has been seen in tinea capitis and trichotillomania [Figure 1]d[15],[16]
  • Coiled hair is a broken hair that curls back on itself and is seen typically in trichotillomania. Due to repetitive pulling, the hair shaft contracts and coils. Circle hair is also coiled but can be distinguished from coiled hair as it is uniform in thickness and shape.[15]
Figure 1: (a) Trichoscopic field is filled with exclamation mark hair (black arrows). It signifies disease activity in alopecia areata. (b) Pohl–Pinkus constriction is commonly seen in alopecia areata and anagen effluvium. (c) Short regrowing hair (red arrow) is upright, has a pointed tip, and is uniformly pigmented. (d) “i hair” is seen in tinea capitis, trichotillomania. It is a short broken hair which resembles the letter “i” as it has an accentuated distal tip with a hypopigmented shaft beneath the dark tip

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Follicular and perifollicular pattern

Follicular pattern on trichoscopy deals with dots which are circular, follicular openings.

  • Black dots are formed as a result of hair broken at the level of the scalp and are found in trichotillomania, alopecia areata, tinea capitis, etc. They are not present in healthy children [Figure 2][17]
  • Yellow dots are dilated follicular openings containing keratosebaceous material. Although they are characteristic of alopecia areata, yellow dots are also seen in discoid lupus erythematosus, dissecting cellulitis of scalp, etc.[18]
  • White dots on trichoscopy are of two types, namely, pinpoint and fibrotic. Pinpoint white dots are regular with a diameter of <0.3 mm and represent openings of empty hair follicles and eccrine sweat glands. They are seen on the normal scalp as well as in nonscarring alopecias. Fibrotic white dots are irregular dots representing areas of fibrosis in scarring alopecias [19],[20]
  • Red dots are rare in pediatric trichoscopy. They are seen in discoid lupus erythematosus and represent dilated follicular openings surrounded by dilated vessels [21]
  • Blue-gray dots are seen in discoid lupus erythematosus, especially in children with a darker phenotype where they are present perifollicularly and also in a speckled pattern. They represent melanophages in the papillary dermis [22]
  • Keratotic plugs are seen in discoid lupus erythematosus and result from keratotic material occluding dilated follicular openings.[21]
Figure 2: Numerous black dots in a trichoscopic field are almost diagnostic of alopecia areata

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Perifollicular pattern on trichoscopy includes perifollicular scales, hair cast, and peripilar sign.

  • Perifollicular scales in the pediatric age group are seen in discoid lupus erythematosus, lichen planopliaris, and ichthyosis vulgaris. They typically surround the hair shaft at the proximal end [Figure 3][23]
  • Hair cast is a cylindrical structure surrounding the hair shaft, and it extends a little beyond the surface of the scalp. Hair casts are seen in conditions such as lichen planopilaris, tinea capitis, seborrheic dermatitis, and psoriasis [1]
  • Peripilar sign (perifollicular brown discoloration) is a trichoscopic feature of patterned alopecia which may be seen in late adolescence.[20]
Figure 3: Perifollicular scales are commonly seen in scarring alopecias. They need to be differentiated from hair casts which surround the hair shaft but extend beyond the surface of the scalp

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Interfollicular pattern

Interfollicular pattern in pediatric trichoscopy includes honeycomb pigmented network, interfollicular scales, vessels, and white patches.

  • Honeycomb pigmented network is a network of melanocytes arranged as contiguous brown rings in a mosaic pattern. The hyperpigmented areas correspond to the melanocytes at the rete ridges while the suprapapillary epidermal melanocytes are responsible for the hypopigmented areas. Honeycomb pigmented network is seen in normal scalp and nonscarring alopecias [24]
  • Interfollicular scales are seen in the interfollicular dermis in seborrheic dermatitis, tinea capitis, ichthyosis vulgaris, scalp psoriasis, etc., [Figure 4][25]
  • Normal scalp vasculature in pediatric age group includes interfollicular red loops and arborizing red lines. Interfollicular red loops are capillaries in the papillary dermis, whereas arborizing red lines have a larger diameter and correspond to the subpapillary plexus. Twisted red loops are seen in scalp psoriasis which on lower magnification appear as dots. Arborizing red lines in an exaggerated pattern are found in seborrheic dermatitis [18],[26],[27]
  • White patches are white colored structureless areas, found rarely in the pediatric age group in scarring alopecias such as discoid lupus erythematosus. They essentially correspond to fibrosis indicating a scarring process in the dermis.[28]
Figure 4: Interfollicular scales are characteristic of inflammatory scalp disorders such as seborrheic dermatitis, scalp psoriasis

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  Cicatricial Versus Noncicatricial Alopecia in Pediatric Trichoscopy Top


A triad of the following three trichoscopic points favors scarring alopecia over a nonscarring alopecia.

  • Absence of hair follicle openings
  • Whitish structureless areas
  • Presence of milky red areas indicating recent onset fibrosis.



  Noncicatricial Alopecia in Pediatric Trichoscopy Top


Alopecia areata

Alopecia areata presents as a circumscribed bald patch on the scalp with key trichoscopic findings such as yellow dots, black dots, tapered hair, broken hair, vellus hair, and Pohl–Pinkus constriction. Disease activity can be monitored by trichoscopy as exclamation mark hair, black dots, and broken hairs are markers for disease activity [Figure 5].
Figure 5: Remitting phase of alopecia areata as regrowing hair seen in this trichoscopic field. Disease activity is bare minimal with lone exclamation mark hair (black arrow). Regrowing phase shows vellus hair admixed with terminal hair

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It is an excellent tool to record severity as the presence of yellow dots, and vellus hair indicate the disease to be severe and in its late, inactive stage.[6],[29]

Another trichoscopic marker for disease severity is “craters of the moon” sign in alopecia areata. This sign signifies extensive yellow dots which resemble the craters on the moon. In alopecia areata, sebum secreted by the sebaceous glands directly opens out onto the scalp surface as the alopecic patch is devoid of hair follicle to form a yellow dot, hence forming a depression resembling a crater on the moon [Figure 6].[30]
Figure 6: Multiple yellow dots forming “craters of the moon” sign in severe alopecia areata. It serves as a poor prognostic marker

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Short regrowing hair and pigtail hair are trichoschopic indicators of hair regrowth.[31] Thus, trichoscopy should be used in the therapeutic assessment of alopecia areata in children.

Trichotillomania

The closest trichological mimic to alopecia areata is trichotillomania. As a result of this repetitive pulling action, the most frequent trichoscopic feature in trichotillomania is broken hair of varying lengths.[32],[33] Mace sign is the newest trichoscopic sign described in trichotillomania which differentiates it from alopecia areata. Due to the constant pulling action, the distal end of the hair shaft becomes rough and bulbous in texture resembling a mace. The entire shaft length in mace hair is hyperpigmented, and the distal end is rough in texture in comparison to the distal end of exclamation mark hair which is smooth in texture and hyperpigmented with its proximal end being hypopigmented.[34]

New trichoscopic features that have recently come to light in trichotillomania are flame hair, tulip hair, i hair, block hair, V sign, and hair powder.[15],[16] Tulip hair is a short hair with the distal end being shaped like a tulip flower which is attributed to the diagonal fracture to the hair shaft [Figure 7].
Figure 7: A chaotic trichoscopic field of trichotillomania with hair of varying length and multiple broken hairs. It also shows mace sign (black arrow), i hair (red arrow), and flame hair (blue arrow)

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When two hairs belonging to the same follicular unit break at the same level, it resembles the letter “V” and is the V sign. This V sign may be seen after regrowth of shaven hair where it will be present in all regrowing hair, whereas in trichotillomania, the hair surrounding the “V” sign will be normal in length. Due to the destruction of the hair shaft as a result of constant manipulation, the hair residues that remain behind are called hair powder.[25] Of recent interest is the “burnt matchstick sign” described in trichotillomania, wherein due to constant pulling action, the proximal end becomes dark and bulbous resembling a burnt match stick [Figure 8].[35]
Figure 8: Burnt matchstick sign in trichotillomania with the proximal end being dark and bulbous

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The other trichoscopic features evident in trichotillomania are black dots, coiled hair, or question mark hair which is a partially coiled hair, short hair with split ends (trichoptilosis).[33]

Tinea capitis

Fungal elements of ectothrix parasitization damage the hair shaft partially causing it to bend resulting in comma hair. Corkscrew hair has multiple twists along their shaft differentiating them from comma hair.[36] Less commonly seen are Morse code hair which has horizontal white bands distributed regularly throughout the hair shaft resembling a Morse code. These horizontal white bands correspond to localized areas of fungal elements responsible for perforation of the hair shaft. Horizontal white bands are seen on polarized trichoscopy, and their fluorescence disappears on ultraviolet enhanced trichoscopy.[37],[38],[39] Broken hair, black dots, i hair, block hair, and hair casts are additional features.[9],[10],[36]

Telogen effluvium

Trichoscopy in telogen effluvium is of limited value as it fails to show key trichoscopic features. Telogen effluvium may be seen in the pediatric age group after prolonged febrile illness or as a result of nutritional deficiencies. Short regrowing hair also called as upright regrowing hair, follicular units with a single hair, and empty follicles are the trichoscopic features in telogen effluvium.[40]

Anagen effluvium

Anagen effluvium is seen in the pediatric age group following chemotherapy. The common trichoscopic features of anagen effluvium are black dots, yellow dots, tapering hair, and Pohl–Pinkus constriction.[41] The most recent trichoscopic characteristics described in anagen effluvium are circle hair, tulip hair-like structure or tulipoid hair, and perpilar sign.[42],[43]

Tulipoid hair needs to be differentiated from tulip hair. The proximal part of tulip hair is light colored, and the distal part is a dark tip due to oblique fracture of the hair shaft [Figure 9]a.
Figure 9: (a) Tulip hair resulting from an oblique fracture of the distal end of the hair shaft. It is a nonspecific feature seen in alopecia areata, trichotillomania. (b) Tulipoid hair – marker of anagen effluvium and indicates prognosis as well

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On the other hand, tulipoid hair is normal in color and thickness in its proximal portion, beyond which there is an acute constriction, and the shaft progressively narrows ultimately to end as a dark tip. The constriction of the tulipoid hair in anagen effluvium corresponds to induction of chemotherapy due to which the distal most part of the hair falls off resulting in a tulip-like tip. The proximal portion of the tulipoid hair signifies cessation of chemotherapy and resumption of follicular activity resulting in normal thickness of the shaft [Figure 9]b.[42]

Peripilar sign is brownish discoloration around the hair follicle and is attributed to perifollicular inflammation. It has been postulated that perifollicular inflammation in anagen effluvium is due to the effect of ultraviolet rays, chemical exposure, melanocytes, etc.[43]

Patterned hair loss

Patterned hair loss may be seen rarely in the adolescent age group. Key trichoscopic features in patterned hair loss include hair diameter diversity of more than 20%, yellow dots, vellus hair, peripilar sign, and decreased number of hair emerging per follicular unit.[44]

Congenital triangular alopecia

Congenital triangular alopecia (CTA) presents with patchy hair loss on the scalp closely resembling alopecia areata and trichotillomania. However, the characteristic trichoscopic feature of CTA is a cluster of short vellus hair with diversity in length. Other trichoscopic features include white hair, the presence of interfollicular honeycomb pigment and arborizing red lines, and absence of classical trichoscopic features of other localized alopecias [Figure 10]a and [Figure 10]b.[45]
Figure 10: (a) Localized patch of hair loss in a young girl leading to differentials such as alopecia areata and trichotillomania. (b) Trichoscopy, however, clinching the diagnosis of congenital triangular alopecia as it demonstrates a carpet of vellus hair of varying length clustered together and fails to demonstrate diagnostic signs of trichotillomania. Remitting phase of alopecia areata also shows clustered vellus hair, but they would be admixed with terminal hair

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  Cicatricial Alopecia in Pediatric Trichoscopy Top


Discoid lupus erythematosus

Trichoscopic identification of discoid lupus erythematosus is of vital significance in the pediatric age group as these pediatric patients run the risk of progressing to systemic lupus erythematosus, especially within the 1st year of diagnosis.[46] Nailfold capillaroscopy should be undertaken to detect progression toward systemic lupus erythematosus. Key trichoscopic features that should be identified are follicular keratotic openings, disruption of the honeycomb pattern resulting in loss of pigment, perifollicular and interfollicular blue-gray dots, loss of follicular openings, and vascular features like thick arborizing vessels and red dots [Figure 11].[21]
Figure 11: Prominent keratotic plugs (black arrows) with interfollicular scales and disruption of the honeycomb pigment pattern seen in discoid lupus erythematosus

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Red dots signify dilated vessels surrounding follicular openings. It acts as a positive prognostic marker as areas with red dots may show hair regrowth if treated promptly.[22]

Lichen planopilaris

Although the typical age of onset is 20–40 years, lichen planopilaris has been reported in the pediatric age group. Perifollicular scaling, peripilar casts, tufting of 2–3 hairs, perifollicular blue-gray dots in a target pattern, milky red areas, fibrotic white patches, absence of follicular openings, and absence of vellus hair are the trichoscopic findings of lichen planopilaris [Figure 12].
Figure 12: Characteristic trichoscopic field of lichen planopilaris showing peripilar cast (black arrow), perifollicular scales (red arrow), blue-gray dots placed perifollicularly (blue arrow), and interfollicularly (green arrow)

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Milky red areas signify fibrosis of recent onset, whereas fibrotic white dots are merging to form white patches indicate inactive late stage lichen planopilaris.[47]

Frontal fibrosing alopecia lies within the spectrum of lichen planopilaris but is not seen in children and hence is beyond the scope of this article.

Folliculitis decalvans

It is an inflammatory scalp disorder with recurrent follicular pustules finally leading to scarring alopecia. The most important trichoscopic feature in folliculitis decalvans in tufting of 6 or more hair originating from a single follicle [Figure 13].
Figure 13: Tufting of more than 6 hair, classically seen in folliculitis decalvans

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These hair tufts are surrounded by yellow scales with collar formation and epidermal hyperplasia in the perifollicular region seen as a star burst pattern. Other trichoscopic features include yellowish follicular pustules, loop and coiled vessels.[48]

Dissecting cellulitis of scalp

Early dissecting cellulitis presents as suppurative nodules and patchy hair loss thus mimicking a nonscarring alopecia, and hence, trichoscopy is imperative to diagnose and monitor the disease. Key features to be observed are enlarged keratotic follicular plugs, black dots, yellow dots, scalp erythema, and broken hair. As the disease progresses, yellow structureless areas are seen on trichoscopy and finally white areas signifying end-stage fibrosis.[49]


  Trichoscopy in Scalp Infestations Top


Pediculosis capitis

An itchy scaly scalp in a child may lead us to differentials such as seborrheic dermatitis, pediculosis capitis, tinea capitis, and scalp psoriasis. Trichoscopy eases out diagnosis by not only demonstrating lice and nits but also helps to differentiate between nits and pseudonits. Adult scalp lice on trichoscopy are viewed as wingless creatures which are dorsoventrally flattened. Viable nits are opaque and ovoid, whereas the empty or dead nits are oval in shape and translucent [Figure 14]a and [Figure 14]b.
Figure 14: (a) Empty/dead nits are oval and translucent. (b) Viable nits are opaque in nature and ovoid in shape. Thus, a trichoscope serves as a monitoring tool to record treatment efficacy

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As trichoscopy differentiates viable nits from the dead, it serves as an effective monitoring tool for treatment response. Caution needs to be exercised while identifying nits as they should be differentiated from pseudonits. A nit is attached to one side of the hair shaft and never encircles it whereas a pseudonits (scale of a different origin) will encircle the entire thickness of the hair shaft [Figure 15].[50],[51],[52]
Figure 15: Trichoscopy effectively differentiates a nit (red arrow) which is attached to one side of the hair shaft and a pseudonits (green arrow) which encircles the entire thickness of the hair shaft

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  Trichoscopy in Genetic Hair Shaft Defects Top


Trichorrhexis Nodosa

It is characterized by increased hair fragility as there is focal longitudinal splitting of the shaft causing the outer fibers to bulge, resulting in nodes. The nodes appear as gray-white areas, and the classical paintbrush bristle appearance is seen on trichoscopy. In acquired cases, these nodes are present distally as against in congenital cases where they are present in the proximal part of the shaft. Eyebrow hair must be examined trichoscopically along with scalp hair [Figure 16].[53]
Figure 16: Classical paintbrush bristle appearance of trichorrhexis nodosa seen on trichoscopy

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Trichorrhexis invaginata

Another genetic hair shaft defect which is marked by hair fragility, wherein there is invagination of the hair shaft on itself. Trichoscopy reveals several tiny nodules along the hair shaft, and on higher magnification; distal portion of the hair shaft invaginating into the proximal end forming the “ball in cup” appearance can be appreciated.[54]

Monilethrix

Monilethrix is characterized by regular constrictions along the shaft resulting in fragility and breakage at those points. Multiple beaded hair with nodes and internodes placed equidistant to each other is the key trichoscopic feature. Eyebrow hair and body hair should be examined for similar changes.[53],[54]

Pili torti

The hair shaft in pili torti rotates onto itself through 180° causing irregular flattening along the shaft. Trichoscopy demonstrates multiple twists along the hair shaft creating a helix-like pattern.[54]

Pili annulati

It is a hair shaft disorder marked by alternating white and dark bands. Transverse bands cloudy white in color on trichoscopy signify air-filled spaces in the cortex, whereas the dark bands correspond to normal unaltered hair shaft.[54]

Loose anagen hair syndrome

It is a disorder, wherein there is defective anchorage of anagen hair to the follicle resulting in anagen hair being easily pulled out. Key trichoscopic features include decreased number of terminal hair, empty follicles, and primarily single follicle hair units. Trichoscopy of a plucked hair will show anagen hair without outer root sheath, which can further be examined by light microscopy for the classical “floppy sock” appearance [Figure 17]a and [Figure 17]b.[53]
Figure 17: (a) Short, sparse hair all over the scalp since birth leading to differentials of monilethrix and loose anagen hair syndrome. (b) Trichoscopy demonstrating decrease in the number of terminal hair, empty follicles, and a predominance of single follicle hair units ruling out monilethrix and establishing the diagnosis of loose anagen hair syndrome

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Trichoscopy is of limited value in diagnosing genetic hair shaft defects such as trichothiodystrophy, short anagen hair syndrome, and woolly hair.

Congenital atrichia with papules

It is a rare disorder manifesting in the first few months of life, characterized by complete and irreversible hair loss along with keratin-filled cysts on the body.

Trichoscopic feature is “cluster of stars” appearance which are pinpoint white dots arranged as a group of 8–10 regularly on the scalp. This could correlate to the trapped papilla and hair bulb in the dermis which get fibrozed to appear as white dots [Figure 18]a and [Figure 18]b.[53]
Figure 18: (a) Congenital atrichia with papules. (b) Aggregates of pinpoint white dots forming “clusters of stars” appearance in congenital atrichia with papular eruption

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  Trichoscopy-Guided Biopsy Top


Trichoscopy is an excellent diagnostic tool. However, in certain trichoscopic conditions, its diagnostic ability is limited, and in such cases, it can be utilized to choose an appropriate area for a biopsy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [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]



 

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