Year : 2009 | Volume
: 1 | Issue : 2 | Page : 123--130
Dermoscopy in female androgenic alopecia: Method standardization and diagnostic criteria
Adriana Rakowska1, Monika Slowinska1, Elzbieta Kowalska-Oledzka1, Malgorzata Olszewska2, Lidia Rudnicka3,
1 Department of Dermatology, CSK MSWiA, Woloska 137, Poland
2 Department of Dermatology, Warsaw Medical University, Koszykowa 82 a, Poland
3 Department of Dermatology, CSK MSWiA, Woloska 137; Division of Health Sciences, Warsaw Medical University, Poland
Department of Dermatology, CSK MSWiA, Woloska 137, 02-507 Warsaw
Objective: Establishing the trichoscopy criteria of female androgenic alopecia (FAGA). Design: Trichoscopy images were retrospectively evaluated. Setting: Dermatologic hospital-based clinic and private practice offices. Patients and methods: One hundred and thirty-one females (59 with androgenic alopecia, 33 with chronic telogen effluvium (CTE), 39 healthy controls). The diagnosis was based on clinical examination and confirmed by histopatology. Main Outcome Measure: Trichoscopy results obtained in frontal, occipital and both temporal areas of the scalp under a 20-fold and 70-fold magnification, including average hair thickness, number of «SQ»yellow dots«SQ» and vellus hairs, number of hairs in one pilosebaceous unit and percentage of follicular ostia with perifollicullar hyperpigmentation. Results: Average hair thickness in frontal area versus occiput was, respectively, 0.061 ± 0.008 mm versus 0.058 ± 0.007 mm in healthy controls, 0.047 ± 0.007 mm versus 0.052 ± 0.008 mm in androgenic alopecia and 0.056 ± 0.007 mm versus 0.053 ± 0.009 mm in CTE. Mean percentage of thin hairs (< 0.03 mm) in androgenic alopecia was 20.9 ± 12% and was significantly higher than in healthy controls (6.15 ± 4.6%, P < 0.001) or in CTE (10.4 ± 3.9%, P < 0.001). The number of yellow dots, pilosebaceous units with only one hair and with perifollicular hyperpigmentation was significantly increased in androgenic alopecia. Classification and Regression Tree Analysis was performed to establish diagnostic criteria for FAGA. Conclusion: FAGA may be differentiated from CTE based on trichoscopy criteria. Major criteria are ratio of (1) more than four yellow dots in four images (70-fold magnification) in the frontal area, (2) lower average hair thickness in the frontal area compared to the occiput and (3) more than 10% of thin hairs (below 0.03 mm) in the frontal area. Minor criteria encompass increased frontal to occipital ratio of (1) single-hair pilosebaceous units, (2) vellus hairs and (3) perifollicular discoloration. Fulfillment of two major criteria or one major and two minor criteria allows to diagnose FAGA based on trichoscopy with a 98% specificity.
|How to cite this article:|
Rakowska A, Slowinska M, Kowalska-Oledzka E, Olszewska M, Rudnicka L. Dermoscopy in female androgenic alopecia: Method standardization and diagnostic criteria.Int J Trichol 2009;1:123-130
|How to cite this URL:|
Rakowska A, Slowinska M, Kowalska-Oledzka E, Olszewska M, Rudnicka L. Dermoscopy in female androgenic alopecia: Method standardization and diagnostic criteria. Int J Trichol [serial online] 2009 [cited 2020 Jan 21 ];1:123-130
Available from: http://www.ijtrichology.com/text.asp?2009/1/2/123/58555
Chronic hair loss frequently affects female patients, but there is little or no objective technology available to aid the dermatologist in setting a proper diagnosis and in monitoring treatment efficacy.  In particular, it may be difficult to differentiate between female androgenic alopecia (FAGA), a subtype of female pattern hair loss, and chronic telogen effluvium (CTE). 
Telogen effluvium is a self-limiting process and almost never causes obvious baldness,  whereas FAGA progresses in time, leading to a significant decrease in hair thickness, which over time may become cosmetically unacceptable and psychologically frustrating. 
Differences in natural history, prognosis and emerging new therapeutic possibilities  make differential diagnosis and early diagnosis of FAGA especially important. Currently, the diagnosis of FAGA is usually based on anamnesis and clinical findings, such as pattern of increased hair thinning, retention of the frontal hairline, and the presence of miniaturized hairs. , The semi-invasive technique of hair root analysis (trichogram) has a decreasing number of advocates among dermatologists. It is considered to be a poor indicator of FAGA and its severity. 
A scalp biopsy examination is usually performed to confirm the diagnosis of FAGA in clinically doubtful cases. , Histopathology findings in FAGA include a decrease in terminal/vellus hair ratio and decline in mean total follicle count with increasing grade of hair loss. This method also has limitations in everyday practice. Typically, punch biopsies are taken for vertical and horizontal embedding. These are 7-12 mm 2 in size and contain only a small number of hair follicles. Thus, some authors suggest performing multiple biopsies for representative sampling, which increases the invasiveness of this diagnostic technique and makes it even less useful for monitoring of treatment efficacy. 
Trichoscopy , is a newly developed method of hair image analysis, based on videodermoscopy of the hair and scalp. The method allows visualization of hair shafts at high magnification and performing measurements, such as hair shaft thickness, without the need of removing hair for diagnostic purposes. It also allows in vivo visualization of the epidermal portion of hair follicles and perifollicular epidermis. , Several reports raise the issue of potential usefulness of this technique in diagnosing hair and scalp disorders, such as microsporiasis,  androgenic alopecia,  alopecia areata, , lipedematous alopecia,  pediculosis  or inherited hair shaft abnormalities, , but the method has not been standardized yet and no criteria for diagnosing acquired diseases of hair and scalp have been established.
The aim of the study was to establish a standardized method of trichoscopy in acquired hair loss and to establish trichoscopy criteria for diagnosing FAGA.
Trichoscopy images from female patients with FAGA, CTE and healthy volunteers collected in the years 2005-2007 were retrospectively evaluated.
The diagnosis was established by clinical examination and histopathology. FAGA was clinically suspected in cases of frontal accentuation ("Christmas tree" pattern), diffuse central or vertex/frontal (male pattern) with sparing of the occiput.  The clinical diagnosis of CTE was based on diffuse form of scalp hair thinning longer than 6 months. 
All patients suspected for FAGA or CTE had three 4-mm punch biopsy specimens taken from the immediately adjacent skin on the mid scalp and all specimens were sectioned horizontally. The terminal to vellus hair ratio (T:V) at the midisthmus level was used to set the diagnosis. The ratio equal or lower than 4:1 was indicative for FAGA and equal or higher than 8:1 together with anagen: Telogen ratio lower than 8:1 was indicative for CTE. 
Dermatologic hospital-based clinic and private practice offices.
Patients and Methods
After obtaining approval from the hospital's review board, a total of 131 female patients were included in the study, 59 with FAGA, 33 with CTE and 39 healthy volunteers.
The mean age was 36.2 (18-59) years in patients with FAGA, 32.2 (18-56) years in patients with CTE and 37.8 (19-58) years in healthy controls. The differences were statistically not significant.
Trichoscopy has been performed with the Fotofinder II videodermoscope, which permits scalp visualization at a 20-160-fold magnification. The device is equipped with software that allows to carry out measurements of structures visualized in magnified images and provides results in real scale. Images of the scalp were taken at a 20- fold magnification, which allows high-quality enlargement of 1 cm 2 of the scalp area to the size of a computer screen and at a 70-fold magnification, which magnifies in a similar manner an area of 9 mm 2 .
In each patient, one image at a 20-fold magnification and four images at a 70-fold magnification were taken in each of the following four areas: Frontal, occipital, right temporal and left temporal.
Hair thickness was measured at a 70-fold magnification, in direct proximity to follicular orifices. Hairs have been identified as 'thin hairs' (below 0.03 mm), 'medium-size hairs' (0.03-0.05 mm) and 'thick hairs' (above 0.05 mm).
The images have been evaluated in accordance with the scheme presented in [Table 1].
Statistical analysis was performed with the use of Student's t-test for paired samples and with analysis of variance (ANOVA). The Classification and Regression Tree technique was used to establish diagnostic criteria.
Both in healthy controls as well as in patients with CTE, the thickest hairs have been observed in the frontal area whereas the thinnest in the occipital area. In the healthy control group, the mean hair thickness was 0.061 ± 0.008 mm in the frontal area vs. 0.058 ± 0.007 mm in the occipital area ( P P P P P = 0.002), left temporal ( P P P Pilosebaceous units
Hairs usually are present in groups of few hair roots growing from one follicular orifice. The number of hairs in pilosebaceous units has been evaluated by trichoscopy at the 20-fold magnification. The percentage of single-hair, double-hair and triple-hair units was evaluated.
In healthy controls and in CTE, the highest proportion of single-hair pilosebaceous units was observed in the temporal areas. The mean percentage of single-hair units in this area was 42 ± 12% in CTE and 32 ± 15% in healthy controls.
In patients with FAGA, the mean percentage of single-hair pilosebaceous units was highest in the frontal area (65.2 ± 19.9%). This was significantly more than in telogen effluvium (39.0 ± 13.4%, P P P P = 0.01) and 10.4 in FAGA ( P Yellow dots
Yellow dots were evaluated at a 20-fold magnification and at a 70-fold magnification. Results are given as total number of yellow dots in one field of vision (FOV) at the 20-fold magnification and as total number seen in four FOVs at the 70-fold magnification. In both calculation methods, the number of yellow dots was significantly higher in patients with FAGA as compared with healthy controls or with patients with CTE. However, in general, the number of yellow dots per 1 mc 2 was on average 20% higher when evaluated at the 70-fold magnification, as compared with the 20-fold magnification. This difference resulted from better visualization of small trichoscopy structures at higher magnifications. [Figure 5] shows the mean numbers of yellow dots in healthy controls, FAGA and telogen effluvium when analyzed in four fields of vision at a 70-fold magnification. The highest number of yellow dots in patients with FAGA was noted in the frontal area (8.86 ± 4.8/4 fields of vision at the 70-fold magnification). The corresponding number in the occipital area was 1.59 ± 2.0.
The percentage of hair-containing units with perifollicular discoloration was evaluated at the 20-fold magnification and in four FOVs at the 70-fold magnification. Both methods yielded highly comparable results. Thus, results are presented for the 20-fold magnification only.
Perifollicular discoloration was found significantly more often in FAGA as compared with healthy controls or patients with CTE. The mean percentage of hair follicles with surrounding discoloration in FAGA was 32.4 ± 4.7% in the frontal area and 6.6 ± 2% in the occipital area ( P Major criteria
More than four yellow dots in four images at a 70-fold magnification in the frontal area.Lower average hair thickness in the frontal area in comparison with the occiput (calculated from not less than 50 hairs from each area).More the 10% of thin hairs (below 0.03 mm) in the frontal area.
Ratio of single-hair unit percentage, frontal area to occiput > 2:1Ratio of number of vellus hairs, frontal area to occiput > 1.5:1Ratio of hair follicles with perifollicular discoloration, frontal area to occiput > 3:1.
Fulfillment of two major criteria or one major and two minor criteria is required to diagnose FAGA based on trichoscopy.
In order to confirm this diagnostic model, a linear regression analysis was performed in which the dependent variable was the diagnosis of FAGA and the diagnostic criteria were independent variables. An analytical model, which was constructed in this manner showed a potential diagnostic sensitivity of this method at the level of 72%.
Based on results collected in this study, we established a trichoscopy report form that contains most important trichoscopy findings in diffuse hair loss and diagnostic criteria for FAGA [Table 2]. Elements, which were not found to be of diagnostic value in this or previous studies, , were not included in this trichoscopy report form. These include trichoscopy results from parietal regions and results from magnifications that were less precise or significantly less comfortable to handle.
Discussion and Conclusions
FAGA, a disease in the spectrum of female-pattern hair loss, is characterized by progressive miniaturization of hair follicles, mediated most probably by dihydrotestosterone within the follicle, and may affect women with normal levels of circulating androgens.  The diagnosis is usually based on anamnesis and clinical findings, such as early age of onset, the pattern of increased hair thinning over the frontal/parietal scalp with greater hair density over the occipital scalp, retention of the frontal hairline and the presence of miniaturized hairs. ,, Histologically, the disease is characterized by miniaturization of a proportion of follicles and an increased percentage of hair in telogen in the affected area.  In advanced stages of disease, when these features are obvious, the diagnosis is not problematic. However, in early disease and in patients in whom other causes of hair loss coexist, the diagnosis may be challenging.
In this study, trichoscopy criteria were established, which allow to diagnose FAGA with 98% specificity. These criteria are based on findings that have partly been known from clinical observations and other diagnostic methods but could not be quantified before trichoscopy was developed. These findings relate to predominance of hair miniaturization in the frontal area compared with the occiput.
This clinical and histopathological observation has been identified and quantified by trichoscopy as lower average hair thickness in the frontal area in comparison with the occiput, more the 10% of thin hairs (below 0.03 mm) in the frontal area and ratio of vellus hair number (frontal area to occiput) above 1.5:1.
A novel approach to quantify hair density in practical dermatology is evaluation of the number of hairs in one pilosebaceous unit. This was previously not possible with the classical diagnostic method or the recently developed phototrichogram.  The number of hairs in one pilosebaceous unit varies from one to three in healthy persons. Occasionally, a four-hair unit may be found. Our results show that the number of single-hair pilosebaceous units is significantly increased in the frontal area in patients with FAGA compared with the occiput (a ratio above 2:1). Hair thinning, decreased number of hairs in pilosebaceous units and predominant prevalence in the frontal area are main features distinguishing FAGA from most other hair diseases, especially alopecia areata. 
Clinical 'patterning' in patients with female-pattern hair loss may be with frontal accentuation ("Christmas tree" pattern), diffuse central or vertex/frontal (male pattern) with sparing of the occiput.  Recently, studies have demonstrated that in patients with FAGA, changes observed in the occiput are similar to those in the frontal area, but are less pronounced. Using the phototrichogram method, both Ekmekci  and van Neste  showed decreased hair density and an increased percentage of thin hair roots (  We hypothesize that these sebaceous glands are still active after advanced hair follicle miniaturization and produce sebum, which creates intra-epidermal sebum lagoons. These sebum lagoons appear as yellow dots in trichoscopy.
Yellow dots have been previously described in alopecia areata , and have been recently suggested as indicative of alopecia areata incognita (Kligman's telogen effluvium) in patients with diffuse hair loss.  Our results show that yellow dots may be characteristic for a wide spectrum of hair diseases and they may also represent a wider than previously anticipated spectrum of histopathological appearances of follicle ostia and infundibula. Our results show that yellow dots are one of the most important trichoscopy features distinguishing FAGA from CTE.
Another important trichoscopy finding is perifollicular discoloration of the skin. This feature, called by some authors as 'hyperpigmentation' or 'peripilar sign' reflects the presence of perifollicular lymphocytic infiltrates in early androgenic alopecia.  Our results confirm the presence of perifollicular discoloration in FAGA, although we found that in FAGA the percentage of hair follicles with this abnormality is significantly higher in the frontal area compared with the occiput. According to statistical analysis, a ratio of hair follicles with perifollicular discoloration and frontal area to occiput higher than 3:1 is highly indicative of FAGA.
CTE has no specific trichoscopy features apart from an increased proportion of short, sharp-ended hairs. A number of five or more in four fields of vision at a 70-fold magnification in both the frontal and another (occipital or temporal) was found highly indicative of CTE. Most likely, these are regrowing hairs in early anagen stage and their increased number indicates an accelerated hair cycle, resulting in an intensive replacement of hair roots. However, CTE may rather be a diagnosis made by exclusion of other causes of hair loss, than by direct fulfillment of specific trichoscopy criteria.
In conclusion, the results of our study indicate that FAGA may be differentiated from CTE and the diagnosis of FAGA may be established based solely on trichoscopy criteria.
|1||van Neste D. Female patients complaining about hair loss: Documentation of defective scalp hair dynamics with contrast-enhanced phototrichogram. Skin Res Technol 2006;12:83-8.|
|2||Sinclair R, Jolley D, Mallari R, Magee J. The reliability of horizontally sectioned scalp biopses in the diagnosis of chronic diffuse telogen hair loss in women. J Am Acad Dermatol 2004;51:189-99.|
|3||Whiting D. Chronic telogen effluvium. Dermatol Clin 1996;14:697-11.|
|4||Harrison S, Sinclair R. Telogen effluvium. Clin Exp Dermatol 2003;27:389-5.|
|5||Sinclair R. Chronic telogen effluvium or early androgenic alopecia? Int J Dermatol 2004;43:842-3.|
|6||Olsen EA. Female pattern hair loss. J Am Acad Dermatol 2001;45:S70-80.|
|7||Price VH. Androgenic alopecia in women. J Investig Dermatol Symp Proc 2003;8:24-7.|
|8||van Neste D. Assessment of hair loss: Clinical relevance of hair growth evaluation methods. Clin Exp Dermatol 2002;27:358-65.|
|9||Olszewska M, Rudnicka L, Rakowska A, Kowalska-Oledzka E, Slowinska M. Trichoscopy. Arch Dermatol 2008;144:1007.|
|10||Rudnicka L, Olszewska M, Majsterek M. Presence and future of dermoscopy. Expert Rev Dermatol 2006;1:769-72.|
|11||Lacarrubba F, Dall`Oglio F, Rita Nasca M, Micali G. Videodermatoscopy enhances diagnostic capability in some forms of hair loss. Am J Clin Dermatol 2004;5:205-8.|
|12||Ross EK, Vincenzi C, Tosti A. Videodermoscopy in the evaluation of hair and scalp disorders. J Am Acad Dermatol 2006;55:799-806.|
|13||Slowinska M, Rudnicka L, Schwartz RA, Kowalska-Oledzka E, Rakowska A, Sicinska J, et al. Comma hairs: A dermoscopic marker for tinea capitis: A rapid diagnostic method. J Am Acad Dermatol 2008;59:S77-9.|
|14||Olszewska M, Rudnicka L. Effective treatment of female androgenic alopecia with dutasteride. J Drugs Dermatol 2005;4:637-40|
|15||Inui S, Nakajima T, Itami S. Dry dermoscopy in clinical treatment of alopecia areata. J Dermatol 2007;34:635-9|
|16||Tosti A, Whiting D, Iorizzo M, Pazzaglia M, Misciali C, Vincenzi C, et al. The role of scalp dermoscopy in the diagnosis of alopecia areata incognita. J Am Acad Dermatol 2008;59:64-7.|
|17||Piraccini BM , Voudouris S, Pazzaglia M, Rech G, Vicenzi C, Tosti A. Lipedematous alopecia of the scalp. Dermatol Online J 2006;12:6.|
|18||Di Stefani A, Hofmann-Wellenhof R, Zalaudek I. Dermoscopy for diagnosis and treatment monitoring of pediculosis capitis. J Am Acad Dermatol 2006;54:909-11.|
|19||Rakowska A, Slowinska M, Kowalska-Oledzka E. Trichoscopy in genetic hair shaft abnormalities. J Dermatol Case Rep 2008;2:14-20.|
|20||Rakowska A, Slowinska M, Czuwara J, Olszewska M, Rudnicka L. Dermoscopy as a tool for rapid diagnosis of monilethrix. J Drugs Dermatol 2007;6:222-4|
|21||Riedel-Baiama B, Riedel A. Female pattern hair loss may be triggered by low oestrogen to androgen ratio. Endocr Regul 2008;42:13-6.|
|22||Shapiro J. Clinical practice: Hair loss in women. N Engl J Med 2007;357:1620-30.|
|23||Leroy T, van Neste D. Contrast enhanced phototrichogram pinpoints scalp hair changes in androgen sensitive areas of male androgenic alopecia. Skin Res Technol 2002;8:106-11.|
|24||Ekmekci RTY, Koslu A. Phototrichogram findings in women with androgenic alopecia. Skin Res Technol 2006;12:309-12.|
|25||Eudy G, Solomon AR. The histopathology of noncicatricial alopecia. Semin Cutan Med Surg 2006;25:35-40.|
|26||Deloche C , de Lacharriere O, Misciali C, Piraccini BM, Vincenzi C, Bastien P, et al. Histological features of peripilar signs associated with androgenic alopecia. Arch Dermatol Res 2004;295:422-8.|