International Journal of Trichology International Journal of Trichology
 Print this page Email this page Small font sizeDefault font sizeIncrease font size
  Home | About IJT | Editorial board | Search | Ahead of print | Current Issue | Archives | Instructions | Online submission | Subscribe | Advertise | Contact us | Login   

 Table of Contents  
Year : 2018  |  Volume : 10  |  Issue : 5  |  Page : 241-243  

The “Starry night sky sign” Using ultraviolet-light-enhanced trichoscopy: A new sign that may predict efficacy of treatment in frontal fibrosing alopecia

Department of Dermatology and Venereology, Ramón y Cajal Hospital, Madrid, Spain

Date of Web Publication3-Dec-2018

Correspondence Address:
Ana Rita Rodrigues-Barata
Department of Dermatology, Ramón y Cajal Hospital, Carretera Colmenar Viejo, Km 9.100, 28034 Madrid
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijt.ijt_17_18

Rights and Permissions

How to cite this article:
Rodrigues-Barata AR, Moreno-Arrones OM, Corralo DS, Galvan SV. The “Starry night sky sign” Using ultraviolet-light-enhanced trichoscopy: A new sign that may predict efficacy of treatment in frontal fibrosing alopecia. Int J Trichol 2018;10:241-3

How to cite this URL:
Rodrigues-Barata AR, Moreno-Arrones OM, Corralo DS, Galvan SV. The “Starry night sky sign” Using ultraviolet-light-enhanced trichoscopy: A new sign that may predict efficacy of treatment in frontal fibrosing alopecia. Int J Trichol [serial online] 2018 [cited 2023 Jun 1];10:241-3. Available from: https://www.ijtrichology.com/text.asp?2018/10/5/241/246795


Treatment regimen in frontal fibrosing alopecia (FFA) is given based on the presence of inflammatory signs (perifollicular erythema and follicular hyperkeratosis) or by the presence of symptoms even though their absence does not exclude disease progression.[1],[2],[3] In early stages, partial hair regrowth is possible; however, in late stages, treatment offers no benefit.[4]

We performed a prospective study with the objective of evaluating if the examination with ultraviolet (UV)-light-enhanced trichoscopy (UVET) may be used to predict potential efficacy of medical treatments in FFA. Twelve female consecutive patients with FFA were included, with a mean age of 48 years (range 39–63 years). Patients received oral dutasteride 0.5 mg, clobetasol propionate 0.05% foam, and topical 5% minoxidil daily. Clinical response was observed after a 6-month follow-up period. A positive pattern of fluorescence within the follicular ostia was observed using UVET with × 50 amplification in seven patients and negative in remaining five patients. In the 6-month follow-up visit, in those patients with positive fluorescence, 57.1% (4/7) showed a partial hair regrowth and 42.9% (3/7) showed disease stabilization [Figure 1]c and [Figure 1]d. In patients with negative UVET, no hair regrowth was observed [Figure 2]c and [Figure 2]d.
Figure 1: Frontal fibrosing alopecia. “Starry night sky sign” positive in frontal region (a and b) in a 46-year-old female patient before partial hair regrowth in the frontal hairline was observed, after a 6-month treatment with a topical corticosteroid, 5% topical minoxidil, and oral dutasteride (c and d, respectively). Red arrows: Follicular Propionibacterium observed with ultraviolet-light-enhanced trichoscopy with ×50

Click here to view
Figure 2: Frontal fibrosing alopecia. “Starry night sky sign” negative (a and b) in a 63-year-old female patient with no hair regrowth after treatment with 5% topical minoxidil and oral dutasteride after a 6-month period (c and d, respectively)

Click here to view

The UVET uses UV type A long wave, with a wavelength peak at 365 nm, which when applied to the skin will generate a characteristic fluorescence in the presence of certain skin conditions. Propionibacterium acnes, which can be found within acne comedones, generates a red-orange fluorescence caused by the production of porphyrins when illuminated with this UVET.[5] Further, compacted keratin usually shows a whitish-yellow fluorescence with the same illumination. We use a ×50 trichoscopy with a UV light lent (MicroCAMERA®, Dermotricos SRL, Coccaglio, Italy) that allows the objective visualization of this pattern of fluorescence within the follicular ostia. This clinical image is reminiscent of “starry night over the Rhone” by Van Gogh, hence why the authors have named the sign “starry night sky sign” [Figure 1]a and [Figure 1]b. Thus, if this fluorescence is positive, it can be assumed the presence of follicular Propionibacterium, and therefore, the possible preservation of the follicular unit viability, indicating a better prognosis. On the contrary, if the follicular unit is fibrosed, this activity will not be observed [Figure 2]a and [Figure 2]b.

We hypothesize that after exploring the entire frontotemporal line, if the “starry night sky sign” is positive in any area, local treatments may be used to stabilize alopecia and even achieve a partial regrowth. In the absence of this sign, local treatment with topical and/or infiltrated corticosteroids would not be advisable because of the unlikelihood of improvement. We believe that UVET is a complementary tool to trichoscopy and clinical examination to improve detection of disease progression. No biopsies were performed because of patients' reluctance of a scar in their frontotemporal line, but the positive clinical response after treatment when the sign is present makes us assume its utility.

We propose UVET as a simple and inexpensive tool that may predict the potential efficacy of medical treatments in FFA.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for 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 identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Moreno-Ramírez D, Ferrándiz L, Camacho FM. Diagnostic and therapeutic assessment of frontal fibrosing alopecia. Actas Dermosifiliogr 2007;98:594-602.  Back to cited text no. 1
Tosti A, Piraccini BM, Iorizzo M, Misciali C. Frontal fibrosing alopecia in postmenopausal women. J Am Acad Dermatol 2005;52:55-60.  Back to cited text no. 2
Fernández-Crehuet P, Rodrigues-Barata AR, Vañó-Galván S, Serrano-Falcón C, Molina-Ruiz AM, Arias-Santiago S, et al. Trichoscopic features of frontal fibrosing alopecia: Results in 249 patients. J Am Acad Dermatol 2015;72:357-9.  Back to cited text no. 3
Vañó-Galván S, Molina-Ruiz AM, Serrano-Falcón C, Arias-Santiago S, Rodrigues-Barata AR, Garnacho-Saucedo G, et al. Frontal fibrosing alopecia: A multicenter review of 355 patients. J Am Acad Dermatol 2014;70:670-8.  Back to cited text no. 4
Klatte JL, van der Beek N, Kemperman PM 100 years of wood's lamp revised. J Eur Acad Dermatol Venereol 2015;29:842-7.  Back to cited text no. 5


  [Figure 1], [Figure 2]

This article has been cited by
1 When in doubt look up to the skies: A skywatchers perspective in dermatology
Aravind Sivakumar, Rashmi Kumari
Indian Journal of Dermatology, Venereology and Leprology. 2022; 0: 1
[Pubmed] | [DOI]
2 Frontal Fibrosing Alopecia: A Review
María Librada Porriño-Bustamante, María Antonia Fernández-Pugnaire, Salvador Arias-Santiago
Journal of Clinical Medicine. 2021; 10(9): 1805
[Pubmed] | [DOI]
3 Frontal fibrosing alopecia
Karolina L.S. Kerkemeyer, Samantha Eisman, Bevin Bhoyrul, Joel Pinczewski, Rodney D. Sinclair
Clinics in Dermatology. 2021; 39(2): 183
[Pubmed] | [DOI]
4 Trichoscopic features of mild frontal fibrosing alopecia
D. Saceda-Corralo, O.M. Moreno-Arrones, M. Rubio-Lambraña, R. Gil-Redondo, C. Bernárdez, Á. Hermosa-Gelbard, P. Jaén-Olasolo, S. Vañó-Galván
Journal of the European Academy of Dermatology and Venereology. 2021; 35(3)
[Pubmed] | [DOI]
5 Evolving eponymous signs in diagnostic dermoscopy
Shashank Bhargava, Atul Bothra, Seujee Das, Anshu Maheswari, Mehak Singh
IP Indian Journal of Clinical and Experimental Dermatology. 2021; 7(2): 98
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Article Figures

 Article Access Statistics
    PDF Downloaded36    
    Comments [Add]    
    Cited by others 5    

Recommend this journal