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| CASE REPORT |
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| Year : 2022 | Volume
: 14
| Issue : 6 | Page : 218-220 |
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Trichoscopic diagnosis and management of a case of scalp dysesthesia with lichen simplex chronicus
Vinupriya Sakkaravarthi1, K Gopalakrishnan1, Sathyaseelan Manivel2, Sandeep Thomas George3
1 Department of Dermatology, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
2 Department of Psychiatry, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
3 Department of Orthopaedics, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| Date of Submission | 19-Feb-2022 |
| Date of Acceptance | 09-Mar-2022 |
| Date of Web Publication | 31-Jan-2023 |
Correspondence Address:
Vinupriya Sakkaravarthi
Department of Dermatology, KMCH Institute of Health Sciences and Research, Coimbatore - 641 014, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijt.ijt_27_22
 Abstract | | |
Scalp dysesthesia (SD), a variant of cutaneous dysesthesia syndrome is an underrecognized cause of scalp pruritus. It usually presents with itch, pain, burning, or stinging sensation over localized or diffuse area of the scalp without any objective findings. Trichoscopy, a rapid and in-office procedure, could aid in the early clinical diagnosis of this condition and initiate management. We report a case of SD in an elderly male diagnosed with the aid of trichoscope, evaluated and treated successfully.
Keywords: Compulsive, dysesthesia, neurocutaneous, scalp, trichoscope, trichoteiromania
How to cite this article:
Sakkaravarthi V, Gopalakrishnan K, Manivel S, George ST. Trichoscopic diagnosis and management of a case of scalp dysesthesia with lichen simplex chronicus. Int J Trichol 2022;14:218-20 |
How to cite this URL:
Sakkaravarthi V, Gopalakrishnan K, Manivel S, George ST. Trichoscopic diagnosis and management of a case of scalp dysesthesia with lichen simplex chronicus. Int J Trichol [serial online] 2022 [cited 2023 May 31];14:218-20. Available from: https://www.ijtrichology.com/text.asp?2022/14/6/218/368905 |
| Introduction | |  |
Scalp dysesthesia (SD) is an underrecognized cause of scalp pruritus. It is a variant of cutaneous dysesthesia syndrome with various neurogenic and psychogenic triggers. Trichoscopy could aid in the early diagnosis and management. We report a case of SD diagnosed with the help of trichoscopy who was evaluated further and treated successfully.
| Case Report | | |
A 55-year-old male came to the dermatology outpatient department for the complaints of localized itching and discoloration of the scalp for the past 6 months. He denied pain or burning sensation and denied pulling of his scalp hair. His past medical history was unremarkable. On examination, he had lichenified oval plaques of size 3 cm over bilateral parietal scalp. The hair shafts overlying the plaques were shortened and macroscopically distorted and rest of the scalp looks normal [Figure 1]. On trichoscopic examination, the hyperpigmented area was covered with multiple short hairs of varying lengths. Most of them were broom hairs (longitudinal splitting of short hairs in the distal end) with a few block hairs (short hairs with horizontal distal end) and trichorrhexis nodosa [Figure 2] and [Figure 3]. The background scalp skin was hyperpigmented with perifollicular scaling [Figure 3]. With these findings, we made a provisional diagnosis of SD with lichen simplex chronicus (LSC). His routine blood workup was normal, and his cervical spine radiograph shows Grade 3 cervical spondylosis. He reported to have disturbed sleep and low mood for the past 6 months due to familial conflicts. On psychiatric evaluation, it was found that his repetitive scratching behavior was noncompulsive, and there were no other obsessive-compulsive symptoms. He was diagnosed with adjustment disorder with depressed mood due to significant psychosocial stressors and was started on sertraline at 50 mg, high potent topical steroids along with the neck muscle strengthening exercises. After a month of treatment, patient reported a significant improvement in symptoms. | Figure 1: Right parietal scalp showing an oval lichenified plaque and overlying sparse hairs and surrounding normal scalp
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 | Figure 2: Trichoscopic image of scalp lichen simplex chronicus (DermLite 3, ×10, nonpolarized mode) showing broom hairs (red arrows), block hairs (black arrows), trichorrhexis nodosa (blue arrows), and background hyperpigmentation and perifollicular scaling (yellow arrows)
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 | Figure 3: Trichoscopic image (DermLite 3, ×10, nonpolarized mode) showing transverse white bands along the length of the hair shaft and at the distal end of the hair shaft depicting trichorrhexis nodosa (blue arrows), and broom hair (red arrows)
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| Discussion | | |
SD is a variant of cutaneous dysesthesia syndrome characterized by chronic cutaneous symptoms of pain, pruritus, burning, and stinging without objective findings.[1] It is often an underrecognized entity which was frequently misdiagnosed as psoriasis and seborrheic dermatitis. Even though the etiology was not completely elucidated, various neurogenic and psychogenic factors were proposed to trigger SD.[1],[2],[3] Cervical spine disease at the level of C5-C6 is the most frequent neurogenic cause of SD.[4] It was hypothesized that the chronic tension placed on occipitofrontalis muscle and scalp aponeurosis lead to unpleasant sensation over the scalp similar to the pathogenesis of notalgia paresthetica.[2],[4] Other potential triggers include psychological stress, hair styling, heat, and seasonality.[3]
Trichoscopy is a rapid, in-office technique which has become a firsthand procedure in the evaluation of scalp disorders and alopecia. The characteristic trichoscopic features of SD were studied in a retrospective analysis by Rakowska et al.,[5] where they observed short hairs of uniform length, broom hairs (78%), block hairs (89%), and trichorrhexis nodosa (78%). This is similar to our case, except that there were predominantly broom hairs of uneven length. The repetitive rubbing of the scalp has led to LSC in our patient evidenced by the presence of background hyperpigmentation and perifollicular scaling in trichoscopy.[6] Broom hairs were recently considered a hallmark finding in trichoteiromania which is a compulsive disorder of rubbing of hair.[7],[8] Fowler and Tosti[9] reported a case of frictional alopecia presenting as trichorrhexis nodosa on trichoscopy. Even though the pathogenesis of SD, trichoteiromania and frictional alopecia differ, they all have a similar mechanism of injury to hair. The repeated mechanical damage in the form of rubbing, touching, and scratching gradually erodes the cuticular cell margin of distal hair shaft where they are less adherent leading to distal splitting in broom hairs and longitudinal splitting that bulge out as nodules in trichorrhexis nodosa.[8],[9],[10]
The management of SD is challenging due to the lack of evidence-based recommendations. The primary aim of treatment is to identify the trigger and break the itch-scratch cycle. We recommend detailed evaluation of SD with past history of psychiatric disorder, substance abuse, psychological stress, medical comorbidities, cervical spine imaging, and psychiatric counseling as required. The treatment includes a combination of medical management and cervical muscle strengthening exercises for optimal response. We summarize the treatment options available for SD in [Table 1]. Our patient had only itching without pain or burning sensation and an underlying adjustment disorder with depression. Our combination therapy targeting itching with topical steroids, mood disturbances with sertraline, and neck muscle strengthening exercises was successful.
| Conclusion | | |
Patients with SD usually present to dermatologists due to their cutaneous symptoms. With the ready availability of trichoscope, the patients can be diagnosed early avoiding invasive diagnostic scalp biopsy. The onus lies with the dermatologist to appropriately evaluate and refer the patient for management. We also recommend the clinicians further research into the etiology, pathogenesis and make treatment recommendations for SD.
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.
| References | | |
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| 2. | Lee JJ, Morillo-Hernandez C, Agarwal V, Standaert CJ, English JC 3rd. Cervical Spine Imaging and Treatment Outcomes in Scalp Dysesthesia: A Retrospective Cohort Study. J Am Acad Dermatol. 2020:S0190-9622(20)32364-1. |
| 3. | Starace M, Iorizzo M, Mandel VD, Bruni F, Misciali C, Apalla Z, et al. Scalp dysaesthesia and lichen simplex chronicus: Diagnostic and therapeutic update with literature review. Clin Exp Dermatol 2022;47:3-8. |
| 4. | Thornsberry LA, English JC 3 rd. Scalp dysesthesia related to cervical spine disease. JAMA Dermatol 2013;149:200-3. |
| 5. | Rakowska A, Olszewska M, Rudnicka L. Trichoscopy of scalp dysesthesia. Adv Dermatol Allergol 2017;34:245-7. |
| 6. | Agrawal S, Dhurat R, Ghate S, Sharma A, Surve R, Daruwalla S. Lichen simplex chronicus on the scalp: Broom fibers on dermoscopy; gear wheel sign and hamburger sign on histopathology. Indian Dermatol Online J 2020;11:401-3. [Full text] |
| 7. | Salas-Callo CI, Pirmez R. Trichoteiromania: Good response to treatment with N-acetylcysteine. Skin Appendage Disord 2019;5:242-5. |
| 8. | João AL, Cunha N, Pessoa E Costa T, Lencastre A. Monotonous broom hairs: A feature of trichoteiromania. Skin Appendage Disord 2020;6:168-70. |
| 9. | Fowler E, Tosti A. A case of friction alopecia in a healthy 15-year-old girl. Skin Appendage Disord 2019;5:97-9. |
| 10. | Banky JP, Sheridan AT, Dawber RP. Weathering of hair in trichoteiromania. Australas J Dermatol 2004;45:186-8. |
| 11. | Kinoshita-Ise M, Shear NH. Diagnostic and therapeutic approach to scalp dysesthesia: A case series and published work review. J Dermatol 2019;46:526-30. |
| 12. | Laidler NK, Chan J. Treatment of scalp dysesthesia utilising simple exercises and stretches: A pilot study. Australas J Dermatol 2018;59:318-21. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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