RANCANGAN PENELITIAN

TESIS MAGISTER
DAN
JURNAL PENDUKUNG

PEMBIMBING 1 : Prof. Dr. dr. Nelva K. Jusuf, Sp.KK(K), FINSDV, FAADV

PEMBIMBING 2 :

Penyaji: dr. Michelle Wiryadana

 RANCANGAN PENELITIAN

Nama : Michelle Wiryadana

Pembimbing : Prof. Dr. dr. Nelva K. Jusuf, Sp.KK(K), FINSDV, FAADV

Judul
Korelasi antara Gambaran Skalp Dermoskopi dengan Derajat Keparahan Alopesia
Androgenetik pada Laki-laki

Novelty
Penelitian pertama yang menilai korelasi antara gambaran skalp dermoskopi dikaitkan dengan
derajat keparahan alopesia androgenetik pada laki-laki di Indonesia
.

Sampel
25 sampel pasien Alopesia Androgenetik dan 25 sampel tanpa Alopesia Androgenetik
berdasarkan jenis penelitian analitik korelatif.

Lokasi Penelitian
Poliklinik Kulit dan Kelamin RS USU

Pemeriksaan yang akan dilakukan

• Pemeriksaan dermoskopi pada bagian frontal, verteks, dan temporal berdasarkan
klasifikasi Hamilton dan Norwood

Tujuan Umum
Untuk mengetahui korelasi antara gambaran skalp dermoskopi dikaitkan dengan derajat

keparahan alopesia androgenetik pada laki-laki.

Tujuan Khusus
1. Untuk mengetahui gambaran skalp dermoskopi pada laki – laki yang mengalami alopesia

androgenetik dan yang tidak mengalami alopesia androgenetik.

2. Untuk mengetahui karakteristik subjek yang mengalami alopesia androgenetik berdasarkan

usia, derajat keparahan dan riwayat keluarga

3. Untuk mengetahui perbedaan gambaran scalp dermoskopi berdasarkan karakteristik usia dan

riwayat keluarga pada laki – laki dengan alopesia androgenetik.

Penelitian Sebelumnya
1. Halilovic EK. Trichoscopic Findings in Androgenetic Alopecia. Medical Archives :
The Academy of Medical Sciences of Bosnia and Herzegovina. 2021; 75(2): 109-111.
2. Ummiti A. Priya PS. Kumar S, Correlation of Trichoscopic Findings in Androgenetic
Alopeia and the Disease Severity. Wolter Kluwer-Medknown Publications, 2019;
11(3):118-122.
3. Kibar M. Aktan S. Bilgin M, Scalp Dermatoscopic Findings in Androgenetic Alopecia
Relations with Disease Severity. Annals of Dermatology. 2014;26(4):478-484.

Cara Kerja Penelitian

Laki – laki dengan alopesia androgenetik Laki – laki tanpa alopesia androgenetik

Anamnesis, pemeriksaan rambut dan kulit kepala

Pasien memenuhi kriteria inklusi dan ekslusi

Pemeriksaan Dermoskopi pada area frontal, temporal dan verteks

Pencatatan Hasil Temuan Dermoskopi

Tabulasi dan analisis data


ORIGINAL PAPER
doi: 10.5455/medarh.2021.75.109-111
MED ARCH. 2021 APR; 75(2): 109-111
RECEIVED: MAR 13, 2021
ACCEPTED: APR 15, 2021
Department of Dermatovenereology,
University Clinical Center Sarajevo, Bosnia
and Herzegovina
Corresponding author:, Emina Kasumagic-
Halilovic, MD, PhD, Department of
Dermatolovenereology,, University
Clinical Center Sarajevo, Bolnicka 25,,
Sarajevo, Bosnia and Herzegovina. E-mail:
eminakahalilovic@gmail.com. ORCID ID:
http//www.orcid.org. 0000-0003-2206-
2555.
© 2021 Emina Kasumagic-Halilovic
This is an Open Access article distributed under
the terms of the Creative Commons Attribution
Non-Commercial License (http://creative-
commons.org/licenses/by-nc/4.0/) which
permits unrestricted non-commercial use,
distribution, and reproduction in any medium,
provided the original work is properly cited.
ORIGINAL PAPER | Med Arch. 2021 APR; 75(2): 109-111
Trichoscopic Findings in Androgenetic Alopecia
Trichoscopic Findings in
Androgenetic Alopecia
Emina Kasumagic-Halilovic
ABSTRACT
Background: Androgenetic alopecia (AGA) is an androgen-related condition that develops
in genetically predisposed individuals. The condition is characterized by the progressive
loss of terminal hairs on the scalp in a characteristic distribution. Trichoscopy represents
the dermoscopy imaging of the scalp and hair. Structures which may be visualized by
trichoscopy include hair shafts, hair follicle openings, perifollicular epidermis and cutane-
ous microvessels. Objective: The aim of this prospective study was to identify the tricho-
scopic features of androgenetic alopecia. Methods: Hundred-four patients with AGA and
80 healthy subjects were enrolled in this study. Data on age, gender, personal and family
history, clinical type and duration of disease were collected and analyzed. Control group
consisted of 80 generally healthy subjects. Trichoscopic examination was performed using
either videodermatoscope or handheld dermatoskope. Trichoscopy results were obtained
in frontal, occipital and both temporal areas of the scalp, including number of yellow dots
and vellus hairs, number of hairs in one pilosebaceous unit and percentage of follicular
ostia with perifollicular hyperpigmentation. The data were statistically evaluated. Results:
The number of yellow dots, pilosebaceous units with only one hair and with perifollicular
hyperpigmentation was significantly increased in androgenetic alopecia (p<0.05). The per-
centage of thin hairs (<0.03 mm) in AGA was significantly higher than in healthy controls
(p<0.05). Conclusion: Our study has shown the significances of trichoscopy of patients
with AGA. Regular clinical and trichoscopical follow-ups are very important to monitor dis-
ease activity and treatment tolerance.
Keywords: androgenetic alopecia, hair, trichoscopy, videodermoscopy.
1. BACKGROUND
Androgenetic alopecia (AGA) is an androgen-related condition that devel-
ops in genetically predisposed individuals. The disease affects up to 80% of
Caucasians man and no less than 42% of women (1). AGA is characterized by
stepwise miniaturization of the hair follicle, resulting from alteration in the
hair cycle dynamics, leading to vellus transformation of terminal hair follicle
(2). The result is a progressive decline in visible scalp hair density.
The clinical presentation of AGA can be different in men and women, shar-
ing the same pathogenesis. While male androgenetic alopecia (MAGA) is
characterized by its typical bitemporal recession of hair and balding vertex,
female androgenetic alopecia (FAGA) is set apart by its more diffuse thinning
of the crown area with an intact frontal hairline.
Standard methods used to diagnose hair disorders are clinical inspection,
pattern of hair loss, pull test, trichogram, biopsy and screening blood tests.
They vary in sensitivity, reproducibility and invasiveness. Trichoscopy is very
useful for in vivo diagnosis of scalp and hair disorders and can greatly improve
clinical management (3). Both handheld dermatoscope and videodermato-
scope can be utilized. The basic principle of dermatoscopy is transillumina-
tion of a lesion and studying it with high magnification to visualize subtle fea-
tures. Structures which may be visualized by trichoscopy include hair shafts,
hair follicle openings, perifollicular epidermis and cutaneous microvessels.
Trichoscopy allows analyzing acquired and congenital hair diseases.
More recent studies have accumulated evidence that the use of trichoscopy
in the clinical evaluation of hair disorders improves diagnostic capability be-
yond simple clinical inspection (4-7).
2. OBJECTIVE
The aim of this study was to identify the trichoscopic features of androge-
netic alopecia.
109
Trichoscopic Findings in Androgenetic Alopecia
3. PATIENTS AND METHODS
A case-control study was conducted and all patients
were from Department of Dermatovenerology, Univer-
sity Clinical Centre Sarajevo. After informed consent,
relevant history was taken and clinical examination was
performed. The following factors were considered: sex,
age, personal and family history, severity and duration
of disease.
The study included 104 patients with AGA (44 fe-
male and 60 male). The diagnosis of AGA was based on
clinical examination. Patients with any scalp disorders
such as irreversible alopecia, trichotillomania, alopecia
areata and scalp psoriasis were excluded from the study.
Control group consisted of 80 generally healthy subjects
(35 female and 45 male). Trichoscopic examination was
performed using either MoleMax II videodermatoscope
or handheld dermatoskope DermLite II pro (3Gen, San
Juan Capistrano, Ca USA).
Trichoscopy results were obtained in frontal, occipital
and both temporal areas of the scalp, including number
of yellow dots and vellus hairs, number of hairs in one
pilosebaceous unit and percentage of follicular ostia
with perifollicular hyperpigmentation.
The data were statistically evaluated. Statistical signif-
icance for variables relationship was considered when
p<0.05.
4. RESULTS
Among the 104 patients included in this study, 60
(57.69%) patients were men and 44 (42.31%) patients
were women. The male /female ratio was 1:0.73. The av-
erage age of the patients was 41, varying from 22 to 69
years old. There was no statistically significant difference
between genders with respect to age (p>0.05). Family his-
tory was positive for AGA in 61 of 104 (58.65%) patients.
The duration of AGA ranged from 2 to 105 months. The
patients enrolled in our study had mostly type II Fitz-
patrick’s skin phenotype. The control group consisted of
80 generally healthy participants: 45 (56.25%) men and
35 (43.75%) women with an age range of 20-71 years, 42
years on average (table 1).
Most common trichoscopic finding was hair thickness
heterogeneity seen in 104 (100%) patients, followed by
yellow dots seen in 55 (52.88%) patients and vellus hairs
AGA group n (%) Control Group n (%)
Men 60 (57.69) 45 (56.25)
Women 44 (42.31) 35 (43.75)
Age range, years 22-69 20-71
The average, years 41 42
Table 1. Demographic data of patients (AGA-androgenetic
alopecia) and volunteers (control group)
Trichoscopic structures n (%)
Hair diversity 104 (100)
Yellow dots 55 (52.88)
Vellus hairs 51 (49.03)
Perifollicular hiperpigmentation 42 (40.38)
Table 2. Trichoscopic findings seen in patients with AGA
110
seen in 51 (49.03%) patients. Perifollicular hyperpigen-
tation had 42 (40.38%) patients. In the control group,
only yellow dots were found in two patients. The num-
ber of yellow dots, pilosebaceous units with only one
hair and with perifollicular hyperpigmentation was sig-
nificantly increased in androgenetic alopecia (p<0.05).
The percentage of thin hairs (<0.03 mm) in AGA was
significantly higher than in healthy controls (p<0.05).
No significant differences in trichoscopy are observed
between female and male androgenic alopecia (table 2).
5. DISCUSSION
Trichoscopy corresponds to scalp and hair derma-
toscopy and has been increasingly used as an aid in the
diagnosis, follow-up, and prognosis of hair disorders.
Trichoscopic evaluation of the scalp is based on the ob-
servation of follicular patterns, interfollicular patterns,
hair shaft characteristics and vascular patterns.
Today, trichoscopy is the most important tool for
diagnosis androgenetic alopecia and it completely
substituted the scalp biopsy. Trichoscopy reflects the
pathophysiology of AGA because it shows the follicular
miniaturization where the hair became shorter, thinner
and paler, the diameter variability and a shorter anagen
phase and it explains the empty follicle phenomenon
due to the prolongation of kerogen phase (8).
Male and female AGA share similar trichoscopic fea-
tures, including hair shaft thickness, heterogeneity, thin
hairs, yellow dots, perifollicular discoloration, an in-
creased proportion of vellus hair, and a large number of
follicular units with only one emerging hair shaft (9). In
AGA, trichoscopic abnormalities are more pronounced
in the frontal than in the occipital area.
Hair thickness heterogeneity is characterized by the
simultaneous presence of hairs in different thicknesses:
vellus, thin intermediate, and thick. In androgenetic al-
opecia a variation of the diameter that affects more than
20% of the hair of the androgen-dependent region is
considered a major diagnostic criterion of androgenet-
ic alopecia. This sign is very useful for diagnosis initial
AGA. Hair diameter diversity or anysotrichosis has been
shown to reflect follicle miniaturization in AGA (10).
Similar to previous studies, all of our patients demon-
strated hair diameter diversity, confirming that this sign
is the main criterion in AGA (11-13).
Trichoscopy of AGA shows an increased proportion
of vellus hairs. Up to 10% of normal human scalp hairs
are vellus hairs, defined as hypopigmented, nonmedul-
lated hairs less than 30 μm thick and less than 2-3 mm
long (14). The presence of more than 10% of thin hair,
below than 0.03 mm, in the frontal area is considered
a major diagnostic criterion of AGA. In our study, the
percentage of thin hairs in AGA was significantly higher
than in healthy controls.
The term “dots” refers to the small, round follicle
openings seen on trichoscopy. Trichoscopy may distin-
guish whether hair follicle openings are normal, empty,
fibrotic or containing biological material, such as hyper-
keratotic plugs or hair residues. Yellow dots are follicular
infundibula with keratotic material or sebum. They vary
ORIGINAL PAPER | Med Arch. 2021 APR; 75(2): 109-111

in color, shape and size. In severe AGA, the presence
of yellow dots in androgen-dependent areas is charac-
teristic: they correspond to empty follicles or they con-
tain completely miniaturized hairs. It is believed that,
in this condition, yellow dots results from the presence
of engorged sebaceous glands that remain functioning
despite the progress of the miniaturization process of
the follicles, leading to the formation of intraepidermal
sebaceous lakes (9). Such findings are observed in both
male and female forms of the disease.
In various studies, yellow dots were observed in 92.4%
(15), 66% (9), 30.5% (16) and 7% (17) of patients with
AGA. This disparity in findings can be explained by the
difference in ethnic group enrolled in studies which im-
plies variation in sebaceous gland activity as well as in
the degree of pigmentation of the scalp in late stages.
Yellow dots found in 55 (52.88%) of patients, in our study
were seen in both early and advanced stages of AGA. On
the other hand, Ross et al. emphasized yellow dots being
higher in late AGA in their study (17).
A decreased number of hairs per follicular unit is a
characteristic but nonspecific feature of AGA. Normally
2-3 hairs of the same follicular unit emerge in the osti-
um, in AGA an increased percentage of single-hair per
pilosebaceous units emerge in the ostium especially in
the frontal area.
Trichoscopy can also show peripilar depressions,
which appear as brown, slightly depressed halos, which
extend for about 1 mm in diameter around the emer-
gence of the hair shaft (18). This sign is linked to super-
fitial perifollicular infiltrates composed mainly of lym-
phocytes. In AGA, brown perifollicular discoloration
is observed in 20-66% of patients (10, 19). In our study,
peripilar sign was seen in 42(40.38%) cases. It is found
more often in patients with initial forms and in the fron-
tal area.
6. CONCLUSION
Hair loss can have significant effects on patient’s quali-
ty of life, and a prompt diagnosis of the different types of
alopecias and an early intervention is needed. Trichos-
copy represents a non-invasive technique for the eval-
uation of patients with hair loss that allows magnified
visualization of the hair and scalp skin. Alopecia andro-
genetica is the most common form of hair loss both in
men and women. Regular clinical and trichoscopical fol-
low-ups are very important to monitor disease activity
and treatment tolerance.
• Pateint Consent Form: The author certify that she has ob-
tained all appropriate patient consent forms.
• Author's contribution: The author was involved in all steps
of the preparation of this study including final proofreading.
• Conflicts of Interest: The author declare no conflict of in-
terest
• Financial support and sponsorship: Nil.
REFERENCES
1. Otberg N, Finner AM, Shapiro J. Androgenetic alopecia. En-
docrinol Metab Clin North Am. 2007; 36(2): 379-398.
ORIGINAL PAPER | Med Arch. 2021 APR; 75(2): 109-111
Trichoscopic Findings in Androgenetic Alopecia
2. Kaliyadan F, Nambiar A, Vijayaraghavan S. Androgenetic al-
opecia: an update. Indian J Dermatol Venereol Leprol. 2012;
79(5): 613-625.
3. Tosti A, Torres F. Dermoscopy in the diagnosis of hair and
scalp disorders. Actas Dermosifiliogr. 2009; 100(1): 114-119.
4. Mahur M, Acharya P. Trichoscopy of primary cicatrial al-
opecias: an updated review. J Eur Acad Dermatol Venereol.
2020; 34(3): 473-484.
5. Widaty S, Pusponegoro EH, Rahmayunita G, Astriningrum
R, Akmad AM, Oktarina C et al. Applicability of trichos-
copy in scalp seborrheic dermatitis. Int J Trichology. 2019;
11(2): 43-48.
6. Waskiel-Burnat A, Rakowska A, Sikora M, Ciechanowicz P,
Olzewska M, Rudnicka L. Trichoscopy of tinea capitis: a sys-
tematic review. Dermatol Ther (Heidelb). 2020; 10(1): 43-52.
7. Galliker NA, Trueb RM. Value of trichoscopy versus tricho-
gram for diagnosis of female androgenetic alopecia. Int J
Trichology. 2012; 4(1): 19-22.
8. Alessandrini A, Starace M, D’Ovidio R, Villa L, Rossi A, Stan
TR. et al. Androgenetic alopecia in women and men: Italian
guidelines adapted from European Dermatology Forum/Eu-
ropean Academy of Dermatology and Venereology guidelines.
G Ital Dermatol Venereol. 2020; 155(5): 622-631.
9. 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(2): 123-130.
10. Inui S, Nakajima T, Itami S. Scalp dermoscopy of androge-
netic alopecia in Asian people. J Dermatol. 2009; 36(2): 82-85.
11. Inui S. Trichoscopy for common hair loss diseases: algorhit-
mic method for diagnosis. J Dermatol. 2011; 38(1): 71-75.
12. Kibar M, Aktan S, Bilgin M. Scalp dermatoscopic findings
in androgenetic alopecia and their relations with disease se-
verity. An Dermatol. 2014; 26(4): 478-484.
13. Govindarajulu SM, Srinivas RT, Kuppuswamy SK, Prem P.
Trichoscopic patterns of nonscarring alopecia’s. Int J Trichol-
ogy. 2020; 12(3): 99-106.
14. Rakowska A, Trichoscopy (hair and scalp videodermos-
copy) in the healthy female. Method standardization and
norms for measurable parameters. J Dermatol Case Rep.
2009; 3(1): 14-19.
15. Ummiti A, Priya PS, Chandravathi PL, Kumar CS. Correla-
tion of trichoscopic findings in androgenetic alopecia and
the disease severity. Int J Trichology. 2019; 11(3): 118-122.
16. Karadag Kose O, Gulec AT. Clinical evaluation of alopecias
using a handheld dermatoscope. J Am Acad Dermatol. 2011;
67(2): 206-214.
17. Ross EK, Vincenzi C, Tosti A. Videodermoscopy in the evalu-
ation of hair and scalp disorders. J Am Acad Dermatol. 2006;
55(5): 799-806.
18. Deloche C, de Lacharriere O, Misciali C, Piraccini BM, Vin-
cenzi C,Bastien P, et al. Histological features of peripilar signs
associated with androgenetic alopecia. Arch Dermatol Res.
2004; 295 (10): 422-428.
19. Hu R, Xu F, Han Y, Sheng Y, Qi S, Miao Y, et al. Trichoscopic
findings of androgenetic alopecia and their association with
disease severity. J Dermatol. 2015; 42(6): 602-607.
111
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Ann Dermatol Vol. 26, No. 4, 2014 http://dx.doi.org/10.5021/ad.2014.26.4.478

ORIGINAL ARTICLE

Scalp Dermatoscopic Findings in Androgenetic Alopecia

and Their Relations with Disease Severity
1 2
Melike Kibar, Şebnem Aktan , Muzaffer Bilgin

Department of Dermatology, Beypazarı Public Hospital, Ankara,

1
Department of Dermatology, Dokuz Eylul University School of Medicine, Izmir,
2
Department of Biostatistics, Eskişehir Osmangazi University School of Medicine, Eskişehir, Turkey

Background: Clinicians are searching for new methods to
diagnose and predict the course of androgenetic alopecia
noninvasively. Objective: Our aim is to evaluate tricho-
scopic findings and their relations with disease severity in
androgenetic alopecia. Methods: The videodermatoscopic
findings of 143 female and 63 male patients with andro-
genetic alopecia were compared with each other, with those
of healthy subjects (n=100), and with those of patients with
other nonscarring alopecias (n=208). Mann-Whitney U-test,
χ2 analyses, and logistic regression analysis were used for
statistical analysis. Results: No statistically significant rela-
tion was found between trichoscopic findings and severity in
male androgenetic alopecia (MAGA) on the basis of the mo-
dified Hamilton Norwood scale (among 7 degrees); how-
ever, multihair follicular unit and perifollicular pigmentation
were related to low severity whereas white dots, honey-
comb pattern pigmentation, and brown dots were related to
high severity. On the other hand, according to the Ludwig
classification, arborizing red lines were related to low se-
verity and brown dots were related to high severity, whereas
there was no difference in stages between the Ebling and
Olsen classifications in female androgenetic alopecia (FAGA).
In the characteristic trichoscopic findings in this study,
perifollicular pigmentation was found as a normal feature of
the scalp, whereas multihair follicular unit and honeycomb
Received April 1, 2013, Revised September 9, 2013, Accepted for
publication September 14, 2013
Corresponding author: Melike Kibar, Department of Dermatology, Bey-
pazarı Public Hospital, Ankara 06000, Turkey. Tel: 90-506-2924963,
Fax: 90-312-7632296, E-mail: kibarmelike@hotmail.com
This is an Open Access article distributed under the terms of the
Creative Commons Attribution Non-Commercial License (http://
creativecommons.org/licenses/by-nc/3.0) which permits unrestricted
non-commercial use, distribution, and reproduction in any medium,
provided the original work is properly cited.
pigment pattern, which were previously considered as
normal features, were observed to be related to androgenetic
alopecia. Conclusion: No relation was found between
MAGA severity and trichoscopic findings, as well as bet-
ween FAGA severity according to different disease severity
classifications and trichoscopic findings. (Ann Dermatol
26(4) 478∼484, 2014)
-Keywords-
Androgenetic alopecia, Dermoscopy, Trichoscopy
INTRODUCTION
Androgenetic alopecia (AGA) is the most common form of
hair loss both in men and women, and is characterized by
a progressive loss of hair diameter, length, and pigmen-
tation1. It is sometimes difficult to diagnose AGA clini-
cally; thus, dermatologists are searching for new methods
to facilitate the diagnosis. Trichoscopy is one of these me-
thods, and AGA is characterized trichoscopically accor-
ding to an increased proportion of thin and vellus hairs,
hair shaft thickness heterogeneity, perifollicular discolo-
ration (hyperpigmentation), and the presence of a variable
number of yellow dots (YD), as reported in previous stu-
dies2-5.
This study aimed to evaluate the trichoscopic findings in
AGA in relation to disease severity, as well as to compare
the trichoscopic findings of male AGA (MAGA) with those
of female AGA (FAGA).
MATERIALS AND METHODS
Patients
The whole scalp of 206 (143 women, 63 men) patients

478 Ann Dermatol


with AGA was evaluated by using videodermoscopy in
dermatology outpatient clinics between January 2011 and
June 2011. This study was approved by local ethics
committee. The trichoscopic findings of the 143 FAGA
and 63 MAGA patients were compared with each other
according to disease severity, as well as compared with
those of patients with other nonscarring alopecias, in-
cluding seborrheic dermatitis (n=112), alopecia areata
(AA) (n=39), psoriasis (n=31), telogen effluvium (TE)
(n=22), and trichotillomania (TC) (n=4), and with those
of healthy subjects (n=100). Among the FAGA patients in
the study group, 56 also had seborrheic dermatitis and 3
also had psoriasis. Moreover, 23 of the MAGA patients
also had seborrheic dermatitis and 4 of them also had
psoriasis.
Diagnosis
FAGA was clinically suspected in cases of frontal (Chris-
tmas tree pattern), diffuse central, or vertex/frontal (male
pattern) accentuation with sparing of the occipital area6.
The diagnosis was established through clinical examina-
tion and confirmed with scalp biopsy in ambiguous cases.
Three patients suspected of having FAGA or TE had punch
biopsy specimens taken from the immediately adjacent
skin on the midscalp, and all specimens were sectioned
horizontally. The terminal-to-vellus hair ratio at the midi-
sthmus level was used to set the diagnosis. A ratio of ≤4 :
1 was accepted as indicative of FAGA, whereas a ratio of
＜8 : 1 together with an anagen-to-telogen ratio of ＜8 : 1
was accepted indicative of TE7. The severity of FAGA was
estimated according to Ludwig’s scale in 3 degrees, and
cases with frontal accentuation (Christmas tree pattern)
were estimated according to the Olsen scale in 3 degrees.
Patients with diffuse central or vertex/frontal (male pattern)
alopecia sparing the occipital area were classified as
having FAGA of a male pattern, and the severity was
estimated according to Ebling’s classification in 5
degrees8,9.
Similar to FAGA, the diagnosis of MAGA was established
according to clinical findings. These findings were alope-
cia starting from the temporal and midfrontal scalp and
reaching to the posterior scalp, or centrifugal alopecia sta-
rting from the vertex. In 3 patients with MAGA alopecia,
the FAGA pattern was observed similar to some Asian
men; there was diffuse thinning in the frontal and midline
areas, whereas temporal and vertex areas were less affec-
ted. To estimate the disease severity in MAGA patients,
the modified Hamilton Norwood (H-N) scale was used
and alopecia was graded in 7 degrees. Afterward, the
MAGA severity was categorized as follows: MAGA di-
sease severity group 1 (DSG-1) as the sum of H-N scales 1,
Dermoscopy in Androgenetic Alopecia
2, and 3, and MAGA disease severity group 2 (DSG-2) as
the sum of H-N scales 4, 5, 6, and 7.
Trichoscopic examination
To elucidate the vascular patterns and to avoid nosoco-
mial infections, a solution combining propanol and butane-
diol and glycerin as immersion gel were used in limited
cases before trichoscopic examination. At least 4 images
were taken with ×100 magnification from the parietal,
frontal, occipital, and lesional areas.
Statistical analysis
Statistical analysis was performed by using SPSS ver. 15.0
(SPSS Inc., Chicago, IL, USA). The concordance of the
data to normal distribution was checked with the Kolmo-
gorov-Smirnov test. Continuous data are given as the
mean±standard deviation. Multiple logistic regression
analysis tests were applied to determine the relation bet-
ween variables and risk factors. Categorical variables were
summarized as percentages and compared by using the χ2
test. Mann-Whitney U-test was applied to compare 2 gr-
oups with continuous data that did not show a normal
distribution. Significance was set at p＜0.05.
RESULTS
The age of the MAGA patients varied from 12 to 75 years
(mean, 37.3±16.6 years), and that of the FAGA patients
varied from 15 to 79 years (mean, 34.3±15.2 years). The
patients enrolled in our study had mostly type III Fitz-
patrick’s skin phenotype.
Male androgenetic alopecia
The common trichoscopic findings were hair diameter
diversity (HDD), structureless red areas (SRA), brown dots
(BD), and perifollicular white scales (PWS) (p＜0.001).
Among the less common trichoscopic findings were white
dots (WD), YD, multihair follicular unit (MHFU), and
hidden hair (HH) (p＜0.05; Table 1). The common tri-
choscopic findings in MAGA compared with those in
other nonscarring alopecias are summarized in Table 1.
There was no statistically significant relation between
MAGA severity (among 7 degrees in the modified H-N
scale) and trichoscopic findings, although WD were seen
in 5 of 9 patients in MAGA degree 5 (p=0.098). On the
other hand, when the 2 MAGA severity groups (DSG-1
and DSG-2) were compared, MHFU and perifollicular
pigmentation (PFP) were found to be related to low se-
verity (mostly seen in DSG-1), whereas WD, honeycomb
pigment pattern (HCPP), and BD were observed to be
related to severe disease (mostly seen in DSG-2) (Table 2).
Vol. 26, No. 4, 2014 479
M Kibar, et al

The relations of trichoscopic findings to disease severity in twisted red loops, arborizing red lines (ARL), SRA, HH,
the DSG-1 and DSG-2 are summarized in Table 2. atypical red vessels (ARV), YD, WD, and BD (p＜0.05;
Table 3). HCPP was also frequent (13.4%, p=0.268);
Female androgenetic alopecia
however, the frequency was not statistically significant as
Among female patients in whom disease severity was seen in MAGA.
assessed according to Ludwig classification, the common When FAGA cases were classified according to the Ebling
trichoscopic findings were miniaturization, PFP, MHFU, and Olsen classifications, there was no difference between
trichoscopic findings in the different severity groups. In
the Ludwig classification, ARL was detected to be more
Table 1. Common trichoscopic findings in patients with male common in stage 1 and BD was detected to be more
androgenetic alopecia in comparison with patients with other common in stage 3 when compared with other nonsca-
nonscarring alopecias (N=63)
rring alopecias (Table 4). Accordingly, early-stage FAGA
Trichoscopic structures n (%) p-value
Arborizing red lines 23 (36.5) ＞0.05
Atypical red vessels 21 (33.3) ＞0.05 Table 3. Common trichoscopic findings in female androgenetic
Comma vessels 0 (0)00. ＞0.05 alopecia and their comparison with those of other nonscarring
Corkscrew vessels 0 (0)00. ＞0.05 alopecias (N=134)
Structureless red areas 33 (52.4) ＜0.001
Trichoscopic structures n (%) p-value
Radial capillaries 0 (0)00. ＞0.05
Red dots and globules 10 (15.9) ＞0.05 Arborizing red lines 25 (18.7) ＜0.001
Glomerular vessels 10 (15.9) ＞0.05 Atypical red vessels 23 (17.2) ＜0.001
Twisted red loops 16 (25.4) ＞0.05 Structureless red areas 25 (18.7) ＜0.001
Honeycomb pigment pattern 16 (25.4) ＞0.05 Twisted red loops 26 (19.4) ＜0.029
Yellow dots 16 (25.4) 0.024 Honeycomb pigment pattern 18 (13.4) ＜0.268
Perifollicular pigmentation 29 (46)0. 0.179 Yellow dots 25 (18.7) ＜0.001
Hair diversity 63 (100). ＜0.001 Perifollicular pigmentation 87 (64.9) ＜0.001
Perifollicular white scales 9 (14.3) 0.001 Hair diameter diversity 134 (100). ＜0.001
White dots 18 (28.6) 0.011 White dots 11 (8.2).. ＜0.001
Multihair follicular unit 38 (60.3) 0.026 Multihair follicular unit 75 (56)... ＜0.012
Brown dots 14 (22.2) ＜0.001 Brown dots 3 (2.2).. ＜0.005
Hidden hair 9 (14.3) 0.002 Hidden hair 25 (18.7) ＜0.001

Table 2. Relations of trichoscopic findings between 2 MAGA severity groups (DSG-1 and DSG-2)
MAGA severity group Arborizing Honeycomb Perifollicular Brown Perifollicular White Multihair
(patient No.) red lines pigment pattern white scales dots pigmentation dots follicular unit
MAGA DSG-1 (40) 18 (45)0.0 6 (15)0 8 (20). 5 (12.5) 23 (57.5)0 7 (17.5) 28 (70)0.
MAGA DSG-2 (23) 5 (21.7) 10 (43.5) 1 (4.3) 9 (39.1) 6 (26.1) 11 (47.8)0 10 (43.5)
p-value 0.065 0.012 0.087 0.014 0.016 0.010 0.038
Values are presented as number (%).
MAGA: male androgenetic alopecia, DSG-1: disease severity group 1, DSG-2: disease severity group 2.

Table 4. Trichoscopic findings and their correlations with disease severity according to the Ludwig classification
Honeycomb Hair Multihair
Ludwig degree Arborizing Atypical Structureless Yellow Perifollicular Brown Hidden
pigment diameter follicular
patient, n red lines red vessels red areas dots pigmentation dots hair
pattern diversity unit
FAGA L-1 (68) 20 (29.4) 11 (16) 16 (23.5) 6 (8.8)0 15 (22) 68 (100) 38 (55.9) 43 (63.2) 0 (0).0 18 (26.5)
FAGA L-2 (61) 4 (6.6).. 11 (18) 7 (11.5) 12 (19.7) 8 (13) 61 (100) 46 (75.4) 29 (47.5) 2 (3.3) 05 (8.2)
FAGA L-3 (5) 1 (20).0 1 (20) 2 (40).0 18 (13.4) 2 (40) 5 (100) 03 (60).4 3 (60).0 1 (20). 02 (40)
p-value 0.004 ＞0.05 0.098 0.131 ＞0.05 ＞0.05 0.066 ＞0.05 0.011 ＞0.05
Values are presented as number (%).
FAGA: female androgenetic alopecia, L-1: Ludwig stage 1, L-2: Ludwig stage 2, L-3: Ludwig stage 3.

480 Ann Dermatol


(low disease severity) was found to be related to ARL and
late-stage FAGA (high disease severity) was observed to be
related to BD similar to MAGA. In the early stage (low-
severity MAGA), PFP and MHFU were common; in the
late stage (high-severity MAGA), HCPP, BD and WD were
common. On the other hand, when the frequencies of the
common trichoscopic findings were compared between
MAGA and FAGA, only 2 findings were statistically more
common: WD and BD in MAGA.
DISCUSSION
White dots
Similar to the findings of Ross et al.3, WD were more com-
mon in chronic and/or severe disease in our study (Fig.
1A, B).
Abraham et al.10 related WD to eccrine glands and folli-
cular ostia histologically in their study. In AGA, the 5-α-
reductase activity stimulates sebaceous glands and causes
hypertrophy; however, its effect on eccrine glands is not
clearly known11,12. Although it is known that the eccrine
glands are stimulated mainly by cholinergic stimulation, 5-
Dermoscopy in Androgenetic Alopecia
α-reductase activity could also be seen in acrosyringium,
which may cause these glands to undergo hypertrophy
like sebaceous glands in AGA. In our study, the WD in
AGA were not similar to those of AA, and the distances
between WD were detected to be more variable in AGA;
thus, we thought that this scattered form of WD in AGA
can be attributed to 5-α-reductase activity and its effects
on both the acrosyringium and pilosebaceous ostium11.
Although AGA is classified within the nonscarring alop-
ecias, it could also show perifollicular infiltrates as a histo-
pathological feature. Furthermore, in advanced disease,
follicles can be replaced by connective tissues, leading to
fibrous tracts and finally causing atrophy in follicles. These
empty follicular ostia are seen as WD3,13-19. In concor-
dance with this finding, WD were observed to be more
common in the late stages of AGA in our study. On the
other hand, Kossard and Zagarella19 observed WD in ca-
ses with scarring alopecia and considered these WD as
being the melanin pour places in fibrous tracts of scar
tissue. Thus, it could be postulated that the fibrous tracts
seen in the late stages of AGA can also cause these tricho-
scopic findings such as WD.
Fig. 1. (A) Perifollicular pigmenta-
tion, brown dots, white dots, mini-
aturization, and hair diameter div-
ersity in a 65-year-old patient with
male androgenetic alopecia Hamil-
ton Norwood stage 5. (B) Miniatu-
rization, hair diameter diversity,
white dots, and perifollicular pigm-
entation in a 25-year-old patient
with female androgenetic alopecia
(FAGA) Ludwig stage 1. (C) Peri-
follicular pigmentation, glomerular,
and signet ring vessel (in green
circle), hidden hairs, miniaturiza-
tion, and hair diameter diversity in
a 23-year-old FAGA Ludwig stage
1 patient with seborrheic derma-
titis. (D) Perifollicular pigmentat-
ion, multihair follicular unit, minia-
turization, and hair diameter diver-
sity in a 32-year-old FAGA Ludwig
stage 1 patient.
Vol. 26, No. 4, 2014 481
M Kibar, et al
As dark skin color makes WD more obvious, the frequency
of WD in our study was high because our patients had dark
skin color, similar to the findings of Zhang et al.20. To our
knowledge, interfollicular pinpoint WD can be seen in the
sun-exposed scalp of patients with skin phototypes III and
IV and in the normal scalp of those with phototypes V and
VI10. These dots appear as small (0.2∼0.3 mm) WD
distributed regularly in the interfollicular scalp, dispersed
across the mosaic pigmented network. They have been
correlated with the acrosyringeal and follicular
openings10,21. In our study, we saw both these regular
pinpoint WD between the HCPP together with irregularly
distributed white areas.
According to our results, WD were more common in
alopecia totalis, sisaipho, and late-stage MAGA. The com-
mon features of these 3 conditions were the effect of cumu-
lative, direct sun damage with inflammatory infiltrates.
Additionally, in our opinion, the more dense and irregu-
larly distributed form of AGA is attributed to 5-α-redu-
ctase activity in the glands.
Women usually have longer hair than men; thus, damage
caused by the sun and, consequently, the frequency of
HCPP are less frequent in women. Thus, in our study
group, WD were observed less commonly in FAGA than
in MAGA.
Honeycomb pigment pattern
In our study group, HCPP was observed to be more com-
3
mon in severe MAGA. Ross et al. related HCPP to ch-
ronic sun exposure, whereas Tosti observed WD in sub-
jects with chronic sun exposure and in those with dark
skin22. Thus, to determine the effect of cumulative sun
exposure on scalp trichoscopic findings, we classified our
patients and 100 healthy controls into 2 groups according
to their ages: ≤25 years and ≥50 years. The ratio of
HCPP in the control group was 0 : 43 in the ≤25-year age
group and 2 : 20 in the ≥50-year age group. Furthermore,
the ratio of HCPP in patients with alopecia was 16 : 122
in the ≤25-year age group and 11 : 43 in the ≥50-year
age group. The difference between the 2 age groups was
found to be not significant in both the alopecia and con-
trol groups; however, HCPP was detected to be signi-
ficantly more common in the alopecia group. Logistic
regression analysis revealed that when this pattern is
observed trichoscopically, the estimated alopecia risk was
3.2 times as high.
Hidden hair
In our study group, HH was common in patients with
FAGA, MAGA, seborrheic dermatitis, and psoriasis. The
presence of psoriasiform hyperplasia and dermal infiltrates
482 Ann Dermatol
both in seborrheic dermatitis and psoriasis together cause
epidermal thickness, whereas pilosebaceous unit was
sparse11,12,23. Consequently, the hair shaft appeared hidd-
en and lying under this thickened epidermis, prompting us
to name this appearance as HH (Fig. 1C).
This sign, observed in AGA in our study group, was attri-
buted to accompanying seborrheic dermatitis and psori-
asis with miniaturized hair shafts in those patients. On the
other hand, isolated AGA may be the only reason because
dermal infiltrates are also common in AGA, which may
cause epidermal augmentation similar to seborrheic der-
matitis and psoriasis24.
Multihair follicular unit
Hair density is related to the number of hairs extending
from 1 pilosebaceous unit; in a healthy person, this is
about 1∼3 hairs from 1 unit. Thus, Rakowska et al.4 acce-
pted 1 hair pilosebaceous unit as a minor criterion for
AGA18. We assessed regularly arranged ≥3 hairs from 1
unit without any epidermal and peripilar sign as MHFU
that differs from tufted hairs seen in folliculitis decalvans,
lichen planopilaris, and central centrifugal cicatricial
alopecias25. Although it could be seen in both healthy
persons and alopecia patients, MHFU was found to be
related to alopecia in our study group. To our knowledge,
the percentage of follicular units with only 1 hair is also
increased in TE and various forms of anagen hair loss4,26. It
was found to be statistically significant in MAGA and
FAGA when compared with other alopecias and with the
healthy control group in addition to this literature.
MHFU was also found to be related to less severe MAGA
and FAGA (Fig. 1D). In early AGA, dermal and peri-
follicular inflammation constituting growth factors and
cytokines, together with the anabolic effects of testoste-
rone, may provoke this augmentation.
Perifollicular pigmentation
PFP was first described by Deloche et al.24. Inui et al.2
reported PFP in almost all patients with alopecia who had
fair skin; however, the ratios were lower in Asian patients,
similar to our study. PFP is thought to be the result of
dermal infiltrates in AGA24-29. Perifollicular inflammation
is thought to be due to the effect of cosmetics, chemicals,
ultraviolet light, mucin deposit, and melanocytes; how-
ever, the etiopathogenesis is still unknown15,29.
PFP was found to be significantly more common in FAGA
patients than in MAGA patients in our study group. Thus,
inflammation could be postulated to be more severe in
FAGA (Fig. 1A, B).
When the relation between skin color and PFP was eva-
luated, PFP was found to be more common in Fitzpatrick’s

skin phenotype 3 both in the alopecia and control groups,
although it was not statistically significant. The ratio of PFP
in the control group was 15 : 43 in the ≤25-year age
group and 0 : 20 in the ≥50-year age group, and the
frequency of PFP was not different between the alopecia
and control groups. Logistic regression analysis for PFP
revealed that when found trichoscopically, the estimated
risk for alopecia is 3.2 times higher.
Thus, PFP seemed to be a normal hair feature in persons
younger than 25 years. Deloche et al.24 detected high
peripilar pigmentation in subjects having high hair den-
sity. Furthermore, Rakowska et al.4 related high hair den-
sity with the number of hairs extending from 1 follicular
unit. Thus, MHFU and PFP were found to be common in
our healthy young controls aged ＜25 years.
Brown and yellow dots
The ratio of YD were 16 : 63 in MAGA and 25 : 143 in
FAGA in our study, similar to previous studies: 13 : 50 in
Deloche et al.’s study24, 6 : 34 in MAGA and 1 : 7 in
FAGA in Inui et al.’s study30, and 13 : 50 in MAGA and 1 :
10 in FAGA in Inui et al.’s other study2. YD were also
seen in TC (1 : 4), psoriasis (6 : 31), seborrheic dermatitis
(44 : 112), and TE (1 : 22) in our study group, whereas
Rakowska et al.4 described YD as the main dermoscopic
criteria to discriminate FAGA and chronic TE.
YD in AGA are thought to be the result of sebaceous hy-
pertrophy and lagooning in glands as a result of end-organ
hypersensitivity4. YD were observed to be more common
in MAGA in both Inui et al.’s2,30 study groups and ours in
relation to higher levels of androgens supporting this
hypothesis.
YD are fırst described as uniform pink-YD by Ross et al.3;
however, in our study, some of them were brown. BD
were detected to be a marker of severity both in MAGA
and FAGA in our study (Fig. 1A).
Rudnicka et al.31,32 described scattered brown areas in
discoid lupus erythematosus and actinic keratosis and
regularly distributed gray or brown-gray dots in the eye-
brow area of patients with frontal fibrosing alopecia. In ad-
dition, Fu et al.33 identified dirty dots as a normal finding
in the scalps of 10 of 19 healthy children that represent
nonmicrobial environmental particles. On the other hand,
in our study, we saw BD in AGA located in perifollicular
and interfollicular areas similar to YD that we think are
brown because of the dark skin color of the patients.
Hair diameter diversity
The characteristic trichoscopic findings of AGA are known
34
as HDD and PFP . Similar to previous studies, all of our
patients with AGA demonstrated HDD, confirming that
Dermoscopy in Androgenetic Alopecia
this sign is the main criterion in AGA2,34,35 (Fig. 1A∼D).
There are no data about the relation between MAGA se-
verity and trichoscopic findings between classifications
such as Ludwig, Ebling, Olsen, and modified H-N. On the
other hand, Zhang et al.20 investigated the relation bet-
ween FAGA and trichoscopic findings according to the
Ludwig classification. In their study, the characteristic tri-
choscopic features (at 10-fold magnification) of FAGA
were brown and white peripilar signs, WD, scalp pigmen-
tation, and focal atrichia. White peripilar signs, scalp pig-
mentation, and focal atrichia positively correlated with the
stage (Ludwig stage 3)20. In both Zhang et al.’s20 and our
study, it would be more appropriate to use the basic and
specific (BASP) classification in addition to Ludwig, Ebl-
ing, Olsen, and modified H-N scale that is applicable to
both MAGA and FAGA. The BASP classification is a new
stepwise, systematic, and universal system for patterned
hair loss, regardless of sex36.
There is no study in the literature about the relation bet-
ween MAGA severity and trichoscopic findings according
to different disease severity classifications. On the other
hand, Ross et al.3 emphasized YD being higher in late
5
AGA in their study. In addition, Lacarrubba et al. un-
derlined miniaturization as being higher in early AGA.
Besides, in our study, PFP was detected to be a charac-
teristic trichoscopic finding of AGA that was described as
a normal feature of the scalp in healthy persons younger
than 25 years. In addition, MHFU and HCPP, which were
previously accepted as normal features, were also found
to be related to alopecias in this study.
Among the study group patients with FAGA, 56 also had
seborrheic dermatitis and 3 also had psoriasis; thus, trich-
oscopic features such as ARL, ARV, and SRA were attri-
buted to the accompanying diseases in these patients.
Twenty-three of the MAGA patients also had seborrheic
dermatitis and 4 of them also had psoriasis; thus, trichos-
copic figures such as PWS, SRA, signet ring vessel, and
HH were attributed to additional diseases. Similar to our
findings, Ross et al.3 detected red loops in AGA patients
and ARL, HCPP, and YD in patients having both AGA and
seborrheic dermatitis. On the other hand, on patient
selection, it might be more accurate to select AGA pati-
ents without seborrheic dermatitis, or compare groups
with or without seborrheic dermatitis.
To have more meaningful and significant results, a better-
designed study with a larger number of patients and con-
trols should be done in different age groups and the re-
sults confirmed histopathologically.
Vol. 26, No. 4, 2014 483
M Kibar, et al
REFERENCES
1. Gordon KA, Tosti A. Alopecia: evaluation and treatment.
Clin Cosmet Investig Dermatol 2011;4:101-106.
2. Inui S, Nakajima T, Itami S. Scalp dermoscopy of andro-
genetic alopecia in Asian people. J Dermatol 2009;36:82-85.
3. Ross EK, Vincenzi C, Tosti A. Videodermoscopy in the eva-
luation of hair and scalp disorders. J Am Acad Dermatol
2006;55:799-806.
4. Rakowska A, Slowinska M, Kowalska-Oledzka E, Olszewska
M, Rudnicka L. Dermoscopy in female androgenic alopecia:
method standardization and diagnostic criteria. Int J
Trichology 2009;1:123-130.
5. Lacarrubba F, Dall'Oglio F, Rita Nasca M, Micali G. Video-
dermatoscopy enhances diagnostic capability in some forms
of hair loss. Am J Clin Dermatol 2004;5:205-208.
6. Olsen EA. Female pattern hair loss. J Am Acad Dermatol
2001;45(3 Suppl):S70-S80.
7. Harrison S, Sinclair R. Telogen effluvium. Clin Exp Dermatol
2002;27:389-385.
8. Camacho-Martínez FM. Hair loss in women. Semin Cutan
Med Surg 2009;28:19-32.
9. Ludwig E. Classification of the types of androgenetic alope-
cia (common baldness) occurring in the female sex. Br J
Dermatol 1977;97:247-254.
10. Abraham LS, Piñeiro-Maceira J, Duque-Estrada B, Barcaui
CB, Sodré CT. Pinpoint white dots in the scalp: dermoscopic
and histopathologic correlation. J Am Acad Dermatol
2010;63:721-722.
11. Wolff H. Diseases of hair. In: Braun-Falco O, Plewig G,
Wolff HH, Landthaler M, editors. Braun-Falco’s Dermatolo-
gy. 3th ed. Heidelberg: Springer Verlag, 2009:1029-1059.
12. Paus R, Peker S, Sundberg JP. Biology of hair and nails. In:
Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 2th
ed. St. Louis: Mosby Elsevier, 2008:965-987.
13. Whiting DA. Diagnostic and predictive value of horizontal
sections of scalp biopsy specimens in male pattern andro-
genetic alopecia. J Am Acad Dermatol 1993;28:755-763.
14. Whiting D. Scalp biopsy as a diagnostic and prognostic tool
in androgenic alopecia. Dermatol Ther 1998;8:24-33.
15. Won CH, Kwon OS, Kim YK, Kang YJ, Kim BJ, Choi CW, et
al. Dermal fibrosis in male pattern hair loss: a suggestive
implication of mast cells. Arch Dermatol Res 2008;300:
147-152.
16. Bertolino PA, Freedberg IM. Disorders of epidermal appen-
dages and related disorders. In: Freedberg IM, Eisen AZ,
Wollf K, editors. Dermatology in general medicine. 4th ed.
New York: McGraw-Hill, 1993.
17. Sperling LC, Winton GB. The transverse anatomy of andro-
genic alopecia. J Dermatol Surg Oncol 1990;16:1127-1133.
18. Leroy T, Van Neste D. Contrast enhanced phototrichogram
pinpoints scalp hair changes in androgen sensitive areas of
male androgenetic alopecia. Skin Res Technol 2002;8:
106-111.
484 Ann Dermatol
19. Kossard S, Zagarella S. Spotted cicatricial alopecia in dark
skin. A dermoscopic clue to fibrous tracts. Australas J Der-
matol 1993;34:49-51.
20. Zhang X, Caulloo S, Zhao Y, Zhang B, Cai Z, Yang J. Female
pattern hair loss: clinico-laboratory findings and trichoscopy
depending on disease severity. Int J Trichology 2012;4:
23-28.
21. Ardigò M, Tosti A, Cameli N, Vincenzi C, Misciali C, Bera-
rdesca E. Reflectance confocal microscopy of the yellow dot
pattern in alopecia areata. Arch Dermatol 2011;147:61-64.
22. Tosti A. Alopecia areata. In: Tosti A, editor. Dermoscopy of
hair and scalp disorders with clinical and pathological corre-
lations. London: Informa Healthcare, 2007:26-50.
23. Cotsarelis G, Botchkarev V. Biology of hair follicles. In:
Wollf K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Le-
ffell DJ, editors. Fitzpatrick’s dermatology in general me-
dicine. 7th ed. New York: McGraw-Hill, 2008:39-749.
24. Deloche C, de Lacharrière O, Misciali C, Piraccini BM, Vin-
cenzi C, Bastien P, et al. Histological features of peripilar si-
gns associated with androgenetic alopecia. Arch Dermatol
Res 2004;295:422-428.
25. Miteva M, Tosti A. Hair and scalp dermatoscopy. J Am Acad
Dermatol 2012;67:1040-1048.
26. Rakowska A. Trichoscopy (hair and scalp videodermoscopy)
in the healthy female. Method standardization and norms for
measurable parameters. J Dermatol Case Rep 2009;3:14-19.
27. Young JW, Conte ET, Leavitt ML, Nafz MA, Schroeter AL.
Cutaneous immunopathology of androgenetic alopecia. J Am
Osteopath Assoc 1991;91:765-771.
28. Headington JT. Transverse microscopic anatomy of the
human scalp. A basis for a morphometric approach to disor-
ders of the hair follicle. Arch Dermatol 1984;120:449-456.
29. Jaworsky C, Kligman AM, Murphy GF. Characterization of
inflammatory infiltrates in male pattern alopecia: impli-
cations for pathogenesis. Br J Dermatol 1992;127:239-246.
30. Inui S, Nakajima T, Nakagawa K, Itami S. Clinical signifi-
cance of dermoscopy in alopecia areata: analysis of 300
cases. Int J Dermatol 2008;47:688-693.
31. Rudnicka L, Rakowska A, Olszewska M. Trichoscopy: how it
may help the clinician. Dermatol Clin 2013;31:29-41.
32. Rudnicka L, Olszewska M, Rakowska A. Atlas of trichoscopy:
dermoscopy in hair and scalp disease. London; New York:
Springer-Verlag, 2012.
33. Fu JM, Starace M, Tosti A. A new dermoscopic finding in
healthy children. Arch Dermatol 2009;145:596-597.
34. Inui S. Trichoscopy for common hair loss diseases: algori-
thmic method for diagnosis. J Dermatol 2011;38:71-75.
35. Tosti A, Iorizzo M, Piraccini BM. Androgenetic alopecia in
children: report of 20 cases. Br J Dermatol 2005;152:556-
559.
36. Lee WS, Ro BI, Hong SP, Bak H, Sim WY, Kim do W, et al.
A new classification of pattern hair loss that is universal for
men and women: basic and specific (BASP) classification. J
Am Acad Dermatol 2007;57:37-46.