A Potpourri of Trichoscopic Findings: Unique Presentation of Hyperthyroidism-Induced Hair Changes

Abstract

Hyperthyroidism is known to cause thin, brittle hair, and premature graying. Hair shaft abnormalities in hyperthyroidism have not been described in the literature. A visible and microscopic change in the hair shaft due to cosmetic procedures and environmental factors is known as hair weathering. Herein, we report a case of hair weathering in an adult female with hyperthyroidism with unique dermoscopic features.

INTRODUCTION

The diagnosis of hair shaft disorders has transformed with the use of dermatoscopy.[1]

We report a unique mix of trichoscopic features of hair weathering in a female patient with hyperthyroidism.

CASE REPORT

A 34-year-old female presented with diffuse hair loss for the past 6 years with a sudden increase in hair shedding for the past 2 months. There was no history of hair treatments, excessive hair brushing, hair pulling, recent stressful episodes, or major illnesses in the past except for hair dye use 2 months ago. She had no systemic complaints.

Clinical examination showed thinning of hair over the frontoparietal scalp with short stubs. Hairs were easily pluckable. Dermoscopy (Dinolite AM4113ZT) revealed the presence of zigzag hairs, coiled hair, corkscrew hair, pili torti, trichorrhexis nodosa, flame hair, block hair, and fractured hair (trichoclasis and trichoptilosis) [Figure 1a-d]. Trichogram showed similar findings. Cutaneous examination showed flexural eczema suggestive of atopic dermatitis. Trichotillomania and tinea capitis were considered differentials.

Figure 1.

(a) Single dermoscopic field on the frontoparietal scalp (50x) showing zigzag hair(yellow arrow), coiled hair (green arrow), corkscrew hair (red arrow), trichorhexxis nodosa (white circle), flame hair (yellow circle), block hair (white arrow) trichoptilosis (black arrow), trichoclasis (blue arrow). (b) Trichorhexxis nodosa. (c) Pilitorti. (d) Cork screw hair

Hair clipping (KOH mount/culture) showed no fungal elements. On detailed serological and biochemical investigations, low hemoglobin (7.7 g/dL), low thyroid-stimulating hormone (0.001uIU/mL), and high thyroid peroxidase antibodies (>1000 IU/mL) were detected. Serum ferritin and Vitamin D3 levels were normal.

The patient was started on iron supplements for anemia for a period of 4 weeks. After thyroid investigations, the endocrinologist initiated carbimazole 10 mg twice daily. Dramatic improvement was noted in clinical and dermoscopic pictures within 2 weeks of carbimazole. [Figure 2a-d). Thus, we attributed this distinctive trichoscopic picture to hyperthyroidism compounded by hair dyeing.

Figure 2.

(a) Pretreatment clinical image showing decreased hair density on the frontoparietal scalp. (b) Pretreatment dermoscopy showing distinct hair shaft changes. (c) Posttreatment clinical image showing improved hair density. (d) Posttreatment dermoscopy showing reversal of hair shaft changes

DISCUSSION

Visible and microscopic changes in the hair shaft due to normal degenerative processes (weathering) could be accelerated due to cosmetic procedures and environmental factors.[1] Extensive weathering due to a single exposure to hair dye was an unusual finding in our case. On trichoscopy, hair shaft features have been classified into (i) fractures, (ii) narrowings, (iii) nodes, (iv) curls and twists, (v) bands, and (vi) short hairs by Rudnicka et al.[2] Trichoscopic features have been described with various clinical associations. Table 1 summarizes the four classes of hair shaft changes seen in our patients with common acquired clinical associations.[3,4,5,6,7,8] Trichorrhexis nodosa is associated with hypothyroidism and iron-deficiency anemia; however, trichoscopic features of hyperthyroidism have not been discussed widely.[7,9] Telogen effluvium, thin brittle hair, and premature graying are seen in hyperthyroidism.[10] The trichoscopic mix of four classes of hair shaft changes seen in this patient was unique and could be attributed to the interplay of multiple factors. It is postulated that subjecting brittle hair (due to hyperthyroidism and anemia) to hair dyeing caused exaggerated cuticular damage and the resultant trichoscopic picture of hair weathering.

Table 1.

Trichoscopy of hair shaft changes with common acquired clinical associations

Type	Trichoscopic features	Dermoscopic appearance	Common acquired clinical associations
Curls and twists	Zigzag hair	Hairs with bends at sharp angles at multiple places	Tinea capitis, alopecia areata, trichorrhexis nodosa, and focal weakening of the hair shaft[3]
	Pili torti	Twists of hair shafts along the long axis, usually through an angle of 180	Oral retinoids, trauma or cicatricial alopecia, anorexia, micronutrient deficiency[4] Alopecia areata Hair transplantation Systemic sclerosis[5]
	Coiled hair	Irregularly twisted hair proximal to the site of fracture	Trichotillomania Due to pulling tension[6]
	Corkscrew hair	Intensely coiled spiral hair	Tinea capitis
Node-like structures	Trichorrhexis nodosa	Multiple nodes are seen along the hair shaft where it splits longitudinally into small fibers leaving brush-like ends	Physical trauma Chemical trauma including hair dyeing[3] Pruritic dermatoses Nutritional Deficiencies[5] Hypothyroidism[7]
Fractured hairs	Trichoptilosis	Longitudinal splitting of the distal end	Hair weathering
	Trichoclasis	Transverse fracture of the hair shaft	Alopecia areata Trichothiodystrophy
Short hairs	Flame hair	Very short pigmented hairs with a thin, wavy, distal tip, resembling the flame on a match point	Alopecia areata Trichotillomania Chemotherapy and radiotherapy-induced alopecia[8]
	Block hair	Very short hairs with the transverse distal end	Increased hair shaft fragility Trichotillomania[2]

CONCLUSION

There is a paucity of literature regarding trichoscopy of hair shaft disorders in hyperthyroidism. A single patient showing varied trichoscopic features and hair shaft changes in hyperthyroidism along with the dramatic reversal of the picture within 2 weeks of carbimazole therapy has not been reported to date.

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.