Abstract
Background:
Alopecia areata (AA) is an unpredictable disease that manifests as rapid and patchy hair loss and may involve any hair-bearing part of the body. We used dermoscopy to compare the dermoscopic findings of AA in patients with and without poor prognostic indicators.
Aims and Objectives:
To compare the key variations in dermoscopic features between patients of AA with and without poor prognostic indicators.
Patients and Methods:
This was a retrospective study carried out at a tertiary care teaching hospital in eastern Odisha. The study included the patients of scalp AA from October 2023 to October 2024. A total of 85 patients of AA were evaluated using the Severity of Alopecia Tool (SALT) score and Dermlite DL3 attached to iPhone 12.
Results:
A total of 85 patients with AA were included in our study (male: female ratio ~ 2:1). The mean (± standard deviation) age of patients was 26.61 ± 9.82 years. The mean duration of the disease was 5.98 ± 11.74 months. Patchy AA was the most common. The most common dermoscopic feature observed was yellow dots (83.5%), followed by broken hairs (65.9%), black dots (51.8%), vellus hairs (51.8%), tapering hairs (50.6%), and coudability hairs (22.4%). Patients with poor prognostic markers had a substantially higher SALT score (34.99 ± 37.21) compared to those without (10.75 ± 14.08), with P = 0.002. A statistically significant high SALT score was recorded in patients with disease duration >3 months. The dermoscopic features that were significantly more frequent in patients having poor prognostic factors were yellow dots (P = 0.000), black dots (P = 0.02), broken hairs (P = 0.03), and coudability hairs (P = 0.000), while in patients without poor prognosis, vellus hairs (P = 0.005) were more commonly seen. The finding of tapering hair (P = 0.1) was not found to be significantly associated with either group.
Limitations:
Retrospective nature of the study and not assessing dermoscopic response to treatment.
Conclusion:
Ours is the first study to emphasize the comparison of dermoscopic features of AA in patients with and without poor prognostic indicators. Yellow dots, black dots, broken hairs, and coudability hairs were associated with adverse prognosis, while vellus hair indicated a favorable outcome. Identifying these key dermoscopic markers can help to assess the disease severity, potentially refine prognostic assessments, and guide treatment decisions.
Keywords: Alopecia areata, dermoscopy, poor prognostic factors
Introduction
Nonscarring hair loss is a commonly encountered problem accounting for 0.7%[1] of all dermatology outpatients, among which alopecia areata (AA) accounts for 25%[1] of cases in India. Clinically, AA can manifest as patchy type, reticular/reticulate type, ophiasis, sisaipho, diffuse alopecia, alopecia totalis, or alopecia universalis. The National Alopecia Areata Foundation devised a Severity of Alopecia Tool (SALT)[2] for quantitative assessment of scalp hair loss.
Although spontaneous recovery is possible in 34–50% of patients within 1 year[3], the presence of a personal/family history of atopy, other autoimmune diseases, nail changes, alopecia totalis, alopecia universalis, ophiasis pattern, early age at onset (<10 years), and longer duration of disease (>1 year) indicate a poor prognosis.[4]
Dermoscopy is a noninvasive technique that has been reported to be useful in diagnosing AA. The trichoscopic features of AA are yellow dots, black dots, broken hair, tapering/exclamation mark hair, coudable hair, and vellus hair.
Yellow dots represent follicular infundibulum distended with keratinous material and sebum, and they were first reported by Ross et al.[5] Hair with a narrowing of the shaft toward the follicle is tapering hair. They are a result of the truncated hair cycle and are usually seen in the periphery of the alopecic patch. Weakening of hair shafts by the inflammatory process or rapid regrowth of incompletely destroyed hair shaft ends up forming broken hair. The remnants of tapering hair and broken hair result in black dots. Shuster[6] introduced the term coudable hair for hairs that can be easily made to kink when bent or pushed inward. Short vellus hairs are the sign of hair regrowth which appear lightly pigmented and thin.
To the best of our knowledge, this is the only study that aimed to compare the key variations in dermoscopic features between patients of AA with and without poor prognostic indicators. This study highlights the use of dermoscopy as a device to determine the disease prognosis without invasive procedures like scalp biopsy.
Patients and Methods
This retrospective observational study was carried out at the Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha. The study included the patients of AA from October 2023 to October 2024. A statement on ethical approval is to be provided by the authors. Ethical approval was obtained from the Institutional Ethics Committee.
The data were collected from the AA register maintained in the department. A total of 85 patients with a clinical diagnosis of AA were included in this study. The patients were divided into two groups based on the presence of any poor prognostic factors. Group A included patients without poor prognostic factors, and group B included patients with poor prognostic factors. The presence of any one of alopecia universalis, alopecia totalis, ophiasis, a personal or family history of atopy, presence of any other autoimmune diseases, nail changes, early age of onset (<10 years), and longer duration of disease (>1 year) was marked as an indicator of poor prognosis.
A written informed consent was obtained from the patient for use of clinical photographs for academic and publication purposes, ensuring anonymity. History, age, gender, complaints, duration, and various prognostic factors were recorded. The inclusion criteria were treatment-naïve patients with patches of AA on the scalp. Exclusion criteria were patches over other parts of the body. A thorough clinical history was obtained. Clinical examination and SALT score calculation for quantitative assessment of scalp hair loss were carried out for each patient. Dermlite DL3 was used to assess and record dermoscopic findings.
Sample size: An all-inclusive sampling technique was used, and all the patients who had presented with a scalp patch of AA during this period were included in the study. The sample size of group A, 63, and group B, 22, was assessed for adequacy using a power analysis, considering a significance level of 0.05 and a power of 0.80. For detecting a medium effect size (Cohen’s d = 0.5), the total sample size of 85 participants is sufficient, making this sample size adequate.
SALT score calculation: The scalp was divided into four areas – vertex 40% (0.4), left profile of scalp 18% (0.18), right profile of scalp 18% (0.18), and posterior surface 24% (0.24). The percentage of hair loss in any area is the percentage hair loss multiplied by the percent surface area of the scalp in that area. A sum of the percentages of hair loss in all four areas gives the SALT score.
Statistical analysis was carried out by determining mean and standard deviation for linear variables, Pearson’s correlation analysis for studying correlation between duration and SALT score, standard normal Z test and the difference of proportion test for comparing dermoscopic findings in different groups of patients. A P value <0.05 was considered to be statistically significant.
Results
A total of 85 patients with AA were included in our study. There were 56 males and 29 females with male: female ratio of ~ 2:1. The profile of the patients is shown in Table 1. The mean age of patients was 26.61 ± 9.82 years. The mean duration of disease was 5.98 ± 11.74 months. The most common clinical presentation was patchy AA (81.1%). One or more clinical poor prognostic factors were present in 22 patients [Table 2]. The mean SALT score was 17.02 ± 24.62, the highest SALT score being 100 and the lowest being 0.9. Patients with poor prognostic markers had a substantially higher SALT score (34.99 ± 37.21) compared to those without (10.75 ± 14.08), with P = 0.002. The SALT score was high (24.90 ± 27.42) and statistically significant in disease duration of >3 months (P = 0.03), whereas no difference in SALT score was seen between males and females (P = 0.48) [Table 3]. Recurrent episodes were observed in 19 (22.3%) patients. Two (2.35%) patients had a positive family history, five (6.9%) patients had history of atopy or autoimmune diseases, and four (5.7%) patients had positive nail findings.
Table 1.
Profile of the patients
| Type of AA | No. of patients (%) | Males | Females | Patients with recurrent episodes | Positive family history | Patients with history of atopy or autoimmune diseases | Nail changes |
|---|---|---|---|---|---|---|---|
| Patchy | 69 (81.1) | 48 | 21 | 16 | 2 | 5 | 1 |
| Reticular | 9 (10.6) | 6 | 3 | 3 | 0 | 0 | 2 |
| Diffuse | 2 (2.4) | 0 | 2 | 0 | 0 | 0 | 1 |
| Ophiasis | 2 (2.4) | 0 | 2 | 0 | 0 | 0 | 1 |
| Sisaipho | 0 (0) | 0 | 0 | 0 | 0 | 0 | 0 |
| Alopecia totalis | 2 (2.4) | 2 | 0 | 0 | 0 | 0 | 0 |
| Alopecia universalis | 1 (1.1) | 0 | 1 | 0 | 0 | 0 | 1 |
Table 2.
Profile of patients with poor prognostic features
| Poor prognostic features | No. of patients |
|---|---|
| Alopecia universalis | 1 |
| Alopecia totalis | 2 |
| Ophiasis | 2 |
| Personal or family history of atopy | 3 |
| Other autoimmune diseases | 2 |
| Nail changes | 4 |
| Early age of onset (<10 years) | 4 |
| Longer duration of disease (>1 year) | 4 |
Table 3.
Dermoscopic features and Severity of Alopecia Tool score
| Dermoscopic pattern | Yellow dots (%) | Black dots (%) | Broken hair(%) | Tapering hair(%) | Vellus hair (%) | Coudability hair(%) | SALT Score |
|---|---|---|---|---|---|---|---|
| Total (n=85) | 71 (83.5) | 44 (51.8) | 56 (65.9) | 43 (50.6) | 44 (51.8) | 19 (22.4) | 17.02±24.62 |
| Patients without poor prognosis (n=63) | 49 (77) | 30 (23) | 40 (63.4) | 30 (23) | 35 (55) | 10 (15.8) | 10.75±14.08 |
| Patients with poor prognosis (n=22) | 22 (100) | 14 (63.6) | 17 (77) | 13 (59) | 8 (36.3) | 9 (40.9) | 34.99±37.21 |
| P | 0.000 | 0.02 | 0.03 | 0.10 | 0.005 | 0.000 | 0.002 |
| Males (n=56) | 51 (91) | 32 (57.1) | 31 (55.3) | 31 (55.3) | 24 (42.8) | 10 (17.8) | 15.63±24.15 |
| Females (n=29) | 20 (68.9) | 12 (41.3) | 17 (58.6) | 12 (41.3) | 19 (65.5) | 9 (31.03) | 19.71±25.74 |
| P | 0.0001 | 0.02 | 0.63 | 0.04 | 0.001 | 0.02 | 0.48 |
| Duration <3 months (n=54) | 45 (83.3) | 30 (55.5) | 39 (72.2) | 29 (53.7) | 27 (50.0) | 12 (22.2) | 12.50±21.88 |
| Duration >3 months (n=31) | 26 (83.8) | 14 (45.1) | 17 (54.8) | 14 (45.1) | 16 (51.6) | 7 (22.5) | 24.90±27.42 |
| P | 0.92 | 0.14 | 0.009 | 0.23 | 0.81 | 0.95 | 0.03 |
Dermoscopic findings
The most common dermoscopic pattern noted was yellow dots (83.5%), followed by broken hair (65.9%), black dot (51.8%), vellus hair (51.8%), tapering hair (50.6%), and coudability hair (22.4%) [Table 3] [Figures 1–4].
Figure 1.
(a) Clinical image of alopecia totalis. (b) Dermoscopic image of the scalp patch of AA showing small, uniformly distributed follicular yellow dots; follicular infundibulae are filled with keratinous material with no hair shaft
Figure 4.
(a, b) Clinical image of AA – ophiasis pattern. (c) Dermoscopic image of AA showing multiple yellow dots, broken hair (red arrow), a few black dots, and regrowing vellus hair (green arrow)
Figure 2.
(a) Clinical image of AA. (b) Dermoscopic image showing a central diffuse area of hyperpigmentation with follicular openings, regrowing vellus hair, white hair, and tapering hair (red arrow). (c) Dermsocopic image of AA showing vellus hair (red arrow), black dots, and follicular openings with remnants of pigmented hairs broken at the scalp level
Figure 3.
(a) Clinical image of AA. (b) Dermoscopic image of AA showing coudability sign, multiple yellow dots, few black dots, and regrowing vellus hair. (c) Dermosocpic image of AA showing black dots (red arrow), broken hair (purple arrow), and regrowing vellus hair
Forty-nine patients (77%) without poor prognostic indicators showed yellow dots, whereas all 22 patients (100%) with poor prognoses had yellow dots. This difference was statistically significant (P = 0.0001). Patients with a poor prognosis had a higher frequency of black dots 14 (63.6%) and broken hairs 17 (77%) than those without a poor prognosis as was seen in 30 (47.6%) and 40 (63%) patients, respectively. Vellus hairs were observed in 8 (36.3%) patients with poor prognostic characteristics and in 35 (55%) patients without them. This difference was statistically significant (P < 0.005). The difference in frequency of coudability hairs was significant- in those without poor prognostic features, the frequency of vellus hairs was significantly higher.
According to duration of disease, broken hairs were significantly more frequent in patients with duration <3 months, while no significant difference was seen in other dermoscopic features. Moreover, a weak positive correlation was seen between the SALT score and the duration of the disease (r = 0.13). The presence of vellus hair and coudability hair were significantly more frequent in females, whereas yellow dots, black dots, and tapering hairs were significantly more frequent in males.
Discussion
AA is a chronic, organ-specific autoimmune disease that affects both sexes equally.[6] In our study, male preponderance was seen, which was consistent with the studies done by Mane et al.[7] and Hegde et al.[8] However, Inui et al.[9] showed females to be more commonly affected. The mean age of patients was 26.61 ± 9.82 years. Similar results were observed in other studies.[7,8,10] The mean duration of AA was 5.98 months in our study, whereas it was 19 months and 10.3 months in the studies by Ankad et al. and Mane et al., respectively.[7,11] Recurrent episodes were recorded in 19 patients (22.35%). Contrary to this, Hegde et al. and Bapu et al. found that 12% and 38.66% of patients in the respective studies had recurrent episodes.[8,10] Patchy alopecia was the most common presentation (81.1%) in the study population which was comparable to other studies.[7,8,9]
Dermoscopy is a noninvasive technique primarily used for differentiating pigmented lesions. It was first used in AA by Lacarrubba et al.[12] In the study conducted by Ross et al., yellow dots were present in 94.8% of patients.[4] In contrast, the incidence of yellow dots in our study was 83.5%, which can be attributed to the skin type of Indian patients. Black dots were seen in 51.8% of patients in this study, while it was seen in 84% of cases by Hedge et al., 67.7% of cases by Mane et al.,[7] and 31% of patients by Bapu et al.[10] We found broken hairs in 65.9% of patients, while lesser incidence was reported in other studies. Although tapering hairs were reported in only 12.1% and 19.8% of cases by Mane et al. and Bapu et al., respectively, the incidence of tapering hairs in our study was 50.6%. This can be attributed to inclusion of a higher number of cases with progressive disease. Vellus hair was seen in only half of the study population, that is, 51.8% of cases, while higher incidence was noted in other studies, possibly because those patients were receiving some treatment.[9,10] In this study, coudable hairs were seen in 22.4% of cases, while fewer incidences were observed in other studies.[1,11]
On comparing patients with and without poor prognostic features, the presence of tapering hairs was comparable, whereas vellus hairs that are depictive of recovery were significantly more frequent in patients without poor prognostic features. On the other hand, yellow dots, black dots, broken hair, and coudability hairs were significantly more frequent in patients with poor prognostic features and can be related to disease activity/severity. Additionally, a significant difference was noted in the SALT score.
In patients with longer disease duration, the SALT score was also high with a positive correlation between the two (r = 0.1). None of the dermoscopic findings other than broken hair showed a significant difference. In a previous study by Lacarrubba et al.,[12] it was reported that broken hairs are commonly found in acute AA and that explains the presence of broken hair in a significant number of patients with a disease duration of <3 months.
There was no significant difference in SALT score and broken hairs between males and females. However, a significantly higher incidence of yellow dots, black dots, and tapering hair was observed in males, while the presence of vellus hair and coudable hair was significantly more frequent in females.
In a recent study by Raheem et al.[13] comparing the dermoscopic features of AA between adults and children, the most prevalent trichoscopic characteristic among all patients was empty follicular opening observed in 82.2% lesions. The most common dermoscopic finding in children was honeycomb pigment in 87.5% of lesions; and in adults, it was empty follicular units in 40 (80%) lesions. In another study by Aryanian et al.,[14] the most common trichoscopic finding in adults was yellow dots, which were much less prevalent in children (48.4% vs 29%), whereas exclamation mark hairs were significantly more common in children than adults (38.7% vs 21%). These studies emphasize the need of taking age into account while doing dermoscopic analysis on AA patients.
The significant difference in our study highlights the critical relevance of including poor prognostic factors in dermoscopic evaluation of AA.
Limitations
Retrospective nature of the study and not assessing dermoscopic response to treatment are limitations of the study. Prospective studies with larger sample size are warranted to further validate these findings.
Conclusion
Ours is the first study to emphasize the comparison of dermoscopic features of AA in patients with and without poor prognostic indicators. Yellow dots, black dots, broken hairs, and coudability hair were associated with adverse prognosis, while vellus hair indicated a favorable outcome. Identifying these key dermoscopic markers can help to assess the disease severity, potentially refine prognostic assessments, and guide treatment decisions. The significant difference between the two groups highlights the importance of dermoscopic analysis of AA patients to prognosticate the disease outcome.
Consent declaration for use of photographs
We confirm that written informed consent was obtained from the patient for use of anonymized clinical photographs in this retrospective study for academic and publication purposes. This declaration complies with ethical and institutional guidelines.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)
The preparation of this manuscript was carried out entirely by the author without the use of artificial intelligence technologies.
Funding Statement
Nil.
References
- 1.Guttikonda AS, Aruna C, Ramamurthy D, Sridevi K, Alagappan SL. Evaluation of clinical significance of dermoscopy in alopecia areata. Indian J Dermatol. 2016;61:628–33. doi: 10.4103/0019-5154.193668. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Oslen EA, Hordinsky MK, Price VH, Roberts JL, Shapiro J, Canfield D, et al. Alopecia areata investigational assessment guidelines –Part II. J Am Acad Dermatol. 2004;51:440–7. doi: 10.1016/j.jaad.2003.09.032. [DOI] [PubMed] [Google Scholar]
- 3.Messenger AG, Sinclair RD, Farrant P, de Berker DAR. Acquired disorders of hair. In: Griffiths C, Barker J, Bleiker T, Chalmers R, Creamer D, editors. Rook's Textbook of Dermatology. 9th ed. United Kingdom: John Wiley and Sons Ltd; 2016. pp. 89.1–89.77. [Google Scholar]
- 4.Spano F, Donovan JC. Alopecia areata: Part 1: pathogenesis, diagnosis, and prognosis. Can Fam Physician. 2015;61:751–755. [PMC free article] [PubMed] [Google Scholar]
- 5.Ross EK, Vincenzi C, Tosti A. Videodermoscopy in the evaluation of hair and scalp disorders. J Am Acad Dermatol. 2006;55:799–806. doi: 10.1016/j.jaad.2006.04.058. [DOI] [PubMed] [Google Scholar]
- 6.Shuster S. ‘Coudability’: A new physical sign of alopecia areata. Br J Dermatol. 1984;111:629. doi: 10.1111/j.1365-2133.1984.tb06637.x. [DOI] [PubMed] [Google Scholar]
- 7.Mane M, Nath AK, Thappa DM. Utility of dermoscopy in alopecia areata. Indian J Dermatol. 2011;56:407–11. doi: 10.4103/0019-5154.84768. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Hegde SP, Naveen KN, Athanikar SB, Reshme P. Clinical and dermoscopic patterns of alopecia areata: A tertiary care centre experience. Int J Trichol. 2013;5:132–6. doi: 10.4103/0974-7753.125608. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Inui S, Nakajima T, Nakagawa K, Itami S. Clinical significance of dermoscopy in alopecia areata: Analysis of 300 cases. Int J Dermatol. 2008;47:688–93. doi: 10.1111/j.1365-4632.2008.03692.x. [DOI] [PubMed] [Google Scholar]
- 10.Bapu NG, Chandrashekar L, Munisamy M, Thappa DM, Mohanan S. Dermoscopic findings of alopecia areata in dark skinned individuals: An analysis of 116 cases. Int J Trichol. 2014;6:156–9. doi: 10.4103/0974-7753.142853. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Ankad B, Beergouder SL, Panchkattimath VS, Sheikh Ahmed M. Trichoscopy of alopecia areata: A diagnostic aide. Hair Ther Transplant. 2014;4:126. [Google Scholar]
- 12.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. doi: 10.2165/00128071-200405030-00009. [DOI] [PubMed] [Google Scholar]
- 13.Raheem A, Al-Dhalimi M. Comparative study of trichoscopic features of alopecia areata between adults and children and between different body parts (scalp, beard, eyebrow, and moustache) Indian J Dermatol. 2024;69:285–291. doi: 10.4103/ijd.ijd_346_23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Aryanian Z, Najafi M, Ansari M, Nassimi M, Etesami I, Heidari S, et al. Trichoscopic findings in children and adults with alopecia areata: A comparative study. J Cosmet Dermatol. 2024;23:2736–42. doi: 10.1111/jocd.16319. [DOI] [PubMed] [Google Scholar]