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. 2022 Apr 12;8(5):412–414. doi: 10.1159/000524135

Scalp Micropigmentation: A Clinicopathologic Correlation

Betty Nguyen a,b,*, Joshua S Mervis a, Paolo Romanelli a, Antonella Tosti a
PMCID: PMC9485964  PMID: 36161085

Abstract

Introduction

Scalp micropigmentation is a method of concealing alopecia by depositing permanent pigment in a tattoo-like manner. Pigment is deposited between hair follicles in a stippling pattern that resembles closely cut hair.

Case Presentation

On trichoscopy, characteristic findings of scalp micropigmentation include homogenous, grey to black circular dots that are evenly spaced and appear larger than adjacent hair follicles. Findings were correlated with histopathology.

Conclusion

Trichoscopy is a useful tool to visualize scalp micropigmentation in place of invasive procedures.

Keywords: Alopecia, Hair cosmetics, Hair histopathology, Hair loss, Micropigmentation, Scalp tattoo

Established Facts

  • Scalp micropigmentation is a method of camouflaging alopecia by depositing pigment into the dermis of the scalp. From afar, pigmented dots resemble shortly cut hair.

Novel Insights

  • On trichoscopy, scalp micropigmentation appears as grey to black circular dots distributed between hair follicles in a stippling pattern.

Introduction/Literature Review

Scalp micropigmentation (SMP) is a newer method of concealing alopecia by depositing permanent pigment in a tattoo-like manner. Micropigmentation of the scalp can be used to camouflage scalp scars, female and male pattern hair loss, alopecia areata, and cicatricial alopecia [1, 2]. The goal is to create dots in a stippling pattern that resemble closely cut hair. SMP is typically performed by cosmetic technicians using regional anesthetics [1, 3]. Multiple treatments are typically required to achieve a layered look, and a full head SMP may require 20–30 h to complete [4].

Characteristic findings of SMP can be visualized on trichoscopy, as reported in this case. Trichoscopy is a reliable, noninvasive tool to distinguish SMP from other scalp mimics.

Trichoscopy Findings

Trichoscopy (FotoFinder Systems, ×10 magnification) showed homogenous black or grey dots that were larger than adjacent follicles and evenly distributed throughout the scalp (Fig. 1). Each dot, which was consistent in size and had smooth borders, appeared to be made up of clusters of smaller dots (microdots), resembling a stippling pattern. Histopathology at the site of dermoscopy-guided scalp biopsy revealed clusters of coarse black pigment within the dermis, similar to findings seen in tattooing (Fig. 2a-c). Unlike that seen in dermoscopy, pigment seen under histopathology had jagged, uneven borders (×4 magnification) and was irregularly shaped (×40 magnification) (Fig. 2a, c). Pigmented dots had variability in size, were uniformly black in color, and appeared to be randomly distributed. Focal granulomatous infiltrate and peri-infundibular infiltrate of lymphocytes and eosinophils were also seen. There were no signs of inflammation or perifollicular fibrosis. These trichoscopic and histopathologic findings of SMP are summarized in Table 1.

Fig. 1.

Fig. 1

Appearance of scalp micropigmentation on trichoscopy (FotoFinder Systems, ×10 magnification) of a patient with female pattern hair loss.

Fig. 2.

Fig. 2

H&E stain of left parietal scalp showing clusters of black pigment deposited within the dermis (×4) (a), (×10) (b), and (×40) (c) consistent with scalp micropigmentation. H&E, hematoxylin and eosin.

Table 1.

Correlations between trichoscopic and histopathologic findings of scalp micropigmentation

Trichoscopy Histopathology
Shape Circular pigmented dots Pigment with jagged, uneven borders (×4 magnification) or irregular shapes (×40 magnification)

Size Larger than adjacent hair follicles, with homogeneity in size Variable in size

Color Multiple gradations of grey to black pigmented dots Single shade of pure black pigment

Distribution Evenly spaced dots in a stippling pattern with interfollicular distribution Clusters of coarse pigment randomly dispersed throughout dermis

Discussion

Tattooing is the process of piercing the skin with needles to deposit pigment into the dermis. However, the traditional method of tattooing has yielded unpleasing results on the scalp [5]. SMP utilizes the same instrumentation as tattooing but relies on carefully diluted pigment to artistically deposit pigment between hair follicles. Black pigment is often diluted to achieve a visual shade of grey that blends with the patient's scalp and hair color [2]. The majority of pigments used are inorganic molecules containing iron oxide, titanium dioxide, or barium sulfate [6].

Pigment is deposited into the upper and midpapillary dermis, with varying depths of up to 1.5 mm, using a handpiece that contains microneedles cycling between 120 and 150 cycles per second [2, 3, 4]. Micro droplets of pigment must be deposited at an appropriate angle and depth depending on the thickness of each individual's scalp [5]. If deposited superficially in the epidermis, the pigment will become exfoliated with the stratum corneum and washed away, and if deposited too deep within the deeper dermis, the pigment may spread out and result in a patchy, blotchy appearance [2, 5]. Multiple treatments are required to achieve a stippling effect, and fading also occurs over time, requiring touch-ups [4]. Pain, edema, and erythema may be expected for several days after the procedure [2, 3]. Allergic reactions to pigment components, causing pruritus and/or paresthesia, may rarely occur [3].

On initial examination, pigmented dots of SMP may resemble the macroscopic appearance of environmental contaminants and/or hair dye. On dermoscopy, however, SMP can be easily distinguished from mimics. Environmental contaminants appear as clumped dots scattered much more sporadically throughout the scalp [7]. Black dots seen in permanent and semipermanent hair dyes are smaller than those seen in SMP and lack the characteristic stippling pattern [8]. In this report, we identify key trichoscopic features (i.e., shape, size, color, distribution) of SMP that have not yet been described in the literature and correlate these findings to histopathologic features.

Statement of Ethics

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. This study was deemed exempt by the University of Miami Institutional Review Board (45 CFR 46.104).

Conflict of Interest statement

Dr. Tosti conflicts. Consultant DS Laboratories, Monat Global, Almirall, Thirty Madison, Eli Lilly, Bristol Myers Squibb, P&G, Pfizer, Myovant. Principal Investigator Eli Lilly, Concert, Erchonia. Dr. Tosti is one of the Editors-in-Chief of Skin Appendage Disorders. The remaining authors have no conflicts of interest to declare.

Funding Sources

The authors have received no funding for this study.

Author Contributions

Betty Nguyen, Joshua S. Mervis, and Antonella Tosti evaluated the dermoscopic images, and Paolo Romanelli performed the histological examination. Betty Nguyen, Joshua S. Mervis, Paolo Romanelli, and Antonella Tosti were involved in the preparation of the manuscript and read and approved the final manuscript.

Data Availability Statement

The datasets used and/or analyzed in the study are available from the corresponding author on reasonable request.

References

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets used and/or analyzed in the study are available from the corresponding author on reasonable request.


Articles from Skin Appendage Disorders are provided here courtesy of Karger Publishers

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