Follicular microhemorrhage: A unique dermoscopic sign for the detection of coexisting trichotillomania in alopecia areata

Abstract

The diagnosis of trichotillomania (TT) is often difficult as it presents similar clinical manifestations with other hair loss diseases, especially alopecia areata (AA). As TT often coexists with AA, the methodology enabling reliable detection of TT in AA needs to be developed. Recently, characteristic dermoscopic findings of TT have been reported, yet, they were most clearly detectable by conventional immersion dermoscopy, not by dry dermoscopy, a technique more easily adoptable in daily practice. In addition, the usefulness of those signs for differentiating TT from AA has not been sufficiently assessed. Through intensive scanning of hair loss lesions by dry dermoscopy in AA patients with TT, we found a sign potentially useful for detecting hidden TT. The sign we named "follicular microhemorrhage" (FMH) represents a red dot corresponding to a follicular ostia capped or stuffed with blood clot and suggests a history of traumatic forced plucking. So far, we have detected FMH in four TT patients with moderate to severe AA. Although further accumulation of cases is necessary, FMH would be beneficial to dissect complicated pathophysiology of hair loss in AA patients with TT.

Trichoscopy in trichotillomania: A useful diagnostic tool

“…It presents as a red dot corresponding to follicular ostia capped or stuffed with the blood clot and suggests a history of traumatic forced plucking. [ 13 ] Authors could observe this pattern in 30% of patients in the present study. Recently, flame hairs, v-sign, tulip hairs, and hair powder are described, and authors claim these signs are specific only for TTM.…”

Alopecia areata. How not to miss Satoyoshi syndrome?

“…Patients with alopecia areata represent a significant number of patients in dermatology hospitals and out‐patient clinics . The diagnostic options in alopecia areata have significantly increased in recent years . However, it is important not to lose sight of caring for the patient as a whole and to question about non‐dermatologic symptoms.…”

“…44,45 The diagnostic options in alopecia areata have significantly increased in recent years. [46][47][48][49] However, it is important not to lose sight of caring for the patient as a whole and to question about non-dermatologic symptoms. In our opinion all patients will alopecia areata (in particular alopecia totalis) should be asked about muscle spasms and diarrhea and tested for antinuclear antibodies to decrease the risk of missing Satoyoshi syndrome.…”

The Dermoscopic “Pluck Out Sign” for Beard Trichotillomania

“…Some reports, however, associate the two diseases which pose a diagnostic challenge to clinicians [7]. In this scenario, dermoscopy has emerged as a noninvasive and useful tool for the diagnosis of the disease [10,11,12,13]. Black dots, coiled hairs, shafts of various lengths, broom fibers, and V-sign (trichoptilosis) are suggestive of TTM.…”

“…On the other hand, exclamation point hairs, which are suggestive of alopecia areata, are commonly absent in TTM [14,15,16]. Follicular microhemorrhages are a unique dermoscopic sign for the detection of coexisting TTM in cases of alopecia areata [11] and can be extremely useful in doubtful cases. In this paper, we describe the “pluck out sign” for beard TTM, which can be added to the previously described aspects of scalp TTM and could be helpful in the diagnosis.…”