INTRODUCTION

Alopecia, the unwanted condition of hair loss, is divided into subtypes. Scarring alopecia, also known as cicatricial alopecia, is a type of hair loss in which hair follicles are destroyed by inflammation or, less frequently, malignancy (such as cutaneous lymphoma) and those that leave scars (cicatricial alopecia) [1]. Alopecia may affect both sexes, occur in the scalp and body, and come in a variety of patterns. Alopecia can be temporary or permanent and has a number of causes, including hormonal changes, heredity, nutritional deficiencies, infectious reasons, and drug reaction effects. Hair loss without scarring is known as non-cicatricial alopecia. There are a variety of causes that can be divided into focal and diffuse hair loss, as well as abrupt and gradual-onset [2]. A receding hairline and dispersed hair loss at the crown (polygenic) are the hallmarks of male pattern hair loss, commonly referred to as androgenic alopecia, a genetically determined alopecia that affects 50% of men by the age of 50 and is steroid-dependent [3]. Similar to male-pattern hair loss, female-pattern hair loss is also common, although it is characterized by a less obvious cause and widespread hair loss that preserves the frontal hair line [4].

Excessive hair loss, or telogen effluvium, may be a chronic disorder associated with female-pattern hair loss or an acute, self-limiting form caused by a number of events, including major surgery, feverish sickness, delivery, and rapid weight loss. Broken hairs that are securely attached in the scalp and tonsural or irregular patches of hair loss are hallmarks of trichotillomania, a hair-pulling urge disorder [5]. Hair loss caused by extended mechanical traction from a hairstyle is known as traction alopecia; it is initially reversible but may become irreversible as a result of follicular deletion [6]. A fungus (such as erythema and scaling of the scalp) causes tinea capitis, a curable ailment that affects children and is characterized by patchy hair loss and symptoms of inflammation of the scalp. And hair shaft infection and presence of fungi [7]. Normal hair density and strength but very little hair growth are the hallmarks of short anagen syndrome, a disease that usually first manifests in children [8]. The hallmark of loose anagen syndrome is non-growing, unmanaged, and slightly thinning hair, which usually appears in youngsters but can also involve adults [9]. The syndrome is characterized by a triangular or lancet-shaped bald area with a normal hair count but few terminal hairs as vellus hairs, a condition known as temporal alopecia triangularis that usually affects infants or young children [10]. Scarring alopecias, also known as cicatritial alopecias, are types of hair loss where chronic inflammation or, less commonly, cancer (such cutaneous lymphoma) irreversibly destroys hair follicles. [11]. A kind of lichen planopilaris known as frontal fibrosing alopecia typically affects postmenopausal women and is characterized by a distinct pattern of hair loss (in the frontal and frontotemporal hair line and eyebrows) [12]. Chronic cutaneous lupus erythematosus is a form of lupus erythematosus that begins as a patch of symptoms and develops into inflated, irregular, or spherical plaques, follicular plugs, telangiectasia, depigmentation, and scaly, indurated papules [13]. Primarily affecting African-American women, central centrifugal cicatricial alopecia is typified by patchy scarring lesions that start at the vertex or posterior crown and radiate out in a centrifugal pattern along the scalp [14]. Hair disease-specific diagnostic techniques, such as trichoscopy and the hair pull test, can be used in conjunction with traditional methods, such as a physical examination, medical history, and laboratory analysis, to diagnose various hair and scalp illnesses [15].

The most effective non-invasive method for diagnosing and monitoring conditions affecting the hair and scalp is trichotography. Trichoscopy examines a collection of alterations in the scalp, hair distribution pattern, follicle and perifollicular region, and hair shaft [16]. By analyzing the presence or absence of follicular apertures (dots) and detecting more disease-specific or sensitive findings, the trichoscopic assessment and distinction of non-scarring and scarring hair loss allow practitioners to make the diagnosis [17].

MATERIALS AND METHODS

This cross-sectional, analytical, observational study included 100 patients with non-scarring alopecia. Each patient underwent comprehensive assessment covering demographic and clinical data such as name, age, sex, history of chief complaint, dressing of the hair, behavioral pattern and tics, abnormalities of nails, other dermatoses, systemic illness, family history of symptoms, and present or recent use of drugs.

Study participants were recruited from the Dermatology, Venereology, and Andrology outpatient clinics of Orchid Medical Center, United Arab Emirates, between July 2022 and June 2023 for a duration of one year.

Trichoscopic Assessment

Vascular patterns, perifollicular epidermis, and follicular openings were examined by trichoscopy.

Imaging by dermoscopy was done with the DermLite DL4 dermatoscope (Model No. DL4-1406B), which offers both polarized and non-polarized light with 10x magnification. Both contact and non-contact dermoscopy modes were used. Images were captured with a 50-megapixel Oppo Reno 8 Pro camera, in addition to a third-generation MCC pocket-sized portable magneticonnect clamp DermLite adapter (Fig. 1).

Figure 1: Polarized and non-polarized dermatoscope DermLite DL4 (DocNo DL4-1406B). The figure also shows the 50-megapixel camera of an oppo Reno 8 Pro that the photographs were shot with, and 3rd Gen MCC pocket-sized portable MagnetiConnect Clamp DermaLite adapter.

All dermoscopic pictures were stored digitally and checked for characteristic trichoscopic features. Wherever clinical diagnosis was still uncertain, dermoscopy was employed to serve as a confirmatory diagnostic tool.

RESULTS

A total of 100 patients (56 females and 44 males) with non-scarring hair loss with androgenic alopecia, alopecia areata, telogen effluvium, and trichotillomania were included in our study. 43 cases (43%) had androgenetic alopecia, which was the highest percentage of non-scarring alopecia in this study, while 3 cases (3%) of trichotillomania were the least compared to other diseases (Fig. 2).

Figure 2: Percentages of non-scarring alopecia patients related to each disease.

The age of the study group ranged from 25 to 48 years, with a mean (± SD) age of 34.5 ± 5.7 years. The chi-squared test showed a significant association between the type of non-scarring alopecia and patient sex (P-value < 0.05). The results indicated a higher percentage of TF (84.8%) and TMM (100.0%) among females. On the other hand, the results showed a higher percentage of AGA (58.1%) and AA (66.7%) among males. As for the participant’s sex, the results showed that females were slightly older, with a mean (± SD) age of 34.8 ± 5.4 years when compared to males, with a mean (± SD) age of 34.1 ± 6.1 years (Table 1).

Table 1: Association between sex and the type of non-scarring alopecia.

The trichoscopic features and types of non-scarring alopecia and a hair diameter diversity of 100% were observed in cases of androgenic alopecia, with short vellus hair (100%) being the most frequent finding. Telogen effluvium, one single follicular hair unit (100%), and upright hair regrowth (100%) were the most common findings. In alopecia areata, the most common findings were black dots and broken hair (100%), followed by exclamation mark hair (90.5%) and short vellus hair (81%). Regarding trichotillomania, finding broken hair at different levels and black dots (100%) was more common than interfollicular hemorrhage (66.67%) (Table 2).

Table 2: Trichoscopic findings in the different types of non-scarring alopecia.

HDD and short vellus hair, which represented about 100%, were more frequent trichoscopic findings compared to white dots, which represented 25.6%, and were the least common (Table 3) (Fig. 3).

Table 3: Trichoscopic findings of androgenic alopecia.

Figure 3: FPHL (AGA) (a), Image (b) Trichoscopy showing hair diameter diversity (HDD) periperilar sign (PPS) short vellus hair and yellow dots.

Regarding telogen effluvium (Fig.4), single hair follicle unit and upright regrowth hair were observed in about 33 patients, which constituted all TE cases (100%) (Fig. 5).

	Figure 4: Telogen effluvium for anemic patients (a). Trichoscopic image (b) showing one follicular hair unit, empty follicles, yellow dots.
	Figure 5: Trichoscopic findings of telogen effluvium and the number of patients.

Alopecia areata, which was considered the third type of non-scarring alopecia, had black dots and broken hair as the most frequent finding (100%) compared with yellow dots as the least frequent one (19%) (Table 4) (Fig. 6). Three patients had trichotillomania among all non-scarring alopecia cases (Table 2). Broken hair in different levels and black dots represented the highest percentage (100%), and the lowest percentage was coiled hairs (33.4%) (Table 5) (Fig. 7).

Table 4: Trichoscopic findings of alopecia areata.

	Figure 6: Alopecia areata (AA) patchy hair loss on the temporal area of the scalp (a). Trichoscopic image (b,c) showing numerous white dots, exclamation mark hairs, and tapering hairs.
	Figure 7: Showing trichotillomania case at the frontal area of the scalp (a) image, on (b,c) trichoscopic picture showing broken hairs at different levels, black dots, perifollicular hemorrhage, and erythema.

Table 5: Trichoscopic findings of trichotillomania.

The results of the chi-squared test showed a significant association between the type of non-scarring alopecia and each of the trichoscopic features (p-value < 0.05). For example, the results showed a significant association between black dots and the type of non-scarring alopecia, as we found that all patients with alopecia areata (100%) and trichotillomania (100%) showed black dots compared to none of the patients with AGA, FPHL, and telogen effluvium (Table 6).

Table 6: Association between trichoscopic features and the type of non-scarring alopecia.

DISCUSSION

Non-scarring alopecia is a common condition found in both men and women and presents as diffuse or localized alopecia. It typically involves the scalp and, on the odd occasion, other areas of the body, often producing severe psychological distress in the form of depression, anxiety, and stress. The condition is generally diagnosed on clinical history and examination, although on certain occasions, confirmatory tests such as scalp biopsy or fungal culture need to be employed. These tests, although definitive, are time-consuming and may not be well tolerated by patients eager for early diagnosis and treatment [18].

Trichoscopy, which is a non-invasive examination technique using a handheld dermoscope, is now a useful tool in the early diagnosis and follow-up of scalp and hair diseases. It enables diagnosis and follow-up of treatment without resorting to invasive procedures such as biopsy. Trichoscopic features vary based on the pattern of non-scarring alopecia [19].

In our patients, androgenetic alopecia (AGA) was the most frequent form, in 43% of the 100 cases. These accounted for 25% of male-pattern AGA and 18% of female-pattern hair loss. Classic trichoscopic findings in these patients included hair shaft thickness heterogeneity (hair diameter diversity, HDD), reflecting follicular miniaturization—present in 100% of AGA cases—which aligned with the literature [20–22]. The peripilar sign (PPS) was commonly observed in 67.44% of AGA patients with Fitzpatrick skin types I–III and, less frequently, in types IV and V. Yellow dots were far more frequent (74.42%) than previously reported, with a common association with the lack of terminal hair and the presence of single follicular hair units and multiple vellus hairs. Moreover, honeycomb pigmentation occurred in 30.23% of cases, likely due to chronic sun exposure.

Alopecia areata (AA) occurred in 13 patients (21%), with a male-to-female ratio of approximately 2:1. The most common trichoscopic findings in these patients were black dots and broken hairs, both of which occurred in 100% of the cases—higher than reported in comparison studies [23–25]. Exclamation mark hairs and short vellus hairs were also observed at increased frequencies (90.5% and 81%, respectively). Yellow dots were observed at a lower frequency compared to other studies, at only 19%. Pigtail hairs, pointing to new regrowth, were observed but were not visibly apparent on trichoscopy, as described in the literature [24,25].

Trichotillomania was diagnosed in 3 patients (3%), in line with international prevalence. Our observations are concurrent with Rakowska et al. [26], who observed typical findings such as trichoptilosis—a mechanical fracture of the hair shaft in a transverse direction—being found in 100% of cases. Perifollicular hemorrhage secondary to traumatic hair pulling was observed in 66.67% of cases, which is similar to findings by Chiramel [25] and Ankad [26]. Coiled hairs were the rarest feature in our study (33.4%), which agrees with Rakowska (39%) but is lower than reported by Ankad (80%).

Telogen effluvium (TE) was diagnosed in 33 patients, mostly female (28 females and 5 males). In most instances, there were recognizable causes such as stress, anemia (16 cases), or deficiency of vitamin D (22 cases). In addition, 11 patients had undergone gastric bypass surgery. Trichoscopic features in TE were single follicular hair units (100%), empty follicles (78.79%), yellow dots (30.4%), and upright regrowing hairs (100%), which are all typical of acute telogen shedding phases.

CONCLUSION

It is advised to utilize trichoscopy in the routine evaluation of non-scarring alopecia, as the appearance of newer hair signals on trichoscopic studies aids in identification and has a definitive function in the diagnosis of clinically challenging cases, helpful for determining the cause of alopecia. Those trichoscopic observations of diagnostic value were distinguished from the others.

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