Journal of Dermatology 2014; 41: 518–520
doi: 10.1111/1346-8138.12500
CONCISE COMMUNICATION
Follicular microhemorrhage: A unique dermoscopic sign for the detection of coexisting trichotillomania in alopecia areata Misaki ISE, Masayuki AMAGAI, Manabu OHYAMA Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
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.
Key words:
alopecia areata, dermoscopy, hair follicle, microhemorrhage, trichotillomania.
INTRODUCTION Trichotillomania (TT) is considered to be a psychogenetic disorder that could cause refractory and sometimes extensive alopecia because of continuous hair pulling and plucking. The diagnosis is often difficult because patients may be reluctant to report or even unconscious of their habitual hair plucking.1 TT is known to coexist with alopecia areata (AA).2 In some cases, AA could be an initial trigger of TT.3 Both conditions present similar clinical manifestations and frequency of coincidence is relatively high in child cases,4 sometimes making differential diagnosis challenging. To accurately assess the efficacy of treatment in AA cases with potential TT, a technique enabling efficient and reliable detection of TT is required. Dermoscopy has been gaining attention as a useful technique for the diagnosis of hair loss disorders.5,6 Recently, Rakowska et al. successfully delineated characteristic findings of AA and TT by dermoscopy using immersion gel.6,7 Some of these were reported to be specific to TT and may provide a useful tool for distinguishing TT from AA. However, adopting conventional dermoscopy with immersion gel for evaluation of hair loss may be laborious and time-consuming in our daily practice and potentially not feasible for children or those with mental illness. Inui et al.8 reported the usefulness of dermoscopy without immersion gel (“dry dermoscopy”) for differential diagnosis of hair disorders. Elucidation of a sign of TT in AA, which is easily detectable with dry dermoscopy, should be
beneficial for the management of some unreasonably intractable AA cases. In the current study, we report a unique dry dermoscopy sign named as “follicular microhemorrhage” (FMH) which, so far as we have investigated, was found only in AA-TT patients. All patients confessed habitual hair plucking by medical interviews commenced by the detection of FMH.
CASE REPORT In the current report, FMH is defined as a red dot corresponding to a follicular ostia capped or stuffed with blood clot, suggesting the history of forced plucking detected by dry dermoscopy. The demographics of four cases with FMH are summarized in Table 1. All of them were school-aged children with moderate to severe AA. Three out of four patients had an atopic background but medical/family histories were not remarkable for mental disorders in all four cases. Presence of unusually persisting hair loss areas urged us to perform intensive dermoscopic investigation.
PATIENT 1 A 14-year-old male was referred to our clinic for hair loss patches that had started to develop 1 month prior to his visit. On physical examination, unclearly bordered alopecic patches were observed in frontal, vertex and bilateral temporal regions
Correspondence: Manabu Ohyama, M.D., Ph.D., Department of Dermatology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo 160-8582, Japan. Email: [email protected] Received 12 February 2014; accepted 23 March 2014.
518
© 2014 Japanese Dermatological Association
Dermoscopic sign of trichotillomania
Table 1. Summary of the clinical profiles of AA patients with FMH
No.
Case Age/sex
1
AA status
Dermoscopic findings
SALT*
Duration
Signs for AA or TT
FMH
Treatments
14/M
S2
1 month
+
Counseling
2
11/F
S2
6 months
+
3
9/F
S1
2 weeks
Contact immunotherapy (using SADBE) Counseling
4
13/M
S1
3 months
Black dots, broken hairs yellow dots, tapered hairs, hypopigmented vellus hairs Yellow dots, tapered hairs, coiled hairs**, V-signs** broken hairs, hypopigmented vellus hairs Black dots, broken hairs, hypopigmented vellus hairs, V-signs** Broken hairs, yellow dots
+ +
Counseling, topical corticosteroid
*SALT (Severity of Alopecia Tool) was judged according to the “Alopecia areata investigational assessment guidelines – Part II”.11 **Signs specific for TT. AA, alopecia areata; FMH, follicular microhemorrhage; SADBE, squaric acid dibutylester; TT, trichotillomania.
(Fig. 1a). A gentle hair pull test collected only telogen hairs. Dry dermoscopy detected yellow dots, black dots, tapered hairs, hypopigmented vellus hairs and many broken hairs typical for AA (Fig. 2). In addition, FMH was detected (Fig. 1b). He had not reported his continuous hair pulling, yet he agreed that he had that habit after we detected FMH and interviewed him. The diagnosis of AA and TT was made. He has been attending our clinic for approximately 4 years. Hair loss is now well controlled. Yet, alopecic patches still appear when he gets frustrated.
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
PATIENT 2 An 11-year-old female presented to our clinic complaining of hair loss of 6 months’ duration. A patchy alopecia spreading from the vertex to bilateral temporal regions was observed (Fig. 1c). Progressive hair loss with dystrophic hair bulbs was observed. Dry dermoscopy revealed yellow dots, tapered hairs, broken hairs, hypopigmented vellus hairs, suggestive of AA (Fig. 2). Though not as clear as those reported in the published work,6 probable coiled hairs, V-signs and the findings of TT (Fig. 2) were also detected (Fig. 1d). Importantly, FMH was noted in some follicular ostia (Fig. 1d). Careful questioning revealed that she had been plucking hairs. We diagnosed this case as AA and TT. Our instruction to stop pulling hairs was well received. This, together with contact immunotherapy by squaric acid dibutylester, enabled us to better control disease activities. Currently, hair loss is hardly noticeable.
PATIENT 3 A 9-year-old female was referred to our clinic because of progressive hair loss. Ambiguously circumscribed alopecic patches were observed on the frontal and bilateral temporal regions (Fig. 1e). Hair pull test was negative. Dry dermoscopy detected black dots, broken hairs and hypopigmented vellus hairs. In addition, a possible V-sign (Fig. 2) and FMH (Fig. 1f) were found. We suspected this case as AA with TT. Further medical interview uncovered her habitual hair plucking. She followed our instruction to stop touching hairs and hair loss is hardly observable nowadays.
© 2014 Japanese Dermatological Association
Figure 1. Clinical presentations and respective dermoscopic images of AA–TT patients with follicular microhemorrhage (FMH). Hair loss area/patches observed in cases 1 (a), 2 (c), 3 (e) and 4 (g). Typical FMH was observed in all cases (b, d, f, h: arrows). Previously reported TT sign, flame hair, was also observed (d: arrowheads). AA signs represented by hypopigmented vellus hairs were observed in all cases. AA, alopecia areata; FMH, follicular microhemorrhage; TT, trichotillomania.
519
M. Ise et al.
Figure 2. Major dermoscopic findings of AA and TT. The overlap areas indicate the frequency of individual findings in each condition. The schemata illustrate the morphological characteristics. AA, alopecia areata; FMH, follicular microhemorrhage; TT, trichotillomania.
PATIENT 4 A 13-year-old male with 3-month history of ongoing hair loss in bilateral temporal regions visited out clinic (Fig. 1g). He had suffered from insomnia for several weeks prior to his visit. Hair shafts with dystrophic bulb were easily pulled out in affected lesions. Dry dermoscopic examination detected yellow dots, broken hairs as well as FMH (Fig. 1h). We diagnosed this case as AA with TT. He had been recognizing his habitual hair pulling, yet he found it difficult to stop while studying. We advised him and his mother to avoid unnecessary stress and prescribed topical corticosteroid. Two months later, his condition was remarkably improved and FMH were no longer found.
DISCUSSION Rakowska et al.6 delineated that hypopigmented vellus hairs represent typical dermoscopic finding of AA, yet, this finding can be best observed in a recovering area. Although tapered hairs and yellow dots are more frequently detected in AA, these findings can be also observed in TT.6 Both black dots and broken hairs indicate past hair shaft destruction and are commonly observed in AA and TT (Fig. 2).5,6 Thus, the demand for establishing dermoscopic signs specific for TT is present. Flame hairs, hair powders and hook hairs have been reported as the signs for TT, while V-signs, coiled hairs and tulip hairs are more likely to be observed in TT than in AA (Fig. 2).6 However, we could detect V-signs and coiled hairs only in two cases. Use of dry dermoscopy may be a major reason why TT signs were less frequently observed in our cases. Immersion gel may be necessary for the detection of flame hairs and hair powders, two characteristic dermoscopic findings of TT. In contrast, FMH can be easily detectable by dry dermoscopy. In addition, FMH can be observable with or without hair shafts (Fig. 1h), while other TT signs mostly reflect damages of hair shafts6 and become undetectable after shed-
520
ding. Thus, FMH also represents a useful diagnostic dermoscopic finding of TT, particularly in AA patients. Among 26 TT cases we have experienced since 2007, FMH was observed in four out of eight patients with AA, while this sign was not detected in 18 cases without AA. In the hair follicle, vascular structures are present within the connective tissue sheath and the dermal papilla.9 Theoretically, any condition damaging this vasculature may result in FMH. It is possible that FMH has been missed in usual TT cases. Hemorrhagic signs are hardly detectable in AA alone.8 In our case, increased fragility in these structures secondary to folliculocentric inflammatory response in AA, together with mechanical damage by hair plucking, may contribute to the formation of FMH. To the best of our knowledge, FMH has not been described in the published work. A possible explanation for this may be difference in hair follicle morphology among races. Large-scale studies to elucidate characteristic dermoscopic findings of hair disorders have been predominantly performed in Western countries.6,7 As Asian hairs shafts are larger in diameter than those of Caucasians,10 stronger force may be required to break hair anchorage. This could cause tissue damage and increase the incidence of FMH. Further accumulation of the cases is necessary to fully dissect the underlying mechanism of FMH formation, however, the current study supports that FMH may be beneficial to uncover the complicated pathophysiology of hair loss in AA patients, especially in child cases with difficulties in medical interview.
CONFLICT OF INTEREST:
None declared.
REFERENCES 1 Sah DE, Koo J, Price VH. Trichotillomania. Dermatol Ther 2008; 21: 13–21. 2 Shelleh HH, Khan SA, Al-Hatiti HS. Trichotillomania or alopecia areata ? Int J Dermatol 2006; 45: 1196–1198. €eb RM, Cavegn B. Trichotillomania in connection with alopecia 3 Tru areata. Cutis 1996; 58: 67–70. 4 Tay YK, Levy ML, Metry DW. Trichotillomania in childhood: case series and review. Pediatrics 2004; 113: e494–e498. 5 Inui S. Trichoscopy for common hair loss diseases: algorithmic method for diagnosis. J Dermatol 2011; 38: 71–75. 6 Rakowska A, Slowinska M, Olszewska M, Rundnicka L. New trichoscopy findings in trichotillomania: Flame hairs, V-sign, Hook hairs, Hair powder, Tulip hairs. Acta Derm Venereol 2013; [Epub ahead of print]. 7 Rudnicka L, Rakowska A, Kurzeja M, Olszewska M. Hair shafts in trichoscopy. Clue for diagnosis of hair and scalp diseases. Dermatol Clin 2013; 31: 695–708. 8 Inui S, Nakajima T, Nakagawa K et al. Clinical significance of dermoscopy in alopecia areata: analysis of 300 cases. Int J Dermatol 2008; 47: 688–693. 9 Sperling LC, Cowper S. An Atlas of Hair Pathology with Clinical Correlations. Parthenon Publishing Group, New York 2003; 2–3. 10 Camacho FM, Randall VA, Price VH. Hair and its Disorders; Biology, Pathology and Management. Martin Dunitz, London 2000; 325–326. 11 Olsen EA, Hordinsky MK, Price VH et al. Alopecia areata investigational assessment guidelines-Part II. J Am Acad Dermatol 2004; 51: 440–447.
© 2014 Japanese Dermatological Association
doi: 10.1111/1346-8138.12500
CONCISE COMMUNICATION
Follicular microhemorrhage: A unique dermoscopic sign for the detection of coexisting trichotillomania in alopecia areata Misaki ISE, Masayuki AMAGAI, Manabu OHYAMA Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
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.
Key words:
alopecia areata, dermoscopy, hair follicle, microhemorrhage, trichotillomania.
INTRODUCTION Trichotillomania (TT) is considered to be a psychogenetic disorder that could cause refractory and sometimes extensive alopecia because of continuous hair pulling and plucking. The diagnosis is often difficult because patients may be reluctant to report or even unconscious of their habitual hair plucking.1 TT is known to coexist with alopecia areata (AA).2 In some cases, AA could be an initial trigger of TT.3 Both conditions present similar clinical manifestations and frequency of coincidence is relatively high in child cases,4 sometimes making differential diagnosis challenging. To accurately assess the efficacy of treatment in AA cases with potential TT, a technique enabling efficient and reliable detection of TT is required. Dermoscopy has been gaining attention as a useful technique for the diagnosis of hair loss disorders.5,6 Recently, Rakowska et al. successfully delineated characteristic findings of AA and TT by dermoscopy using immersion gel.6,7 Some of these were reported to be specific to TT and may provide a useful tool for distinguishing TT from AA. However, adopting conventional dermoscopy with immersion gel for evaluation of hair loss may be laborious and time-consuming in our daily practice and potentially not feasible for children or those with mental illness. Inui et al.8 reported the usefulness of dermoscopy without immersion gel (“dry dermoscopy”) for differential diagnosis of hair disorders. Elucidation of a sign of TT in AA, which is easily detectable with dry dermoscopy, should be
beneficial for the management of some unreasonably intractable AA cases. In the current study, we report a unique dry dermoscopy sign named as “follicular microhemorrhage” (FMH) which, so far as we have investigated, was found only in AA-TT patients. All patients confessed habitual hair plucking by medical interviews commenced by the detection of FMH.
CASE REPORT In the current report, FMH is defined as a red dot corresponding to a follicular ostia capped or stuffed with blood clot, suggesting the history of forced plucking detected by dry dermoscopy. The demographics of four cases with FMH are summarized in Table 1. All of them were school-aged children with moderate to severe AA. Three out of four patients had an atopic background but medical/family histories were not remarkable for mental disorders in all four cases. Presence of unusually persisting hair loss areas urged us to perform intensive dermoscopic investigation.
PATIENT 1 A 14-year-old male was referred to our clinic for hair loss patches that had started to develop 1 month prior to his visit. On physical examination, unclearly bordered alopecic patches were observed in frontal, vertex and bilateral temporal regions
Correspondence: Manabu Ohyama, M.D., Ph.D., Department of Dermatology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo 160-8582, Japan. Email: [email protected] Received 12 February 2014; accepted 23 March 2014.
518
© 2014 Japanese Dermatological Association
Dermoscopic sign of trichotillomania
Table 1. Summary of the clinical profiles of AA patients with FMH
No.
Case Age/sex
1
AA status
Dermoscopic findings
SALT*
Duration
Signs for AA or TT
FMH
Treatments
14/M
S2
1 month
+
Counseling
2
11/F
S2
6 months
+
3
9/F
S1
2 weeks
Contact immunotherapy (using SADBE) Counseling
4
13/M
S1
3 months
Black dots, broken hairs yellow dots, tapered hairs, hypopigmented vellus hairs Yellow dots, tapered hairs, coiled hairs**, V-signs** broken hairs, hypopigmented vellus hairs Black dots, broken hairs, hypopigmented vellus hairs, V-signs** Broken hairs, yellow dots
+ +
Counseling, topical corticosteroid
*SALT (Severity of Alopecia Tool) was judged according to the “Alopecia areata investigational assessment guidelines – Part II”.11 **Signs specific for TT. AA, alopecia areata; FMH, follicular microhemorrhage; SADBE, squaric acid dibutylester; TT, trichotillomania.
(Fig. 1a). A gentle hair pull test collected only telogen hairs. Dry dermoscopy detected yellow dots, black dots, tapered hairs, hypopigmented vellus hairs and many broken hairs typical for AA (Fig. 2). In addition, FMH was detected (Fig. 1b). He had not reported his continuous hair pulling, yet he agreed that he had that habit after we detected FMH and interviewed him. The diagnosis of AA and TT was made. He has been attending our clinic for approximately 4 years. Hair loss is now well controlled. Yet, alopecic patches still appear when he gets frustrated.
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
PATIENT 2 An 11-year-old female presented to our clinic complaining of hair loss of 6 months’ duration. A patchy alopecia spreading from the vertex to bilateral temporal regions was observed (Fig. 1c). Progressive hair loss with dystrophic hair bulbs was observed. Dry dermoscopy revealed yellow dots, tapered hairs, broken hairs, hypopigmented vellus hairs, suggestive of AA (Fig. 2). Though not as clear as those reported in the published work,6 probable coiled hairs, V-signs and the findings of TT (Fig. 2) were also detected (Fig. 1d). Importantly, FMH was noted in some follicular ostia (Fig. 1d). Careful questioning revealed that she had been plucking hairs. We diagnosed this case as AA and TT. Our instruction to stop pulling hairs was well received. This, together with contact immunotherapy by squaric acid dibutylester, enabled us to better control disease activities. Currently, hair loss is hardly noticeable.
PATIENT 3 A 9-year-old female was referred to our clinic because of progressive hair loss. Ambiguously circumscribed alopecic patches were observed on the frontal and bilateral temporal regions (Fig. 1e). Hair pull test was negative. Dry dermoscopy detected black dots, broken hairs and hypopigmented vellus hairs. In addition, a possible V-sign (Fig. 2) and FMH (Fig. 1f) were found. We suspected this case as AA with TT. Further medical interview uncovered her habitual hair plucking. She followed our instruction to stop touching hairs and hair loss is hardly observable nowadays.
© 2014 Japanese Dermatological Association
Figure 1. Clinical presentations and respective dermoscopic images of AA–TT patients with follicular microhemorrhage (FMH). Hair loss area/patches observed in cases 1 (a), 2 (c), 3 (e) and 4 (g). Typical FMH was observed in all cases (b, d, f, h: arrows). Previously reported TT sign, flame hair, was also observed (d: arrowheads). AA signs represented by hypopigmented vellus hairs were observed in all cases. AA, alopecia areata; FMH, follicular microhemorrhage; TT, trichotillomania.
519
M. Ise et al.
Figure 2. Major dermoscopic findings of AA and TT. The overlap areas indicate the frequency of individual findings in each condition. The schemata illustrate the morphological characteristics. AA, alopecia areata; FMH, follicular microhemorrhage; TT, trichotillomania.
PATIENT 4 A 13-year-old male with 3-month history of ongoing hair loss in bilateral temporal regions visited out clinic (Fig. 1g). He had suffered from insomnia for several weeks prior to his visit. Hair shafts with dystrophic bulb were easily pulled out in affected lesions. Dry dermoscopic examination detected yellow dots, broken hairs as well as FMH (Fig. 1h). We diagnosed this case as AA with TT. He had been recognizing his habitual hair pulling, yet he found it difficult to stop while studying. We advised him and his mother to avoid unnecessary stress and prescribed topical corticosteroid. Two months later, his condition was remarkably improved and FMH were no longer found.
DISCUSSION Rakowska et al.6 delineated that hypopigmented vellus hairs represent typical dermoscopic finding of AA, yet, this finding can be best observed in a recovering area. Although tapered hairs and yellow dots are more frequently detected in AA, these findings can be also observed in TT.6 Both black dots and broken hairs indicate past hair shaft destruction and are commonly observed in AA and TT (Fig. 2).5,6 Thus, the demand for establishing dermoscopic signs specific for TT is present. Flame hairs, hair powders and hook hairs have been reported as the signs for TT, while V-signs, coiled hairs and tulip hairs are more likely to be observed in TT than in AA (Fig. 2).6 However, we could detect V-signs and coiled hairs only in two cases. Use of dry dermoscopy may be a major reason why TT signs were less frequently observed in our cases. Immersion gel may be necessary for the detection of flame hairs and hair powders, two characteristic dermoscopic findings of TT. In contrast, FMH can be easily detectable by dry dermoscopy. In addition, FMH can be observable with or without hair shafts (Fig. 1h), while other TT signs mostly reflect damages of hair shafts6 and become undetectable after shed-
520
ding. Thus, FMH also represents a useful diagnostic dermoscopic finding of TT, particularly in AA patients. Among 26 TT cases we have experienced since 2007, FMH was observed in four out of eight patients with AA, while this sign was not detected in 18 cases without AA. In the hair follicle, vascular structures are present within the connective tissue sheath and the dermal papilla.9 Theoretically, any condition damaging this vasculature may result in FMH. It is possible that FMH has been missed in usual TT cases. Hemorrhagic signs are hardly detectable in AA alone.8 In our case, increased fragility in these structures secondary to folliculocentric inflammatory response in AA, together with mechanical damage by hair plucking, may contribute to the formation of FMH. To the best of our knowledge, FMH has not been described in the published work. A possible explanation for this may be difference in hair follicle morphology among races. Large-scale studies to elucidate characteristic dermoscopic findings of hair disorders have been predominantly performed in Western countries.6,7 As Asian hairs shafts are larger in diameter than those of Caucasians,10 stronger force may be required to break hair anchorage. This could cause tissue damage and increase the incidence of FMH. Further accumulation of the cases is necessary to fully dissect the underlying mechanism of FMH formation, however, the current study supports that FMH may be beneficial to uncover the complicated pathophysiology of hair loss in AA patients, especially in child cases with difficulties in medical interview.
CONFLICT OF INTEREST:
None declared.
REFERENCES 1 Sah DE, Koo J, Price VH. Trichotillomania. Dermatol Ther 2008; 21: 13–21. 2 Shelleh HH, Khan SA, Al-Hatiti HS. Trichotillomania or alopecia areata ? Int J Dermatol 2006; 45: 1196–1198. €eb RM, Cavegn B. Trichotillomania in connection with alopecia 3 Tru areata. Cutis 1996; 58: 67–70. 4 Tay YK, Levy ML, Metry DW. Trichotillomania in childhood: case series and review. Pediatrics 2004; 113: e494–e498. 5 Inui S. Trichoscopy for common hair loss diseases: algorithmic method for diagnosis. J Dermatol 2011; 38: 71–75. 6 Rakowska A, Slowinska M, Olszewska M, Rundnicka L. New trichoscopy findings in trichotillomania: Flame hairs, V-sign, Hook hairs, Hair powder, Tulip hairs. Acta Derm Venereol 2013; [Epub ahead of print]. 7 Rudnicka L, Rakowska A, Kurzeja M, Olszewska M. Hair shafts in trichoscopy. Clue for diagnosis of hair and scalp diseases. Dermatol Clin 2013; 31: 695–708. 8 Inui S, Nakajima T, Nakagawa K et al. Clinical significance of dermoscopy in alopecia areata: analysis of 300 cases. Int J Dermatol 2008; 47: 688–693. 9 Sperling LC, Cowper S. An Atlas of Hair Pathology with Clinical Correlations. Parthenon Publishing Group, New York 2003; 2–3. 10 Camacho FM, Randall VA, Price VH. Hair and its Disorders; Biology, Pathology and Management. Martin Dunitz, London 2000; 325–326. 11 Olsen EA, Hordinsky MK, Price VH et al. Alopecia areata investigational assessment guidelines-Part II. J Am Acad Dermatol 2004; 51: 440–447.
© 2014 Japanese Dermatological Association
