Trichoscopy findings in dissecting cellulitis

AnBrasDermatol.2019;94(5):608---611

Anais

Brasileiros

de

Dermatologia

IMAGES

IN

DERMATOLOGY

Trichoscopy

findings

in

dissecting

cellulitis

夽,夽夽

Daniel

Fernandes

Melo

,

Erica

Bertolace

Slaibi

,

Thais

Marques

Feitosa

Mendes

Siqueira

,

Violeta

Duarte

Tortelly

AlopeciaOutpatientClinic,HospitalNavalMarcílioDias,RiodeJaneiro,RJ,Brazil

Received30May2018;accepted3November2018

KEYWORDS Alopecia; Cellulitis; Dermoscopy; Folliculitis; Hair; Scalpdermatoses

Abstract Dissectingcellulitisisaninflammatory,chronic,andrecurrentdisease ofthehair folliclesthatmainlyaffectsyoungAfro-descendentmen.Trichoscopyisamethodofgreat diag-nosticvaluefordisordersofthescalp.Clinicalandtrichoscopicfindingsofdissectingcellulitis areheterogeneousandmaypresentfeaturescommontonon-cicatricialandscarringalopecia. Thisarticlepresentsthetrichoscopicfindingsofdissectingcellulitisthathelpinthediagnosis andconsequentinstitutionoftheappropriatetherapyandbetterprognosisofthedisease. ©2019PublishedbyElsevierEspa˜na,S.L.U.onbehalfofSociedadeBrasileiradeDermatologia. ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/ by/4.0/).

Introduction

Dissectingcellulitis(DC),alsocalledfolliculitisabscedensor perifolliculitiscapitisabscedensetsuffodiens,isan inflam-matory,chronic,andrecurrentdiseaseofthehairfollicles, withuncertainetiopathogenesisandprobablegenetic influ-ence,whichcanbetriggeredbyenvironmentalfactors.1_It

predominantlyaffectsyoung Afro-descendent men,atthe vertexandoccipitalregion.1,2

Initially, papulopustularlesions evolve withthe forma-tionofareasofnon-cicatricialalopeciaandlater,multifocal painfulnodules and interconnectedabscesses, whichmay

夽 _{Howtocitethisarticle:MeloDF,SlaibiEB,SiqueiraTM,Tortelly} VD.Trichoscopyfindingsindissectingcellulitis.AnBrasDermatol. 2019;94:608---11.

夽夽_{StudyconductedattheAlopeciaOutpatient Clinic, Hospital} NavalMarcílioDias,RiodeJaneiro,RJ,Brazil.

∗_{Correspondingauthor.}

E-mail:[email protected](T.M.Siqueira).

ormaynotfistulize.Iftheinflammatoryprocessisnot con-tainedortherearefrequentrecurrences,therewillbeareas ofscarringalopeciawithaestheticandpsychosocial impair-mentforthepatient.3,4

Trichoscopy is a practical, useful, and non-invasive method that has shown great value in a range of disorders of thescalp andhair shaft.3,4 _Trichoscopic

find-ings contribute to early diagnosis, execution of guided biopsy, andconsequentappropriatechoiceoftherapy and follow-up of cases with potential evolution to cicatricial alopecia.

GiventhehighprevalenceofAfro-descendantsinBrazil, the increasing recognition of cases, and the scarcity of publications on the subject, the purpose of this arti-cle is to enumerate and detail, in a didactic way, the trichoscopic findings of DC. The aim is to con-tribute to the diagnosis and, eventually, to modify the disfiguring scarring course that is characteristic of the disease.

https://doi.org/10.1016/j.abd.2019.09.006

0365-0596/©2019PublishedbyElsevierEspa˜na,S.L.U.onbehalfofSociedadeBrasileiradeDermatologia.Thisisanopenaccessarticle undertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

Trichoscopyfindingsindissectingcellulitis 609

Table1 Trichoscopicfindingsofdissectingcellulitis.

01 Brokenhair 11 Yellowish,hematiccrusts

02 Blackdots 12 Largebrowndots

03 Exclamationmarkhairs 13 Polytrichia

04 Circularhairs 14 Cutaneuscleftswithemerginghairs

05 Yellowdots 15 Whitedots

06 3Dyellowdots(soapbubble) 16 Amorphouswhiteareas 07 Emptyfollicularopenings 17 Blue-graydots

08 Peri-andinterfollicularscales 18 Punctatevessels

09 Erythema 19 Reddots

10 Pustulesandstructurelessyellowareas 20 Shortregrowinghairs

Figure 1 (A) ‘‘3D’’yellow dot (blue arrow), polytrichia (redarrow), and yellow areas (greenarrow). (B) Amorphouswhite area(bluearrow),largebrowndots(redarrow),diffuseerythema(greenarrow),perifollicularscales(yellowarrow).Trichoscopy performedwith3GenDermLite® _{IIHybridMwithpolarizedlightandinterfaceliquid(A)andwithoutinterfaceliquid(B)(alcohol}

70%);×20magnification.

Figure2 (A)Brokenhairs(bluearrow),shortregrowinghairs(redarrow),blackdots(greenarrow),largebrowndots(yellow arrow),follicularpustules(blackarrow),interfollicularerythema(whitearrow),andemptyfollicularopenings(grayarrow).(B) Skincleftswithemergenthairs(bluearrow),yellowdots(redarrow),‘‘3D’’yellowdots(greenarrow),andperi-andinterfollicular erythema(yellowarrow).Trichoscopyperformedwith3GenDermLite®_{IIHybridMwithpolarizedlightwithinterfaceliquid(alcohol}

70%);_×20magnification.

Discussion

The heterogeneityoftheclinical andtrichoscopicfindings of DC isexplained bythe recurrenceof theinflammatory processinthesamepatientoverthesamearea.4,5

Inearlystagesofthedisease,theinflammatory compo-nentislessexuberantandtrichoscopymay,onthisoccasion, resemblethatofpatchynon-cicatricialalopecia,and alope-ciaareatarepresentsanimportantdifferentialdiagnosis.3,4

610 MeloDFetal.

Figure3 (A)Hematiccrust(bluearrow)anderythematous-yellowisharea(redarrow).(B)Yellowdots(bluearrow),short regrow-inghairs (redarrow),andinterfollicularerythema (greenarrow).Trichoscopyperformedwith3GenDermLite® _{IIHybridMwith}

polarizedlightandwithinterfaceliquid(alcohol70%);×20magnification.

Figure4 (A)Reddots(blue arrow),peri-andinterfollicularerythema (redarrow), andperifolliculargray-bluepigmentation (greenarrow).(B)Blackdots(bluearrow),exclamationmark,anddystrophichairs(redarrow)andpustule(greenarrow)Trichoscopy performedwith3GenDermLite®_{IIHybridMwithpolarizedlightandwithinterfaceliquid(70%alcohol);×20magnification.}

found,aswellasblackdots,correspondingtolumpsof ker-atinresultingfromthebreakingofshaftsattheemergence ofthefollicularostium.5_{Although controversial,the}

pres-enceofexclamationmarkhairs4_{andcirclehairsintheinitial}

stagesofDChasalsobeendescribed.6,7

Yellowdotsrepresentsebumaccumulationandkeratinin thefollicularinfundibulumand,usuallywhenfoundinDC, arelargeinsize,yellowish-brownincolor,double-bordered, andmayormaynotcontaindystrophicshafts.These char-acteristicsconferthetypicalthree-dimensional(‘‘3D’’)or ‘‘soapbubble’’aspecttothisyellowdot,whichrepresents themostspecifictrichoscopicfindingofDC.8---10 _Empty

fol-licularopenings,betterevaluatedbydermoscopy,seemto berelatedwithabetterprognosisfor hairregrowth,since theyareviablehairfollicles.Atthispoint,institutionof ade-quatetreatment confersthepossibilityofnon-progression toanirreversiblecicatricialstage.4,5,8

Inthepresenceofamoreexuberantinflammatory pro-cess,inanabscessingphaseperse,peri-andinterfollicular scalesanderythemainvaryingdegreescanbeseenat tri-choscopy.Adisruptedyellowareaandpustulescanbeseen onDCandrepresenttruepuslakessurroundingthefollicular openings,whichlatergiverisetoinfectionandevenhematic

crustsifthereisassociatedlocaltrauma.10_{Largedarkbrown}

follicularopenings(largebrowndots),withtheappearance ofcomedones,werealsoobservedbyAbedinietal.10 _Such

structuresarecommonlyseenandarecharacteristicofDC, corroboratingthefactthatthisconditionisinsertedinthe context of diseases caused by follicular obstruction, such asacneconglobata,hidradenitissuppurativa,andpilonidal cyst.1,2

Polytrichia,which representsthe emergence of fiveor more shafts per follicular unit, may be present in later stagesofthedisease.5,6,8_{Thesameoccurswithskinclefts}

withemergenthairs,correspondingtoskinfoldscontaining shafts.10 _{Emptyfollicular units replacedby fibrosis}

repre-sented bywhitedots andamorphouswhite areascanalso bevisualizedinadvancedformsofthedisease,wherethe fibroticcomponentprevails.5,6,8_{Additionalfindingsalready}

describedincludeblue-graydotswithhistopathological cor-respondence to pigmentary incontinence and nonspecific vascular signs,suchaspunctatevesselsandreddots.6,7,10

Thepresenceofshortregrowinghairsisindicativeof peri-odsofremission,oftenfoundinearlyphasesofthedisease, whilethescarringareasdenotelatestageswitharecurrent poorresponsetoclinicaltherapy.4,5

Trichoscopyfindingsindissectingcellulitis 611 The major trichoscopic findings of DC and their

rep-resentative images are shown in Table 1 and Figs. 1---4, respectively.

Final

considerations

There aremany trichoscopicfindings of DC andthey may be heterogeneous and even overlapped throughout the evolution of the disease. Although not pathognomonic, recognitionofthetrichoscopicalterationsalreadydescribed isimportantandmorestudiesareneededtodeterminethe sensitivity and specificity of thesefindings in this clinical condition.Therefore,theuseoftrichoscopy,anon-invasive techniquewithrapidapplication,whenassociatedwithgood clinical evaluation, increases the diagnostic accuracy and allows a better follow-up and prognosis for the affected patients.

Financial

support

Nonedeclared.

Author’s

contribution

DanielFernandesMelo:Approvalofthefinalversionofthe manuscript;conceptionandplanningofthestudy; elabora-tionandwritingofthemanuscript;obtaining,analyzingand interpretingthedata;effectiveparticipationinresearch ori-entation;intellectualparticipationinpropaedeuticand/or therapeuticconductofthecasesstudied;criticalreviewof theliterature;criticalreviewofthemanuscript.

Erica Bertolace Slaibi: Elaboration and writing of the manuscript;criticalreviewoftheliterature;criticalreview ofthemanuscript.

ThaisMarquesFeitosaMendesSiqueira:Elaborationand writingofthemanuscript;criticalreviewoftheliterature; criticalreviewofthemanuscript.

Violeta Duarte Tortelly: Approval of the final version of the manuscript;conception and planning of thestudy; elaboration and writing of the manuscript; obtaining, analyzing and interpreting the data; effective participa-tion in research orientation; intellectual participation in propaedeuticand/ortherapeuticconductofthecases stud-ied;criticalreviewoftheliterature;criticalreviewofthe manuscript.

Conflicts

of

interest

Nonedeclared.

Acknowledgements

Dr.TaynaradeMattosBarretoforhersupportinreviewing thearticle.

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