Trichoscopic stages of dissecting cellulitis: a potential complementary tool to clinical assessment,

AnBrasDermatol.2020;95(4):514---517

Anais

Brasileiros

de

Dermatologia

IMAGES

IN

DERMATOLOGY

Trichoscopic

stages

of

dissecting

cellulitis:

a

potential

complementary

tool

to

clinical

assessment

夽,夽夽

Daniel

Fernandes

Melo

_,

_Luciana

_Rodino

_Lemes

_,

_Rodrigo

_Pirmez

_,

Bruna

Duque-Estrada

a_{CenterforTrichologyStudies,HospitalPedroErnesto,UniversidadedoEstadodoRiodeJaneiro,RiodeJaneiro,RJ,Brazil} b_{OutpatientClinicofCapillaryDisorders,InstitutodeDermatologiaProfessorRubemDavidAzulay,SantaCasadeMisericórdiado}

RiodeJaneiro,RiodeJaneiro,RJ,Brazil

Received19March2019;accepted29October2019 Availableonline11May2020

KEYWORDS

Alopecia; Dermoscopy; Folliculitis

Abstract Dissectingcellulitisis achronic, progressive,andrelapsing inflammatory disease thatpredominantlyaffectsthevertexandocciputofyoungAfro-descendentmen.Itstartswith papulesandpustulesthatevolvetonodules,abscesses,andcicatricialalopecia.Thisarticle illustratestheevolutivetrichoscopyofdissectingcellulitis,fromitsearlyphase,throughthe abscessphase,tothefibroticcicatricialphase.Trichoscopycomplementsclinical-pathological classification,representingacomplementarytoolusefulinearlydiagnosisandmonitoringof thepatientduringtreatment.

©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

Dissectingcellulitis(DC)isarare,chronic,progressive,and relapsing inflammatory disease, with a predominance of histopathologicalneutrophilicinfiltrate.Itismorefrequent in young Afro-descendent men in the vertex and occipi-talarea,1 _{withpapulesandpustulesthatcandevelop into}

夽 _{Howtocitethisarticle:MeloDF,LemesLR,PirmezR,}

Duque--Estrada B. Trichoscopic stages of dissecting cellulitis: a poten-tialcomplementarytooltoclinicalassessment.AnBrasDermatol. 2020;95:514---7.

夽夽_{StudyconductedattheHospitalNavalMarcílioDias, Riode}

Janeiro,RJ,Brazil.

∗_{Correspondingauthor.}

E-mail:rodinolemesluciana@gmail.com(L.R.Lemes).

nodules andinterconnectingabscesses,or evencicatricial alopecia.Clinicalfindingsvaryaccordingtotheextentand severityofthedisease.Recently,Leeetal.proposeda dis-easeseverity-basedclassificationforDC,dividingitinthree different clinical-pathological stages: stage I and II being non-scarring, and stage III representing cicatricial alope-cia, without contemplating their trichoscopic findings.2

Trichoscopyhasshowntobeusefulinthediagnosis, prognos-ticevaluation,andtreatmentmonitoringofscalpdisorders.3

RegardingDC,Verzietal.reinforcedthattrichoscopyallows magnificationofstructuresbarelyvisibletothenakedeye, clarifyingclinicalexaminationuncertainties,andtherefore could be a valuable tool for both diagnosis and treat-ment choice in this still poorly elucidated disorder.4 _The

https://doi.org/10.1016/j.abd.2019.10.008

0365-0596/©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BYlicense(http://creativecommons.org/licenses/by/4.0/).

Trichoscopicstagesofdissectingcellulitis 515

Figure1 Earlystageofdissectingcellulitis,withtrichoscopyfindingsonalopeciaareata.A,blackdots;B,yellowdots;C,broken hair.

Figure2 Abscedensstageofdissectingcellulitis.A,yellowstructurelessarea;B,three-dimensionalyellowdots.

presentarticleillustratestrichoscopicfeaturesofDC, cor-relating their images to the clinical stages of disease progression.

Inearlierstagesofthedisease,thetrichoscopicpicture ofDC maysimulate thatofalopeciaareata.Thepresence offollicularandperifollicularlymphocyticinfiltratesonthe lowerpartsofterminalfollicles5,6_{explainsthetrichoscopic}

resemblance toalopecia areata,a condition in which the intenseperibulbarinflammatoryinfiltrateisoftenreferred toasaswarm ofbees.Involvementof thelowerportions of the follicle may lead to telogen and consequent hair loss.Thefollicleisunabletostartanewanagenphaseand remainsempty,accumulatingsebumandkeratin,thus justi-fyingyellowdotsintrichoscopy.Alternatively,inflammation mayimpairadequatehairshaftformation.6_{Weakenedshafts}

break,leadingtotheformation of brokenhairsand black dots. Recently, exclamation mark hairs,7 _{a trichoscopic}

featuretypicallyassociatedtoalopeciaareata,have been described in early DC (Fig. 1). Importantly,such features indicatethat this stage is stillnon-scarring and that hair regrowth is possible with adequate treatment. This non-scarring aspect is represented by Lee et al. in clinical stagesIandII.2_{Nevertheless,itispointedintheconclusion}

of their article that DC underdiagnosis is possible, espe-ciallyat earlystages.Thus,theinclusionoftrichoscopyin thecriteriawould beof great valuefor betterdiagnostic accuracy.

Non-treatedDCprogressestotheabscedensstage,which presentswithsevereinflammationandischaracterizedby the presence of pustules, nodules, and abscesses. In this phase,it is possible to observe three-dimensional yellow dots, which may or may not be imposed over dystrophic hairs,aswellasyellowstructurelessareas.8,9_Theseyellow

516 MeloDFetal.

Figure3 Fibroticstageofdissectingcellulitis.A,lackoffollicularopenings;B,cutaneouscleftswithemerginghairs.

andintheearlierstageofDC.Theyhavealsobeendescribed ashavinga‘‘soapbubble’’-likeappearance.8,9 _Theyellow

structurelessareasare‘‘lakesofpus’’easilyfoundaround hair follicles and are typical of DC (Fig. 2). Pinpoint-like vessels with a whitish halo can also be observed, even though they are not uncommon in other scalp diseases.7

Intheauthors’experience,ifpatientsareproperlytreated atthisstage,theymight recovermuchoftheirhair. How-ever, progression to scarring seems inevitable in some areas.

Withtheprogressionofthediseasetothefibroticstage,it ispossibletoidentifyextensivedermalfibrosisand destruc-tion of sebaceous glands in histopathology. The fibrotic stage has trichoscopic features that are similar to the end phases of others scarring alopecias, like white areas lacking follicular openings that represent tissue fibrosis, clinicallydescribed asshinypatches of alopecia. Another featurethatis quite characteristic of advancedDC is the formation of cutaneous clefts. Hair shafts may emerge from such clefts organized into hair tufts with different sizes(Fig.3).

Inconclusion,thisarticlehighlightsthetrichoscopic fea-turesofDCfocusingondemonstratingtheirevolutivestages, whichcouldbeassociatedwiththeclinicalcriteriaproposed byLeeetal.2 _{andenhancetrichoscopy’sroleindiagnosis,}

treatmentchoice,andfollow-up.Thisisasuggestionofan additionaldidacticclassificationbasedontheauthors’ expe-rience,andsomeoverlapofstagesispossible.4_Theauthors

emphasizethat furtherinvestigationsareneededin order toconfirmtheobservations.Nonetheless,itisbelievedthat adoptionoftrichoscopybydermatologistswillrefinecareof patientswithDC,particularlyformonitoringpatientswhile ontreatment.

Financial

support

Authors’

contributions

Daniel Fernandes Melo: Approval of final version on the manuscript;conceptionandplanningofstudy;draftingand editingofmanuscript.

Luciana Rodino Lemes: Drafting and editing of manuscript.

BrunaDuque-Estrada:Draftingandeditingofmanuscript. RodrigoPirmez:Draftingandeditingofmanuscript.

Conflicts

of

interest

Acknowledgment

TheauthorswouldliketothankDr.TaynaraBarretoandDr. VioletaTortellyfortheirscientificcontributions.

References

1.BadaouiA,ReygagneP,Cavelier-BalloyB,PinquierL,Deschamps L,CrickxB,etal.Dissectingcellulitisofthescalp:a restrospec-tivestudyof51patientsandreviewofliterature.BrJDermatol. 2016;174:421---3.

2.LeeCN, ChenW,Hsu CK, WengTT,Lee JY,YangCC. Dissect-ingfolliculitis(dissecting cellulitis) of thescalp:a 66-patient caseseriesandproposalofclassification.JDtschDermatolGes. 2018;16:1219---26.

3.Pirmez R, Tosti A. Trichoscopy tips. Dermatol Clin. 2018;36:413---20.

4.VerzìAE,LacarrubbaF,MicaliG.Heterogeneity oftrichoscopy findings in dissecting cellulitis of the scalp: correlation with disease activity and duration. Br J Dermatol. 2017;177: e331---2.

Trichoscopicstagesofdissectingcellulitis 517 5.RossEK,TanE,ShapiroJ.Updateonprimarycicatricialalopecias.

JAmAcadDermatol.2005;53:1---37.

6.TostiA,TorresF,MitevaM.Dermoscopyofearlydissecting celluli-tisofthescalpsimulatesalopeciaareata.ActasDermosifiliogr. 2013;104:92---3.

7.Segurado-Miravalles G, Camacho-Martınez F, Arias-Santiago S, Rodrigues-BarataR,Serrano-FalcónC,Moreno-ArronesOM,etal. Trichoscopyofdissectingcellulitisofthescalp:exclamationmark

hairsandwhitedotsasmarkersofdiseasechronicity.JAmAcad Dermatol.2016;75:1267---8.

8.RudnickaL,OlszewskaM,RakowskaA,SlowinskaM.Trichoscopy update2011.JDermatolCaseRep.2011;5:82---8.

9.LimaCS,LemesLR, MeloDF.Yellow dotsintrichoscopy: rele-vance,clinicalsignificanceandpeculiarities.AnBrasDermatol. 2017;92:724---6.