Diagnostic Accuracy of Trichoscopy in Trichotillomania: A Systematic Review
Keywords:trichotillomania, hair-pulling disorder, trichoscopy, dermoscopy, dermatoscopy
Trichotillomania is formally classified as a mental health disorder, but it is commonly diagnosed by dermatologists. The aim of this systematic review is to assess the diagnostic value of trichoscopy in diagnosing trichotillomania. The analysis identified the 7 most specific trichoscopic features in trichotillomania. These features had the following prevalence and specificity: trichoptilosis (57.5%; 73/127 and 97.5%, respectively), v-sign (50.4%; 63/125 and 99%), hook hairs (43.1%; 28/65 and 100%), flame hairs (37.1%; 52/140 and 96.5%), coiled hairs (36.8%; 46/125 and 99.6%), tulip hairs (36.4%; 28/77 and 89.6%), and hair powder (35.6%; 42/118 and 97.9%). The 2 most common, but least specific, features were broken hairs and black dots. In conclusion, trichoscopy is a reliable new diagnostic method for hair loss caused by hair pulling. Trichoscopy should be included as a standard procedure in the differential diagnosis of trichotillomania in clinical practice.
Jafferany M, Patel A. Trichopsychodermatology: the psychiatric and psychosocial aspects of hair disorders. Dermatol Ther 2020; 33: e13168.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013: p. 251-257.
Rudnicka L, Olszewska M, Rakowska A. Atlas of trichoscopy: dermoscopy in hair and scalp disease. London: Springer, 2012: p. 257-275.
Woods DW, Flessner CA, Franklin ME, Keuthen NJ, Goodwin RD, Stein DJ, et al. The Trichotillomania Impact Project (TIP): exploring phenomenology, functional impairment, and treatment utilization. J Clin Psychiatry 2006; 67: 1877-1888.
Rakowska A, Slowinska M, Olszewska M, Rudnicka L. New trichoscopy findings in trichotillomania: flame hairs, v-sign, hook hairs, hair powder, tulip hairs. Acta Derm Venereol 2014; 94: 303-306.
Rudnicka L, Olszewska M, Rakowska A, Kowalska-Oledzka E, Slowinska M. Trichoscopy: a new method for diagnosing hair loss. J Drugs Dermatol 2008; 7: 651-654.
Malakar S. Trichoscopy: a text and atlas. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd, 2017: p. 73.
Moneib HA, El-Shiemy SMH, Saudi WM, El-Fangary MM, Nabil T, Mohy SM. Hair loss among a group of Egyptian children: a clinical and dermoscopic study. J Egypt Women's Dermatol Soc 2017; 14: 9-24.
Khunkhet S, Vachiramon V, Suchonwanit P. Trichoscopic clues for diagnosis of alopecia areata and trichotillomania in Asians. Int J Dermatol 2017; 56: 161-165.
Park J, Kim JI, Kim HU, Yun SK, Kim SJ. Trichoscopic findings of hair loss in Koreans. Ann Dermatol 2015; 27: 539-550.
Ankad BS, Naidu MV, Beergouder SL, Sujana L. Trichoscopy in trichotillomania: a useful diagnostic tool. Int J Trichology 2014; 6: 160-163.
Thakur BK, Verma S, Raphael V, Khonglah Y. Extensive tonsure pattern trichotillomania-trichoscopy and histopathology aid to the diagnosis. Int J Trichology 2013; 5: 196-198.
Elmas Ö F, Metin MS. Trichoscopic findings of trichotillomania: new observations. Postepy Dermatol Alergol 2020; 37: 340-345.
Said M, El-Sayed SK, Elkhouly NDE. Trichoscopic evaluation of frontal hairline recession in Egyptian female patients. J Cosmet Dermatol 2020; 19: 2706-2716.
Malakar S, Mukherjee SS. 'Mace sign' - a definitive sign of trichotillomania? Our Dermatology Online/Nasza Dermatologia Online 2017; 8: 491-492.
Nikam VV, Mehta HH. A nonrandomized study of trichoscopy patterns using nonpolarized (contact) and polarized (noncontact) dermatoscopy in hair and shaft disorders. Int J Trichology 2014; 6: 54-62.
Miteva M, Tosti A. Flame hair. Skin Appendage Disord 2015; 1: 105-109.
Rossi A, Caterina Fortuna M, Caro G, Cardone M, Garelli V, Grassi S, et al. Monitoring chemotherapy-induced alopecia with trichoscopy. J Cosmet Dermatol 2019; 18: 575-580.
Miteva M, Tosti A. Hair and scalp dermatoscopy. J Am Acad Dermatol 2012; 67: 1040-1048.
Shim WH, Jwa SW, Song M, Kim HS, Ko HC, Kim BS, et al. Dermoscopic approach to a small round to oval hairless patch on the scalp. Ann Dermatol 2014; 26: 214-220.
Inui S, Nakajima T, Nakagawa K, Itami S. Clinical significance of dermoscopy in alopecia areata: analysis of 300 cases. Int J Dermatol 2008; 47: 688-693.
Malakar S, Mukherjee SS. Burnt matchstick sign - a new trichoscopic finding in trichotillomania. Int J Trichology 2017; 9: 44-46.
Polat M. Evaluation of clinical signs and early and late trichoscopy findings in traction alopecia patients with Fitzpatrick skin type II and III: a single-center, clinical study. Int J Dermatol 2017; 56: 850-855.
Kowalska-Oledzka E, Slowinska M, Rakowska A, Czuwara J, Sicinska J, Olszewska M, et al. 'Black dots' seen under trichoscopy are not specific for alopecia areata. Clin Exp Dermatol 2012; 37: 615-619.
Rudnicka L, Olszewska M, Rakowska A, Slowinska M. Trichoscopy update 2011. J Dermatol Case Rep 2011; 5: 82-88.
Lima CDS, Lemes LR, Melo DF. Yellow dots in trichoscopy: relevance, clinical significance and peculiarities. An Bras Dermatol 2017; 92: 724-726.
Peralta L, Morais P. Photoletter to the editor: The Friar Tuck sign in trichotillomania. J Dermatol Case Rep 2012; 6: 63-64.
Ise M, Amagai M, Ohyama M. Follicular microhemorrhage: a unique dermoscopic sign for the detection of coexisting trichotillomania in alopecia areata. J Dermatol 2014; 41: 518-520.
Brzezinski P, Cywinska E, Chiriac A. Report of a rare case of alopecia areata coexisting with trichotillomania. Int J Trichology 2016; 8: 32-34.
Waskiel A, Rakowska A, Sikora M, Olszewska M, Rudnicka L. Trichoscopy of alopecia areata: An update. J Dermatol 2018; 45: 692-700.
Rudnicka L, Olszewska M, Waskiel A, Rakowska A. Trichoscopy in hair shaft disorders. Dermatol Clin 2018; 36: 421-430.
Grant JE, Dougherty DD, Chamberlain SR. Prevalence, gender correlates, and co-morbidity of trichotillomania. Psychiatr Res 2020; 288: 112948.
Güleç AT. Trichoscopic features of eyebrow trichotillomania: it looks similar to scalp trichotillomania. Dermatol Pract Concept 2020; 10: e2020040.
Adil M, Amin SS, Mohtashim M, Agrawal D. Concomitant trichotillomania, trichotemnomania and skin picking disorder in a woman. Ind J Dermatol Venereol Leprol 2020; 86: 286-289.
Slawinska M, Opalska A, Mehrholz D, Sobjanek M, Nowicki R, Baranska-Rybak W. Videodermoscopy supports the diagnosis of eyelash trichotillomania. J Eur Acad Dermatol Venereol 2017; 31: e477-e478.
Cutrone M, Grimalt R. The dermoscopic "pluck out sign" for beard trichotillomania. Skin Appendage Disord 2018; 4: 15-17.
Malakar S, Mehta PR. "i hair": A prognostic marker in alopecia areata & trichotillomania. Indian J Dermatol 2017; 62: 658-660.
Pinto ACVD, de Brito FF, Cavalcante MLLL, de Andrade TCPC, da Silva GV, Martelli ACC. Trichotillomania: a case report with clinical and dermatoscopic differential diagnosis with alopecia areata. Anais Brasileiros de Dermatologia 2017; 92: 118-120.
Miteva M, Tosti A. Dermoscopy guided scalp biopsy in cicatricial alopecia. J Eur Acad Dermatol Venereol 2013; 27: 1299-1303.
How to Cite
Copyright (c) 2021 Agnieszka Kaczorowska, Lidia Rudnicka, Catherine M. Stefanato, Anna Waskiel-Burnat, Olga Warszawik-Hendzel, Malgorzata Olszewska, Adriana Rakowska
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.