ORIGINAL ARTICLE

Year: 2018 I Volume: 1 I Issue: 2 I Page: 38-41

Comparison of Trichoscan Findings of Diffuse Hair Loss in Females Versus Controls

Dr. Nancy M. Raiyani ¹, Dr. Prachi Chetankumar Gajjar¹, Dr. Hita H. Mehta¹, Dr. Chandra Shekhar R. Jaiswal ¹

¹ Department of Dermatology, Venereology and Leprosy, Government Medical College, Bhavnagar, Gujarat, India

Corresponding Author:
Dr. Prachi Chetankumar Gajjar
115, Dept. of Skin & V.D., Sir T. Hospital, Bhavnagar, Gujarat, India
Email: prachi93gajjar@gmail.com

How to cite this article:
Raiyani NM, Gajjar PC, Mehta HH, Jaiswal CSR. Comparison Of Trichoscan Findings Of Diffuse Hair Loss In Females Versus Controls. JDA Indian Journal of Clinical Dermatology 2018;1:38-41.

Abstract:

Introduction: Diffuse hair loss is a worrisome complain specially in females, commonly encountered in clinical dermatological practice. Trichoscan is a non-invasive method of hair analysis that is a combination of epiluminescencetrichoscopy and automatic image analysis system. In this study we analyzed 115 number of volunteer females.

Aim -To find association between clinical presentation and objective parameters found by trichoscan.

Method: All Participants went through detailed history taking, for grouping them under acute telogen effluvium, chronic telogen effluvium, patternhair loss (PHL) and control group. On day 0, scalp hair of approx 1 cm2 area were shaved to leave an approx 0.5 mm hair stump on the area 1 cm lateral to midline on a line joining highest point of pinna. On day 3, patient would undergo hair pull test, trichoscopy and trichoscan study. Trichoscan parameters like anagen:telogen ratio, density/cm2,vellus and terminal hairs were considered for analysis.

Statistical analysis : Raw data was analysed using appropriate one way ANOVAor Kruskal-Wallis Test followed by appropriate post-hoc test.

Results : The mean hair density/cm² is lowest in PHLgroup with having significant difference with control (p<0.01), chronic and acute TE group (p<0.05). Anagen ratio is lowest in acute TE followed by chronic TE, PHLand control group. The terminal hair ratio is significantly low in PHLgroup as compared to control, acute and chronic TE groups. (p<0.001)

Conclusion : Trichoscan is easy useful tool for female hair analysis and satisfactorily used in differentiating PHL, acute telogen effluvium and normal.

Key Words- Trichoscan, Acute telogen effluvium, Chronic telogen effluvium, Pattern hair loss (PHL)

Introduction : Diffuse hair loss is a very common complaint encountered in clinical dermatological practice which can be acute or chronic. Diffuse hair loss is a very common complaint encountered in clinical dermatological practice. It includes various conditions like acute and chronic telogen Though females are less prone to get bald naturally, it is found to be more troublesome among themit found more troublesome among them.. It is noticed that female seek medical advice more than men. Any non-patchy hair loss appreciable to patient can be considered as diffuse hair loss. Various pattern of diffuse hair loss seen in female are: telogen effluvium, anagen effluvium, patterned hair loss (androgenetic alopecia), diffuse alopecia areata and other shaft disorders.1 Trichoscan is a unit containing epiluminescence surface microscopy and digital image analysis system.^2,3 It is recently developed, computer assisted non-invasive method of assessment of hair biological peculiarities that is explained as user-friendly, time-saving and reproducible method.^3,4

The aim of our study was to find out if there is any association between clinical presentation and objective measurements of hair biological parameters determined by trichoscan method.

Subjects and Methods:

After approval from the Institutional Review Board,total of 115 f e m a l e s v i s i t i n g t h e o u t p a t i e n t d e p a r t m e n t o f Dermatologyduring the period of one and half years were enrolled after written informed consent.We included the females between second and fifth age groups. Females with other dermatological scalp conditions like psoriasis, lichen planus, discoid lupus erythematosus, hair shaft abnormality and cicatricial alopecia as well as those who deny for consent were excluded from the study.All participants went through detailed history including associated dermatological and other systemic diseases and thorough scalp examination. This helped us furtherfor grouping them as-anagen effluvium, acute telogen effluvium, chronic telogen effluvium, patterned hair loss, diffuse alopecia areata and control group. But, we did not comeameacross cases of anagen effluvium and diffuse alopecia areata. Routine laboratory investigations like complete blood count,renal function test, liver function test, urine analysis, HbsAg, erythrocyte sedimentation rate and serum ferritin level were carried out. Thyroid function test and other respective investigations were done if required.

Scalp examination for trichoscan was carried out as belows:
On day one, scalp hairs of approximately1 cm² area were trimmed to leave an approximately 0.5 mm hair stump. The area was fixed as -one cm lateral to midline on a line joining highest points of both pinna in all subjects to maintain the uniformity. Gross photographs were captured. All participants were called back after 48 hours with an instruction not to wash their hair during this period. The site was re-examined by putting contact mode dermoscope (Heine Delta 20 Plus P set, Germany) with polarized light that is attached with digital camera (Canon EOS 550 D Camera, Tokyo, Japan). After proper alignment the image was captured, saved and analysed with trichoscan software. This programme analyses 1.195 cm² area and gives different hair parameters like density/cm²,anagen hairs (%), telogen hairs (%), density vellus hairs (per cm2), density terminal hairs (per cm2), ratio vellus hairs (%) and ratio terminal hairs (%)(Figure 1 and 2).

Figure 1: Example of the Trichoscan analysis of ATE Click here to view

Figure 2: Example of the Trichoscan analysis of PHL Click here to view

The principle of trichoscan is based on hair biologic characteristics like anagen hairs grows daily by approximately 0.3 mm while telogen hairs do not grow. Using this trichoscan c o u n t s , h a i r s w i t h l e n g t h o f > 0 . 7 m m w µ m w e r e consideredanagen and other non-growing hairs as telogen. This value of 0.7 mµm is manually adjustable. Black permanent hair colour (Streax hair colour) was used only in few persons with white hair to improve contrast between hair and scalp skin and only on the area to be examined with dermoscope. This was made possible by applyingmixture of cream and developer solution on examination area for 15 minutes in aproportion of 1:1 ratio with the help of a wooden spatula. Hair Pull Test(HPT)from area other than clipped hair was performed in all subjects. Pulled hairs were examined under microscope to confirm whether they areanagenor telogen hairs.Hair loss pattern werethen classified as: (1) Acute Telogen Effluvium (ATE) (2) Chronic Telogen Effluvium (CTE) (3) Patterned hair loss (PHL) and (4) C o n t r o l . P a t i e n t s c o m i n g f o r o t h e r d e r m a t o l o g i c a l conditions(excluding scalp), relatives accompanying the patients, hospital staff like nurse, medical students, technicians and other healthy volunteerswith normal hair cycle were included as controls.

Statistical analysis was done using Graph pad InStat software version 3.06. Raw data was put on normality test and data with Gaussian distribution like overall hair density and terminal hair density (per cm²) (Table 1) wereanalysed using oneway ANOVA while those with non-Gaussian distribution like anagen, telogen, vellus, terminal hair (%) and vellus hairs (per cm²) (Table 2) were analysed using Kruskal-Wallis test followed by appropriate post-hoc test. P value < 0.05 were accepted to be significant.

Table 1: Comparison of hair density and terminal hairs among different groups Click here to view

Table 2: Comparison of Anagen, Telogen, Vellus and Terminal hairs among different groups Click here to view

Results:

We enrolled total 115 females with age ranging between 13 to 50 years. The mean age of all with diffuse hair loss and control group were 28.9 ± 9.6 and 25.1 ± 7.6 years, respectively. The age-wise distribution was as follows: 35 (30.4%) in second decade, 39 (33.9%) in third decade, 27 (23.5%) in forth decade and 14 (12.2%) in fifth decade. We did not observe muchchanges in number of hairs per cm2, telogen hairs, vellus hairs or terminal hairs content with advancing age in any group.

In acute TE group, 45.5% cases showed positive hair pull test in whom duration of hair fall was less than or equal to two months. Specific triggering factors like febrile illness, major operative procedure and recovery from debilitating illness, etc. was identified from history only in 30.3% cases of acute TE and 17.9% cases of chronic TE.

Three out of 16 (18.8%) patients of PHL had positive family history of androgenetic alopecia. Only one participant of 16 from PHL group had clinical sign of hyperandrogenismcharacterised byexcessive hairs on upper lips and irregular menstruation.

The hair density was lowest in PHL group followed by CTE, ATE group and highest in control group with statistically significant difference between PHL and other three groups (Table 1). The control group showed highest anagen hair content(%) while acute TE group showed lowest. The percentage of telogen hairs was highest in acute TE groupfollowed by the chronic TE and PHL group while lowest in control group.Terminal hair count was significantly lower infemales with PHL compared to other groups (p <0.000). Vellus hair content was higher in PHL compared to other three groups though not significant (p < 0.3)( Table 2). We reclassified all the females with diffuse hair loss in two groups based on Hair pull test results as Hair pull test positive and Hair pull test negative. There was no significant difference in mean values of different trichoscan parameters between two groups. Average Telogen hair count was slightly higher in females with positive HPT while average anagen hair count was slightly lower in HPT positive group (Table 3).

Table 3: Values of parameters between groups made as per Hair Pull Test results. Click here to view

Serum ferritin level was done in 106 subjects. Low serum ferritin level (<11 ng/ml) was found in 40.6% (43) subjects. Eight out of 24 subjects in control group had low serum ferritin.

Discussion:

Diffuse hair loss is defined as acute or chronic generalised thinning of hairs from the scalp. It includes various conditions like acute and chronic telogen effluvium, anagen effluvium, pattern hair loss and diffuse alopecia areata. Of them, telogen effluvium is the most common encountered form of diffuse hair loss which is similar to our observation.⁵ It is difficult to monitor the therapy of hair loss. Previously, dermatologist used to measure the hair length and diameter manually, but it is very tedious and is subjected to subjective variation. Though, invasive procedure like scalp biopsy is standard for measuring the anagen: telogen ratio and for diagnosing hair disorders but in every follow up, patient would not get convinced for biopsy to monitor the therapy. Also patient would feel discomfort for hair pulling in semi invasive methods like trichogram and unit area trichogram. Other non invasive hair evaluation methods like global hair count, hair weight test and daily hair count are prone to manual errors and often results are not reproducible. ^2,3,5

So, a reliable,non invasive, safe, easy and OPD tool is required to assess the biological hair parameters.Trichoscan, introduced in 2001 is a novel, handy, non- invasive, reproducible, easy, validated and investigator independent automated image analyser which is a computer based video dermatoscopy which identifies anagen, telogen, terminal, vellus hairs and hair density.^3,5 One validation trial conducted proved excellent correlation between hair parameter results analysed by trichoscan and manually.⁶

There is no defined or fixed normal value for hair density as there are differences according to race and genetic constitution.In the review of various studies, Rushton et al. demonstrated hair density as average 181 hairs/cm² by phototrichogram and 237 hairs/cm² by unit area trichogram in female subjects.⁷ Saraogiet al., found hair density 291.3/cm² in normal control females and in study by Aktanet al., mean hair density of healthy volunteers was found to be 141.7 hairs/cm² by Trichoscan while it was 212.8 hairs/cm² by photomacrographs.8,9 Birch et al., detected hair density of 293 hairs/cm² on using photomacrographs.10 In our study we found hair density of 277.9 ± 51.8 hairs/cm² in control group (Table 1, Figure 3).³

Figure 3: Bar chart showing comparison of hair densities in control groups of different studies Click here to view

Acute telogen effluvium is defined as diffuse hair loss occurring from all over scalp around 6 weeks to 3 months of inciting event and have self-limiting course. If precipitating event is repeated or continued, hair loss may persist for more than 6 months and considered under chronic telogen effluvium. CTE was first described by Whiting DA in 1996 as idiopathic telogen hair loss primarily affecting middle-aged women, having long fluctuating course and diffuse hair shedding that may show bitemporal thinning.11Other secondary causes of chronic telogen shedding l i k e t h y r o i d d y s f u n c t i o n , i r o n d e fi c i e n c y a n e m i a , acrodermatitisenteropathica and others were known.12,13In our study, ATE and CTE group did not show any statistically significant difference in trichoscan parameters. Hair density and terminal hair density (per cm²) were higher in ATE group than CTE while terminal and vellus hair ratio wasfound to be almost similar (Table 1, 2).

A study by Haticeet al. showed statistically significant difference in the hair density and terminal hairs between the TE group and PHL.5 In our study also, we found similar results for hair density and terminal hairs (p<0.05 and <0.001 respectively) in the acute TE and PHL group. We observed slight difference of hair density between chronic TE and PHL group (Table 1). Thus, it can be said that clinical dilemma of differentiation of chronic telogen effluvium and patterned hair loss does not completely resolve with trichoscan.

Sinclair et al., in their using punch biopsy for differentiation between chronic telogen effluvium and PHL the ratio of terminal hairs to vellus hairs (T:V) >8:1 in CTE and 4:1 in PHL.14In contrast to these findings, in our study carried out by trichoscan, we calculated the Terminal : vellus hair ratio to be 4:1 in CTE group and 3:1 in PHL group (Table 2 ). The trichoscopic features diagnostic for PHL are variation in hair shaft diameter due to miniaturization of hair follicle, peripilar sign, single hair bearing follicles, focal areas of atrichia and yellow dots while telogen effluvium is a diagnosis of exclusion (Figure 4).

Figure 4: Dermoscopic features of Female androgenic alopecia: miniaturized hair follicles (arrow), variation in hair shaft diameter, single hair bearing follicles and yellow dots (arrow head). Click here to view

Decreased hair density and follicular units with single hair in the absence of characteristic signs of other causes of alopecia is considered to support clinical diagnosis of telogen effluvium.^15,16 Scrutiny of trichoscopic images in our study lead to a perception that few images from telogen effluvium group showed thin hairs with equal diameter in contrast to PHL group where it showed thinned hairs with varyingdiameters.

Hair pull test which is used to determine disease activity is found to be positive during active shedding phase of both telogen effluvium and anagen effluvium.17Interesting finding noted in our study that the test is positive in cases of early androgenetic alopecia at the areas of thinningwhile negative at occipital area.There was no any statistically significant difference in telogen hairs (%) found between HPT positive PHL subjects and HPT negative PHL subjects in contradictory to that found by Haticeet al(Table 3).⁵ Earlier in a study by Van Nesteet al. with contrast-enhanced phototrichogram method, it was showed that increase in age and duration of complain were associated with decreased hair density in females with ludwig pattern hair loss.18 Here, our observation showed no relation of hair density with patient’s age and duration of hair loss unlike the inference made by Aktanet al.⁹

There are few studies which suggest relation between serum ferritin level and hair loss. Ideal ferritin level was considered to be at least40 ng/ml for healthy hair growth.19 We found very low values of serum ferritin among cases and contols,all groups, where only 6.6% (7 out of 106) showed normal range. There was no any difference in the values of serum ferritin among study groups. No association between serum ferritin level and density of hairs per cm2, anagen (%), telogen (%) and terminal hairs per cm2 were noticed in our study.

Limitations:

Limitations of the study design includes limited sample size for controls and PHL group.Our study is confined to a single centre. Few limitations experienced during procedure and the software are mentioned as below: 1) Crossing of two hair strands lead to false counting yielding higher telogen ratio 2) If the hair is cut very short, near to scalp surface it may not be detected by the software 3) Very thin hairs escape from the counting. These can be overcome by avoiding the processing of this kind of images. Similar errors are also mentioned by Saraogiet al.⁸

Conclusion

Trichoscan, being a non-invasive and simple office procedure, has a scope for use in routine OPD for evaluation of hair loss if the limitations of procedure are meticulously taken care off. It can be used satisfactorily in differentiating acute telogen effluvium, patterned hair loss and normal hairs. In cases of clinical conundrum, trichoscanalong with dermoscopic confirmation of condition will further allow clinician to manage patients with disease specific treatment and prognosis. Trichoscan as part of evaluation, gives psychological satisfaction to the patient which may lead to improved compliance with treatment prescribed by the physician.^3,5

References:

1. Disease of Skin Appendages, In: William DJ, Timothy GB, Dirk ME, Issac MN, editors. Andrew’s Diseases of the Skin – clinical dermatology. 12th ed. Elsevier publication; 2015. p. 747-749.

2. Hoffman R. Trichoscan: combining epiluminescence microscopy with digital image analysis for the measurement of hair growth in vivo. Eur J Dermatol 2001; 11: 362-368.

3. Hoffman R. Trichoscan: A novel tool for the analysis of hair growth in vivo. J Invest DermatolSympProc 2003; 8: 109-115.

4. Singal A, Sonthalia S, Verma P. Female pattern hair loss. Indian J DermatolVenereolLeprol 2013;79: 626-640.

5. Hatice UCE ÖZKOL, Ömer ÇALKA, Necmettin AKDENIZ. Is TrichoScan a new diagnostic method for diffuse hair loss? Turk J Med Sci (2014) 44: 432-438.

6. Gassmueller J., Rowold E., Frase T., Hughes-Formella B. Validation of TrichoScan® technology as a fully-automated tool for evaluation of hair growth parameters. Eur J Dermatol 2009; 19 (3): 224-231

7. Rushton DH, Ramsey ID, James KC. Biochemical and trichological characterization of diffuse alopecia in women.Br J Dermatol 1990; 123: 187–197.

8. Saraogi PP, Dhurat RS. Automated Digital Image Analysis (TrichoScan®) for Human Hair Growth Analysis: Ease versus Errors. Int J Trichology. 2010 JanJun; 2(1): 5–13.

9. Aktan S, Akarsu S, Ilknur T, Demirtasoglu M, Ozkan S. Quanti?cation of female pattern hair loss: A study in a Turkish population. Eur J Dermatol. 2007;17:321–324.

10. Birch MP, Messenger JF, Messenger AG. Hair density, hair diameter and the prevalence of female pattern loss. Br J Dermatol2001; 144: 297-304.

11. Whiting DA. Chronic telogen ef?uvium: Increased scalp hair shedding in middleaged women. JAm AcadDermatol 1996;35: 899-906.

12. G r o v e r C , K h u r a n a A . Te l o g e n e f ? u v i u m . I n d i a n J DermatolVenereolLeprol 2013;79:591-603

13. Dawber RPR, Simpson NB, Barth JH. Diffuse alopecia: Endocrine, metabolic and chemical in?uences on the follicular cycle. In: Dawber RP, editor. Diseases of the Hair and Scalp. Oxford: Blackwell Science;1997. p. 123-150.

14. Sinclair RD, Jolley D, Mallari R, Magee J. The reliability of horizontally sectioned scalp biopsies in the diagnosis of chronic diffuse telogen hair loss in women. J Am AcadDermatol 2004; 51: 189–199.

15. Jain N, Doshi B, Khopkar U. Trichoscopy in alopecias: diagnosis simpli?ed. Int J Trichology 2013;5: 170-178.

16. Rudnicka L, Olszewska M, Rakowska A, Slowinska M. Trichoscopy update 2011. J Dermatol Case Rep. 2011;5: 82–88.

17. Dhurat R. Saraogi P. Hair Evaluation Methods: Merits and Demerits. .Int J Trichology. 2009 Jul-Dec;1(2): 108–119.

18. Van Neste D. Female patients complaining about hair loss: documentation of defective scalp hair dynamics with contrast-enhanced phototrichogram. SkinResTechnol2006;12: 83-88.

19. Harrison S, Sinclair R. Telogen ef?uvium. ClinExpDermatol 2002; 27: 389–395.