Dermatology: Practical and Conceptual Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S 1 Dermoscopy of Hair and Scalp Disorders (Trichoscopy) in Skin of Color – A Systematic Review by the International Dermoscopy Society “Imaging in Skin of Color” Task Force Soumil Khare1, Biswanath Behera2, Delaney D Ding3, Aimilios Lallas4, Payal Chauhan5, Nkechi Anne Enechukwu6, Martyna Sławińska7, Bengu Nisa Akay8, Balachandra S Ankad9, Yasmeen J Bhat10, Abhijeet Kumar Jha11, Feroze Kaliyadan12, Awatef Kelati13, Shekhar Neema14, Nisha V Parmar15, Jennifer Stein16, Richard P Usatine17, Keshavamurthy Vinay18, Enzo Errichetti19 1 Department of Dermatology, Venereology and Leprosy, AIIMS, Raipur, India 2 Department of Dermatology and Venereology, AIIMS, Bhubaneswar, India 3 University of Florida College of Medicine, Gainesville, FL, USA 4 First Department of Dermatology, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece 5 Department of Dermatology, All India Institute of Medical Sciences (AIIMS), Bilaspur, Himachal Pradesh, India 6 Nnamdi Azikiwe University/Nnamdi Azikiwe Teaching Hospital Nnewi, Anambra State, Nigeria 7 Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, Poland 8 Department of Dermatology, School of Medicine, Ankara University, Ankara, Turkey 9 Department of Dermatology, Venereology and Leprosy, SN Medical College, Bagalkot, Karnataka, India 10 Department of Dermatology, Venereology and Leprology, Government Medical College, University of Kashmir, Srinagar, Jammu and Kashmir, India 11 Department of Dermatology & STD, Patna Medical College & Hospital, Patna, India 12 Department of Dermatology, Sree Narayana Institute of Medical Sciences, Ernakulum, India 13 Dermatology Department, Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco 14 Department of Dermatology, Venereology and Leprology, Armed Force Medical College, Pune, Maharashtra, India 15 Department of Dermatology, Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates 16 The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY, USA 17 Department of Dermatology and Cutaneous Surgery, Department of Family and Community Medicine, University of Texas Health San Antonio, San Antonio, TX, USA 18 Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India 19 Institute of Dermatology, “Santa Maria della Misericordia” University Hospital, Udine, Italy Key words: dermoscopy, dermatoscopy, epiluminescence, hair diseases, scalp diseases, skin of color, dark skin, black skin, ethnic skin, dark phototype, african skin, systematic review Citation: Khare S, Behera B, Ding DD. Dermoscopy of Hair and Scalp Disorders (Trichoscopy) in Skin of Color – a systematic review by the International Dermoscopy Society “Imaging in Skin of Color” Task Force. Dermatol Pract Concept. 2023;13(4)S1:e2023310S. DOI: https://doi.org/10.5826/dpc.1304S1a310S Accepted: September 3, 2023; Published: October 2023 Copyright: ©2023 Khare et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. 2 Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Enzo Errichetti, MD, Institute of Dermatology, “Santa Maria della Misericordia” University Hospital, Piazzale Santa Maria della Misericordia, 15. 33100-Udine, Italy. E-mail: enzoerri@yahoo.it Hair and scalp disorders are of significant interest for physicians dealing with dark phototypes due to their prevalence and potential aesthetic impact resulting from a higher tendency for scarring. In order to facilitate their non-invasive diagnosis, several dermoscopic studies have been published, yet data are sparse and no systematic analysis of the literature has been performed so far. This systematic literature review summarizes published data on trichoscopy of hair and scalp diseases (trichoscopic findings, used setting, pathological correlation, and level of evidence of studies). A total of 60 papers addressing 19 different disorders (eight non-cicatricial alopecias, nine cicatricial alopecias, and two hair shaft disorders) were assessed, for a total of 2636 instances. They included one cross-sectional analysis, 20 case-control studies, 25 case-series, and 14 single case-reports, so the level of evidence was V and IV in 65% and 33% of cases, respectively, with only one study showing a level of evidence of III. Notably, although there is a considerable body of literature on trichoscopy of hair/scalp diseases, our review underlined that potentially significant variables (e.g., disease stage or hair texture) are often not taken into account in published analyses, with possible biases on trichoscopic patterns, especially when it comes to hair shaft changes. Further analyses considering all such issues are therefore needed. ABSTRACT Introduction Hair and scalp disorders represent a relevant part of der- matologist’s practice when it comes to dark-skinned patients due to their significant prevalence as well as potential aes- thetic impact resulting from a higher tendency for scarring in case of cicatricial alopecias [1]. Additionally, there are sev- eral alopecic diseases that are exclusively or predominantly seen in darker phototypes (Fitzpatrick’s phototypes IV-VI), especially subjects of African descent [1,2]. In order to facili- tate the recognition of hair and scalp disorders, some studies focusing on their dermoscopic pattern have been performed, yet data are sparse and no systematic analysis of the litera- ture evidence has been published so far 2. This review, performed by the International Dermoscopy Society (IDS) Task Force on “Imaging in Skin of Color”, sought to systematically analyze trichoscopic findings of hair and scalp diseases reported in dark-skinned patients. Materials and Methods This systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and MetaAnalyses) guidelines. A search of the articles published up to 30th June 2022 was performed through the PubMed electronic database using the following search terms: “trichoscopy” OR “dermoscopy” OR “epilu- minescence” OR “dermatoscopy” AND “skin of color” OR “dark skin” OR “black skin” OR “ethnic skin” OR “dark phototype” OR “african skin” OR “indian skin”. Titles and abstracts were screened by two independent reviewers to identify papers reporting trichoscopic findings of hair and scalp disorders; non-English articles, reviews, personal opin- ions and editorials as well as duplicates were excluded. A manual search was also performed by assessing the reference sections of all significant studies or reviews on this topic. Articles considered not relevant and those not provid- ing trichoscopic structures according to specific dermatosis/ number of patients with particular tichoscopic structures were excluded after full-text reading. Only articles specif- ically dealing with Fitzpatrick’s phototypes IV-VI were in- cluded. In case information on the skin phototype was not provided, decision on inclusion was made based on a title/ abstract/full text showing that the manuscript concerned “dark skin” or “skin of color” and for single cases also based on the attached figures. We also included papers from Afri- can, Indian subcontinent, and Caribbean countries as most of patients from these areas feature IV-VI skin phototype. Importantly, studies grouping light and dark phototypes without dedicated subanalyses were excluded, apart from those with only a minority of light-skinned patients being involved (i.e., less than 20% of total). All of the retrieved studies were classified based on standard definitions for diagnostic accuracy studies [3,4] and their level of evidence was assigned according to The Oxford 2011 Levels of Evidence [5]. Trichoscopic findings, Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S 3 histopathological background (if available), trichoscopic set- ting (polarized vs non-polarized/magnification degree), skin type of the patient (if specified), and number of cases were assessed and summarized. Results The initial PubMed search showed 1287 publications, with a total of 71 items admitted to the full-text reading after title and abstract screening and excluding duplicates. Of these, eleven papers were ruled out according to the exclusion cri- teria, with 60 articles being eventually admitted to the re- view analysis. The flow chart displaying the study selection process is showed in Figure 1. The full-text review included a total of 60 studies, in- cluding one cross-sectional analysis, 20 case-control studies, 25 case-series, and 14 single case-reports; the number of re- cords according to the level of evidence presented were as follows: I: 0; II: 0; III: 1; IV: 20; and V: 39. In detail, 19 different disorders (also accounting for relevant disease vari- ants with clinical/trichoscopic peculiarities) were evaluated, including eight non-cicatricial alopecias, nine cicatricial alopecias, and two hair shaft disorders for a total of 2636 cases. Table 1 shows the number of studies and total number of included instances for each condition. Trichoscopic setting (polarized vs non-polazised) was reported in 24/60 records (14 polarized; 5 non-polarized; 5 both), magnification in 46/60 records (24: x10; 7: x20; 1: x30; 1: x58; 1: x60; 12: variable magnification), and trichoscopic-pathological correlation in 18/60 records (even though some correlated not all trichoscopic findings). Supple- mental Table summarizes all such data, along with analytical description of each of the study evaluated in the review (number of patients, type of study and level of evidence), trichoscopic features, skin type of the patient. Table 1 also displays the general prevalence of trichoscopic findings for each condition, calculated considering all the data available from the literature. For practical purpose, we have grouped analyzed disorders into non-cicatricial alopecias, cicatricial alopecias, and hair shaft disorders. Figures 2 and 3 show dermoscopic clues of such conditions. Non-Cicatricial Alopecias Alopecia Areata Alopecia areata (AA) is one of the most studied non-cicatricial alopecias from a trichoscopic point of view in skin of color, with 24 studies (11 case-control analyses [6-16], 11 case-series [7-27], and two single case-reports [28,29]) retrieved from the literature with a total of 1206 patients. The most commonly observed finding were yel- low dots, found in 67% of cases, followed by black dots and short vellus hairs, detected in 62% and 48% of cases, respectively. Other frequent features included broken hairs (36%) and “micro-exclamation mark” hairs (31%). Pigtail and straight regrowing hairs, coudability hairs (hairs tapered at the proximal end), off-white dots (empty follicles), ery- thema, honeycomb pigmentation, white dots, i-hairs, tulip hairs, Pohl-Pinkus constrictions, perifollicular scales, and perifollicular discoloration were all observed in less than 10% of cases. With regard to diagnostic accuracy, yellow dots have been identified as a sensitive marker for AA diagnosis, though their sensitivity increased from 89.6% to 97.4% when associated with short vellus hairs according to a study Figure 1. PRISMA flowchart displaying the selection process for study inclusion in the systematic review. 4 Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S Ta b le 1 . T ot al n um be r of s tu di es , i ns ta nc es a nd p re va le nc e of t ri ch os co pi c fin di ng s of h ai r an d sc al p di so rd er s in s ki n of c ol or . D is o rd er To ta l n u m b er o f st u d ie s To ta l n u m b er o f in st an ce s Tr ic h o sc o p ic fi n d in g s* ( to ta l p re va le n ce ) N on -c ic at ri ci al a lo pe ci as A lo pe ci a ar ea ta 24 12 06 C om m on fi nd in gs : Y el lo w d ot s (6 7% ); B la ck d ot s (6 2% ) L es s co m m on fi nd in gs : S ho rt v el lu s ha ir ( 48 % ); B ro ke n ha ir ( 36 % ); E xc la m at io n m ar k ha ir ( 31 % ); P ig ta il  ha ir (9 % ); S tr ai gh t re gr ow in g ha ir ( 9% ); C ou da bi lit y ha ir ( 8% ); O ff w hi te d ot s (6 % ); W hi te d ot s (5 % ); H on ey co m b pi gm en t pa tt er n (3 % ); E ry th em a (3 % ); V as cu la r pa tt er n (3 % ); A ty pi ca l r ed v es se ls ( 1% ); P er if ol lic ul ar s ca le s (1 % ); T ul ip h ai r (1 % ); L eu ko tr ic hi a (1 % ); P er if ol lic ul ar p ig m en ta ti on ( 1% ) A nd ro ge ne ti c al op ec ia Fe m al e pa tt er n ha ir lo ss M al e pa tt er n ha ir lo ss 9 3 54 4 10 2 C om m on fi nd in gs : H ai r di am et er d iv er si ty > 20 % ( 87 % ); S ho rt v el lu s ha ir ( 66 % ) L es s co m m on fi nd in gs : B ro w n pe ri pi la r si gn ( 35 % ); S in gl e- ha ir f ol lic ul ar u ni t (2 9% ); T hi n ha ir ( 22 % ); Y el lo w do ts ( 18 % ); L ow er m ea n ha ir t hi ck ne ss in f ro nt al a re a (9 % ); > 10 % t hi n ha ir s in f ro nt al a re a (9 % ); H on ey co m b pi gm en t pa tt er n (6 % ); W hi te d ot s (5 % ); F oc al a tr ic hi a (5 % ); W hi te p er ip ila r si gn ( 4% ); > 2: 1 si ng le h ai r un it s, fr on ta l: oc ci pu t (4 % ); > 3: 1 ha ir f ol lic le s w it h pe ri fo lli cu la r di sc ol or at io n, f ro nt al : o cc ip ut ( 4% ); > 4 ye llo w d ot s in fr on ta l a re a (3 % ); > 1. 5: 1 ve llu s ha ir, f ro nt al : o cc ip ut ( 3% ); S ca le s (1 % ); O ff w hi te d ot s (1 % ); B ro ke n ha ir ( 1% ) C om m on fi nd in gs : H ai r di am et er d iv er si ty > 20 % ( 85 % ); Y el lo w d ot s (8 4% ); H on ey co m b pi gm en t pa tt er n (7 8% ); B ro w n pe ri pi la r si gn ( 67 % ) L es s co m m on fi nd in gs : W hi te p er ip ila r si gn ( 39 % ); S ho rt v el lu s ha ir ( 22 % ); T hi n ha ir ( 19 % ); F oc al a tr ic hi a (1 3% ); W hi te d ot s (8 % ) P re ss ur e- in du ce d al op ec ia 1 6 C om m on fi nd in gs : Y el lo w d ot s (1 00 % ); S ho rt v el lu s ha ir ( 10 0% ); B la ck d ot s (8 3% ); C om ed o- lik e bl ac k do ts (6 7% ); B ro ke n ha ir ( 50 % ); A re as o f sc ar ri ng ( 50 % ) L es s co m m on fi nd in gs : - T el og en e ffl uv iu m 3 53 C om m on fi nd in gs : S tr ai gh t re gr ow in g ha ir ( 81 % ) L es s co m m on fi nd in gs : S in gl e- ha ir f ol lic ul ar u ni t (3 8% ); O ff w hi te d ot s (2 8% ); Y el lo w d ot s (1 7% ); T hi n ha ir (1 3% ); P er if ol lic ul ar e ry th em a (2 % ) Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S 5 T in ea c ap it is 14 26 1 C om m on fi nd in gs : B la ck d ot s (5 7% ); C om m a ha ir ( 55 % ) L es s co m m on fi nd in gs : B ro ke n ha ir ( 47 % ); C or ks cr ew h ai r (3 1% ); P er if ol lic ul ar s ca le s (2 2% ); Z ig za g ha ir (2 0% ); E ry th em a, t el en ge ct as ia h ea m or rh ag e (1 3% ); M or se c od e ha ir ( 11 % ); i- ha ir ( 8% ); P us tu le s (4 % ); W hi te do ts ( 3% ); P er if ol lic ul ar p ig m en ta ti on ( 3% ); O ff w hi te d ot s (e m pt y fo lli cl e) ( 2% ); F la m e ha ir ( 1% ); H on ey co m b pi gm en t pa tt er n (1 % ); T hi n ha ir ( 1% ); W hi te a re as ( 1% ); L os s of f ol lic le s (1 % ) T ra ct io n al op ec ia 3 9 C om m on fi nd in gs : - L es s co m m on fi nd in gs : P er ip ila r ca st s (4 4% ); S in gl e- ha ir f ol lic ul ar u ni t (4 0% ); L os s of f ol lic le s (3 3% ); B la ck  d ot s (1 1% ); F ol lic ul ar p us tu le s (1 1% ); S ho rt v el lu s ha ir ( 11 % ) T ri ch ot ill om an ia 14 46 C om m on fi nd in gs : B ro ke n ha ir a t di ff er en t le ng th ( 93 % ); T ri ch op ti lo si s (6 7% ); B la ck d ot s (6 3% ); H oo k  ha ir  ( 52 % ) L es s co m m on fi nd in gs : P er ip ila r ha em or rh ag es ( 48 % ); V -s ig n (3 0% ); F la m e ha ir ( 26 % ); T ul ip h ai r (1 7% ); S tr ai gh t re gr ow in g ha ir ( 17 % ); Y el lo w d ot s (1 1% ); P er if ol lic ul ar s ca le s (1 1% ); V ar ia ti on -H D D ( 9% ); W hi te d ot s (9 % ); Sh or t ve llu s ha ir ( 7% ); H ai r du st ( 7% ); H on ey co m b pi gm en t pa tt er n (7 % ); P ig ta il ha ir ( 4% ); S in gl e- ha ir f ol lic ul ar un it ( 4% ); B lo tc hy -p ig m en ta ti on ( 2% ); P er if ol lic ul ar w hi ti sh h al o (2 % ) C ic at ri ci al a lo pe ci as C en tr al c en tr if ug al ci ca tr ic ia l a lo pe ci a 2 65 C om m on fi nd in gs : H on ey co m b pi gm en t pa tt er n (1 00 % ); P er if ol lic ul ar w hi ti sh h al o (9 5% ); P in po in t w hi te d ot s (8 1% ); T er m in al h ai r (7 8% ); C ic at ri ci al w hi te p at ch es ( 74 % ); S ho rt v el lu s ha ir ( 74 % ) L es s co m m on fi nd in gs : E ry th em a (4 8% ); B ro ke n ha ir ( 40 % ); S ca le s (3 6% ); A st er is k lik e br ow n ar ea s (1 9% ); D ar k pe ri pi la r ha lo ( 7% ) D is co id lu pu s er yt he m at os us 9 15 9 C om m on fi nd in gs : F ol lic ul ar p lu gg in g (6 8% ); C ic at ri ci al w hi te p at ch es ( 50 % ) L es s co m m on fi nd in gs : S ca le s (4 7% ); P er if ol lic ul ar w hi ti sh h al o (4 3% ); T el an gi ec ta si as ( 39 % ); R ed d ot s (3 5% ); B ro w n do ts ( 30 % ); R os et te s (1 9% ); T hi ck a rb or iz in g ve ss el s (1 7% ); P er if ol lic ul ar s ca le s (1 7% ); B lu e- gr ey d ot s (1 4% ); H on ey co m b pi gm en t pa tt er n (1 1% ); P er if ol lic ul ar e ry th em a (9 % ); S ca lp e ry th em a (8 % ); E nl ar ge d br an ch in g ve ss el s (5 % ); R ed lo op v es se ls ( 5% ); W hi te d ot s (e cc ri ne o pe ni ng s) ( 3% ); B la ck d ot s (2 % ); C ru st fo rm at io n (1 % ); S ho rt v el lu s ha ir ( 1% ); B lu e- w hi te v ei l ( 1% ); P er ip ila r ca st s (1 % ); F ib ro ti c w hi te d ot ( 1% ) Ta bl e 1 C on ti nu es D is o rd er To ta l n u m b er o f st u d ie s To ta l n u m b er o f in st an ce s Tr ic h o sc o p ic fi n d in g s* ( to ta l p re va le n ce ) 6 Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S D is o rd er To ta l n u m b er o f st u d ie s To ta l n u m b er o f in st an ce s Tr ic h o sc o p ic fi n d in g s* ( to ta l p re va le n ce ) D is se ct in g ce llu lit is o f th e sc al p Sc ar ri ng s ta ge E ar ly ( no n- sc ar ri ng ) st ag e 2 1 9 5 C om m on fi nd in gs : L os s of f ol lic le s (1 00 % ); C ic at ri ci al w hi te p at ch es ( 78 % ); B la ck d ot s (7 8% ); C ru st f or m at io n (6 7% ); P er if ol lic ul ar s ca le s (6 7% ); Y el lo w d ot s (6 7% ); E lo ng at ed li ne ar v es se ls ( 67 % ); I nt er fo lli cu la r sc al in g (6 7% ); S ca lp e ry th em a (6 7% ) L es s co m m on fi nd in gs : 3 D y el lo w d ot s (4 4% ); H ai r sh af t di so rd er ( pi li to rt i a nd P oh l- Pi nk us c on st ri ct io ns ) (4 4% ); E pi de rm al a tr op hy ( 33 % ); F ol lic ul ar p us tu le s (3 3% ); H on ey co m b pi gm en t pa tt er n (3 3% ); F ol lic ul ar hy pe rk er at os is ( 22 % ); R ed lo op v es se ls ( 22 % ); B lu e- gr ey d ot s (2 2% ); P er if ol lic ul ar e ry th em a (1 1% ); P er ip ila r ca st s (1 1% ); F ib ro ti c w hi te d ot ( 11 % ); Pe ri fo lli cu la r pi gm en ta ti on ( 11 % ) C om m on fi nd in gs : Y el lo w d ot s (1 00 % ); R ed d ot s (1 00 % ); E m pt y fo lli cu la r op en in gs ( 10 0% ); B la ck d ot s (1 00 % ); C ad av er iz ed h ai rs ( 10 0% ) L es s co m m on fi nd in gs : - Fi br os in g al op ec ia in a pa tt er ne d di st ri bu ti on 1 16 C om m on fi nd in gs : L os s of f ol lic le s (1 00 % ); H ai r di am et er d iv er si ty ( 10 0% ); P er if ol lic ul ar er yt he m a an d sc al in g (8 8% ); H yp er pi gm en te d pe ri fo lli cu la r ha lo ( 75 % ); S ca tt er ed w hi te pa tc he s (7 5% ); H on ey co m b pi gm en t pa tt er n (7 5% ); P er if ol lic ul ar w hi ti sh h al o (5 6% ) L es s co m m on fi nd in gs : F ol lic ul ar p lu gg in g (1 9% ) Fo lli cu lit is d ec al va ns 5 12 C om m on fi nd in gs : L os s of f ol lic le s (8 3% ); P er if ol lic ul ar s ca le s (6 7% ); F ol lic ul ar p us tu le s (5 8% ); H ai r  tu ft in g  (5 0% ) L es s co m m on fi nd in gs : C ic at ri ci al w hi te p at ch es ( 42 % ); P er if ol lic ul ar e ry th em a (4 2% ); S ca lp e ry th em a (4 2% ); Sc al es ( 33 % ); C ru st f or m at io n (3 3% ); B la ck d ot s (2 5% ); P er if ol lic ul ar w hi ti sh h al o (2 5% ); W hi te d ot s (e cc ri ne op en in gs ) (2 5% ); H on ey co m b pi gm en t pa tt er n (2 5% ); E pi de rm al a tr op hy ( 17 % ); E lo ng at ed li ne ar v es se ls ( 17 % ); Y el lo w d ot s (1 7% ); A rb or iz in g ve ss el s (1 7% ); F ol lic ul ar p lu gg in g (1 7% ); R ed lo op v es se ls ( 8% ); F ib ro ti c w hi te do t (8 % ); S pe ck le d pi gm en ta ti on ( 8% ); B lu e- gr ey d ot s (8 % ); H ai r sh af t di so rd er ( pi li to rt i a nd P oh l P in ku s co ns tr ic ti on s) ( 8% ) Fr on ta l fi br os in g al op ec ia 4 14 C om m on fi nd in gs : L os s of f ol lic le s (9 3% ); P er if ol lic ul ar e ry th em a (5 7% ); P er if ol lic ul ar s ca le s (5 7% ); C ic at ri ci al w hi te p at ch es ( 50 % ); H on ey co m b pi gm en t pa tt er n (5 0% ); L es s co m m on fi nd in gs : T el an gi ec ta si as ( 36 % ); S ca lp e ry th em a (2 9% ); B lu e- gr ey d ot s (2 9% ); P re do m in an ce of o ne h ai r fo lli cl es ( 14 % ); E pi de rm al a tr op hy ( 14 % ); F ol lic ul ar h yp er ke ra to si s (1 4% ); P er ip ila r ca st s (1 4% ); In te rf ol lic ul ar s ca lin g (1 4% ); H ai r sh af t di so rd er ( pi li to rt i a nd P oh l P in ku s co ns tr ic ti on s) ( 14 % ); B la ck do ts ( 14 % ); W hi te d ot s (1 4% ); O ff w hi te d ot s (e m pt y fo lli cl es ) (7 % ); S ca tt er ed b ro w n di sc ol or at io n (7 % ); Pe ri fo lli cu la r pi gm en ta ti on ( 7% ); S ho rt v el lu s ha ir ( 7% ); Y el lo w d ot s (7 % ) Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S 7 L ic he n pl an op ila ri s 8 10 7 C om m on fi nd in gs : L os s of f ol lic le s (9 8% ); P er if ol lic ul ar s ca le s (7 8% ); C ic at ri ci al w hi te p at ch es ( 69 % ); H on ey co m b pi gm en t pa tt er n (6 0% ); S ca lp e ry th em a (5 7% ) L es s co m m on fi nd in gs : B lu e- gr ey d ot s in t ar ge to id p at te rn ( 42 % ); P er if ol lic ul ar e ry th em a (3 7% ); S ca le s (3 4% ); B lu e- gr ey d ot s (2 1% ); W hi te d ot s (e cc ri ne o pe ni ng s) ( 19 % ); B lu e- gr ey d ot s in s pe ck le d pa tt er n (1 6% ); H ai r sh af t di so rd er ( pi li to rt i a nd P oh l P in ku s co ns tr ic ti on s) ( 14 % ); R ed lo op v es se ls ( 13 % ); E nl ar ge d br an ch in g ve ss el s (1 2% ); P er ip ila r ca st s (1 2% ); Fi br ot ic w hi te d ot ( 10 % ); B la ck d ot s (1 0% ); F ol lic ul ar p lu gg in g (9 % ); H ai r tu ft in g (5 % ); E lo ng at ed li ne ar v es se ls (4 % ); R ed d ot s (2 % ); O ff w hi te d ot s (e m pt y fo lli cl es ) (1 % ) P se ud op el ad e of B ro cq 6 13 C om m on fi nd in gs : L os s of f ol lic le s (1 00 % ) L es s co m m on fi nd in gs : W hi te d ot s (e cc ri ne o pe ni ng s) ( 46 % ); C ic at ri ci al w hi te p at ch es ( 46 % ); P er if ol lic ul ar s ca le s (3 9% ); Y el lo w d ot s (2 3% ); B lo tc hy p ig m en ta ti on ( 23 % ); E pi de rm al a tr op hy ( 16 % ); P er if ol lic ul ar e ry th em a (1 6% ); T hi n ha ir ( 16 % ); H on ey co m b pi gm en t pa tt er n (7 % ); S ca le s (7 % ); B ro ke n ha ir ( 7% ); B la ck d ot s (7 % ) H ai r sh af t di so rd er s M on ile th ri x 6 8 C om m on fi nd in gs : B ea de d ha ir w it h eq ui di st an t no de s an d in te rn od es ( 10 0% ) L es s co m m on fi nd in gs : B ro ke n ha ir ( 25 % ); A ng ul at ed h ai r (2 5% ); Y el lo w d ot s (1 3% ) Pe ri fo lli cu la r Sc al es ( 13 % ) W oo lly h ai r sy nd ro m e 1 1 C om m on fi nd in gs : S ho rt w av e ci rc le s of h ai r sh af t - “ cr aw lin g sn ak e ap pe ar an ce ” (1 00 % ) L es s co m m on fi nd in gs : - *T ri ch os co pi c fi nd in gs a re d iv id ed in to c om m on ( pr ev al en ce ≥ 5 0% ) an d le ss c om m on ( pr ev al en ce < 5 0% ). D is o rd er To ta l n u m b er o f st u d ie s To ta l n u m b er o f in st an ce s Tr ic h o sc o p ic fi n d in g s* ( to ta l p re va le n ce ) Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S 8 alopecia universalis (50.3 ± 53.6) and the lowest density (22.2±13.1) being detected in localized patchy AA. Con- versely, the study by Kibar et al found no relationship between the number of yellow dots and AA subtype and activity, while the authors observed honeycomb-pattern pigmentation, cumulus-like clustered white dots, white dots and black dotted pigmentation to be positively cor- related with disease severity [9] Finally, Ganjoo et al evaluated trichoscopic changes following intralesional steroid therapy and found that the presence of exclamation mark hairs was the first feature to disappear after four weeks of treatment, followed by broken hairs/black dots and yellow dots (12 and 16 weeks, respec- tively). At four weeks of treatment, the appearance of pigtail hairs and pigmented hairs was also noted [20]. Other stud- ies showed that treated or remitting lesions of AA showed an increased number of short vellus hairs and terminal hairs [14,18,19]. by Bapu et al. [6] Similarly, diagnostic value of exclamation mark hairs in AA was higher when detected along with yel- low dots, black dots, short vellus hairs and/or short regrow- ing hairs based on the study by Amer et al [15]. Additionally, the same authors found that the presence of pigtail hairs was related to spontaneous remission [15]. Moving to disease activity, yellow dots and short vellus hairs were related to stability, while black dots, broken hairs, coudability hairs, tapering hairs, and exclamation mark hairs were are all positively correlated with disease activity, with coudability hairs being reported to be more specific than broken hairs [22]. However, exclamation mark hairs have also been observed in long-standing non-progressive AA in a study by Govindarajulu et al [14]. Of note, based on the studies by Bapu et al [6] and Jha et al [19], a higher density of yellow dots would be related to the disease severity, with the highest mean number of yellow dots per field of view being seen in Figure 2. Examples of trichoscopic clues of non-cicatricial alopecias in dark-skinned patients: Exclamation mark hairs (arrows) in alopecia areata (A); Hair diameter diversity along with thin hairs in early androgenetic alopecia (B); Multiple vellus hairs and brown pigmentation round follicular ostia (brown peripilar sign – arrows) in advanced androgenetic alopecia (C); Comedo-like black dots and yellow dots in pressure-induced alopecia (D); Several follicular units with single hair shaft and lack of other specific trichoscopic criteria in telogen effluvium (E); Comma-like hairs as well as corkscrew-like hairs in tinea capitis (F); Diffuse and perifollicular white scaling along with “Morse code” hairs (arrow) in tinea capitis (G); White peripilar casts, single-hair follicular units, loss of follicles and thin/vellus hair (arrow) in traction alopecia (H); Broken hairs at different length, trichoptilosis, black dots and flame hairs (arrow) in trichotillomania (I). 9 Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S Bhrama et al focused on the diagnostic value of HDD >20% in FPHL, with a sensitivity of 75% for Grade 1 FPHL and 93% for FPHL in general, thereby underling that it is a consistent feature in pattern hair loss and can be used as a diagnostic tool [33]. Notably, Nikam et al found that the brown peripilar sign, which represents perifollicular inflammation, was seen more frequently in cases of androgenetic alopecia compared to tinea capitis and trichotillomania [11]. Finally, Tawfik et al observed that yellow dots and white dots were positively correlated with advanced stages of hair loss and that all pa- tients displayed HDD with an increased percentage of min- iaturized vellus hairs in the frontal and temporal areas [31]. Moving to male pattern hair loss (MPHL), a total of three trichoscopic studies (two case-control [12,14] and one Androgenetic Alopecia A total of nine studies (eight case-control analyses [10-12,14,30-33] and one case-series [34]) assessing trichoscopic features of female pattern hair loss (FPHL) comprising a total of 544 cases were identified. The most prevalent finding was hair diameter diversity (HDD), seen in 87 % of cases (also including two studies which consid- ered HDD of more than 10% of hair instead of the most used cutoff of 20% [14,34]). Further notable findings in- cluded short vellus hairs (66%), brown peripilar sign (35%), single-hair follicular units (29%), thin hairs (20%), and yel- low dots (18%), while several other features were found in less than 10% of cases, such as honeycomb pigment pat- tern, white dots, white peripilar sign, and focal atrichia [10-12,14,30-34]. Figure 3. Examples of trichoscopic clues of cicatricial alopecias in dark-skinned patients: Honeycomb pigment pattern, pinpoint white dots and the characteristic perifollicular thick whitish halo in central centrifugal cicatricial alopecia (A); Brown follicular plugs (arrow), cicatricial white patches and diffuse brown honeycomb pigmentation in discoid lupus erythematosus (B); loss of follicles, cicatricial white patches, a black dot, yellow crusting and the characteristic “3D yellow-brown dots” (arrow) in dissecting cellulitis (scarring stage) (C); Loss of follicles, perifollicular white scaling, hyperpigmented perifollicular halo (white arrow), and perifollicular whitish halo (back arrow) in fibrosing alopecia in a patterned distribution (D); Yellow crusting and white scaling in folliculitis decalvans (early stage) (E); Loss of follicles, cicatricial white patches and hair tufting in folliculitis decalvans (advanced stage) (F); Perifollicular scales, multiple fibrotic white dots and small patches, blue-grey dots in targetoid pattern (around fibrotic white dots) in lichen planopilaris (G); Loss of follicles but evidence of white dots (eccrine openings) along with honeycomb pigment pattern in pseudopelade of Brocq (H); Beaded hair with equidistant nodes and internodes (arrow) in monilethrix (I). Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S 10 Importantly, trichoscopic variability according to the clinical/microbiological subtype was also observed. In detail, corkscrew hairs, comma hairs and zigzag hairs turned out to be more suggestive of the endothrix variant, while peri- follicular scales were more specific of “grey patch” TC and black dots, erythema, telangiectasias and haemorrhages of kerion [35]. Finally, comma hairs, black dots, and perifol- licular scaling were reported to be more frequent in “black dot” TC [35]. With regard to post-treatment monitoring, the disap- pearance of dystrophic hairs was reported as a marker of therapeutic success in a prospective study by Campos et al involving 50 patients [42]. In the same study, the authors also found persistence of perifollicular scaling despite nega- tive results of mycological culture. Traction Alopecia A total of nine instances of traction alopecia (TA) with trichoscopic description have been reported in the literature (two case-control studies [8,10] and a single case series [43]), with peripilar casts and single hair follicular units being the most common features (44% and 40% of cases, respectively). Peripilar casts have also been reported to be present in case of diffuse TC at the margins of the patches. Additional less common findings included loss of hair follicles, black dots, follicular pustules, and short vellus hairs. Trichotillomania We found five case-control studies [8,10-12,14] as well as three case-series [44-46] and three single case-reports [47-49] on trichotillomania encompassing 46 cases. Broken hairs of variable length were the most common trichoscopic feature, being observed in 93% of cases. Further common findings included trichoptilosis, black dots and hook hairs (more than half of all cases) as well as peripilar hemorrhages, V-sign and flame hairs (more than one-fourth of all cases). On the other hand, less frequent features were tulip hairs, straight regrowing hairs, yellow dots, perifollicular scales, hair diameter diversity, white dots (eccrine openings), short vellus hairs, hair dust, and honeycomb pigment pattern. Of note, broken hairs of variable length and trichoptilosis were found to be indicative of trichotillomania when compared to alopecia areata in a study by Chiramel et al [12]. Finally, according to a study conducted by Saqib et al, the presence of straight and pigtail hairs indicate hair regrowth in patients with trichotillomania [10]. Cicatricial Alopecias Central Centrifugal Cicatricial Alopecia A retrospective case-control study [50] and a case series [51] involving a total of 65 instances of central centrifugal cicatri- cial alopecia (CCCA) were retrieved. In general, honeycomb case-series [34]) were retrieved for a total of 102 instances. The most common finding was still HDD greater than 20%, observed in 85% of cases, whereas additional common features included yellow dots (84%), honeycomb pigment pattern (78%), brown peripilar sign (67%), white peripilar sign (39%), and short vellus hairs (22%). Thin hairs, focal atrichia and white dots were seen in less than 20% of cases. Pressure-Induced Alopecia A single retrospective case-control study by Neema et al on trichoscopy of pressure-induced alopecia (PIA) was found in the literature [13]. The most common features included yellow dots and short vellus hairs, while black dots, come- do-like black dots, broken hairs and areas of scarring were additional findings. When compared with alopecia areata, comedo-like black dots, black dots, and scarring areas were significantly more prevalent in PIA, while exclamation mark hairs were significant for alopecia areata. Telogen Effluvium Three case-control studies describing trichoscopy of telo- gen effluvium (TE) were retrieved with a total of 53 cases [10,12,14]. In general, the most common reported tricho- scopic feature was upright regrowing hairs seen in 81% of cases, followed by single hair follicular units (38% of cases) and off-white dots (empty follicles) (28% of cases) [10,12,14]. Additional less commonly described findings included thin hairs and perifollicular erythema. However, prevalence variability among studies did exist [10,12,14]. Notably, unlike other studies, Chiramel et al found a low prevalence of upright regrowing hairs, while thin hairs were found to be the most common feature [12]. Moreover, the same authors also observed honeycomb pigment pattern, pigtail hairs and yellow dots in chronic TE [12]. Tinea Capitis A total of 261 cases of tinea capitis (TC) have been inves- tigated from a trichoscopic point of view in nine studies (one cross-sectional [35] and eight case-control [8,10-12,14- 16,36]) along with two case-series [37,38] and three single case-reports [39-41]. The most prevalent finding was the presence of black dots (57% of cases). Other common fea- tures (observed in more than 20% of cases) included comma hairs, broken hairs, perifollicular white scales, and corkscrew hairs. Less frequent findings were zigzag hairs, erythema, tel- angiectasias, hemorrhages, morse code hairs, i-hairs, pustules, and white dots (eccrine openings). Of note, the association of perifollicular scaling with any dystrophic hairs or broken hairs was found to be a specific trichoscopic pattern of TC in a controlled study by Brasileiro et al [36 ], whereas Chiramel et al showed that the presence of comma hairs was in favor of TC diagnosis when compared to alopecia areata [12]. 11 Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S although considered to be a characteristic sign of DCS, they were observed in 44% of cases in total [52, 53]. Moving to early DCS, Tosti el al, described yellow dots, red dots, empty follicular openings, black dots, and cadav- erized hairs, also emphasizing that the lack of exclamation mark hairs may be a clue to differentiate early DCS from alopecia areata [58]. Fibrosing Alopecia in a Patterned Distribution A single trichoscopic study involving a total of 16 patients with fibrosing alopecia in a patterned distribution (FAPD) is available from the literature [59]. Loss of follicle openings and hair diameter diversity were detected in all cases. Ad- ditionally, perifollicular scaling and erythema were present in 88% of cases, while hyperpigmented perifollicular halos, scattered white patches, and a honeycomb network were ob- served in 75% of cases. Lastly, white perifollicular halos and follicular plugs were observed in 56% and 19% of cases, re- spectively. Importantly, the study underlined that FAPD and CCCA may share several trichoscopic findings, with possible difficulties in their differentiation. Folliculitis Decalvans Twelve instances of folliculitis decalvans (FD) have been investigated on trichoscopy by five case-control studies [8,10,12,52,53]. In general, loss of follicular openings, peri- follicular scaling, follicular pustules and hair tufting were the most common features, being detected in more than 50% of cases. Moreover, several additional findings were reported (Table 1/Supplemental table). According to the study by Abedini et al, follicular pus- tules may also be observed in dissecting cellulitis of the scalp, yet the prevalence was higher in FD [52]. Another hallmark of FD was hair tufting, defined as tufts of ≥ 6 hair shafts emerging from one follicular opening [8,10,12,52,53]. Of note, pustules were found to be a marker of active FD, whereas hair tufting turned out to be an indicator of disease severity [53]. Frontal Fibrosing Alopecia A total of 14 cases of frontal fibrosing alopecia (FFA) have been investigated from a trichoscopic point of view in three case-control studies [52-54] and one single case-report [60]. Besides the lack of follicular openings, showing a prevalence of 93%, the main trichoscopic findings included perifollic- ular erythema and scaling, both being detected in 57% of cases. Several other additional features were reported and are showed in Table 1/Supplemental table. Lichen Planopilaris Seven case-control studies [8,10-12,52-54] and a single case-report [57] on trichoscopy of lichen planopilaris (LPP) pigmentation pattern, perifollicular white halo, pinpoint white dots and cicatricial white patches were the main find- ings (100%, 95%, 81% and 74% of cases, respectively), being commonly found in both studies. When compared to other scarring alopecias, perifollicular white halo turned out to be the most accurate finding, with 100% of specificity and 94% of sensitivity. Notably, this trichoscopic feature was present in both early and late stages of CCCA. Additional trichoscopic findings included terminal hairs, short vellus hairs, erythema, scaling (mainly perifollicular), asterisk-like brown areas, bro- ken hairs, black dots, and dark peripilar halos. Discoid Lupus Erythematosus Discoid lupus erythematosus (DLE) was one of the most studied form of scarring alopecias from a trichoscopic point of view, with seven case-control studies, [10-12,52-54] two case-series, [55,56] and a single case-report [57] involving a total of 159 instances. Follicular plugs, white scarring patches and perifollicular white halos were the most com- mon findings, with a prevalence of 50%, 47% and 43%, respectively. Other main features included telangiectasias, red dots and brown dots (39%, 35% and 30% of cases). Many additional less frequent findings have been reported (Table 1 and Supplemental Table). Considering diagnostic accuracy, tortuous branching vessels (seen as irregular coiled vessels) were found to be specific (100% specificity) of DLE when compared to other forms of scarring alopecias based on the study by Abedini et al [52]. In line with such a finding, Chiramel et al showed that the detection of branching vessels was in favor of DLE compared to lichen planopilaris [12]. Of note, follicular plugs, thick arborizing vessels, peri- follicular erythema, and follicular red dots have been found to be indicators of disease activity [55]. On the other hand, white areas and thin arborizing vessels have been reported more commonly in inactive DLE [11, 55]. Finally, red dots were found to be a positive prognostic factor of hair re- growth in a study by Thakur et al [53]. Dissecting Cellulitis of the Scalp Fourteen instances of dissecting cellulitis of the scalp (DCS) reporting trichoscopic findings have been retrieved (two case-control studies including eight scarring cases [52,53] and a case-series involving five early cases [58]). Considering scarring cases, besides the lack of follicular openings, being seen in all instances, other frequent findings (more than two-thirds of cases) included cicatricial white patches, black dots, crusts, perifollicular scales, yellow dots, elongated linear vessels, interfollicular scaling, and erythema. Less frequent findings are listed in Table 1/Supplemental Table. Notably, according to the study by Abedini et al, black dots were observed with a higher prevalence compared to other cicatricial alopecias [52]. Regarding “3D yellow dots”, Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S 12 studies did not take into account disease stage, that may sig- nificantly affect trichoscopic pattern. Finally, there is little data on possible trichoscopic differences according to the hair texture as a significant variability does exist in the spec- trum of dark-skinned populations, with patients of African descent being typically characterized by tight curly hair, that may potentially influence the trichoscopic patterns, espe- cially when it comes to hair shaft changes. Further analyses considering all such gaps are therefore needed. References 1. Errichetti E, Lallas A. Dermoscopy in General Dermatology for Skin of Color. London: CRC Press; 2021. 2. Ocampo-Garza J, Tosti A. Trichoscopy of Dark Scalp. Skin Appendage Disord. 2018;5:1-8. 3. Campbell JM, Kulgar M, Ding S, et al. Chapter 9: diagnostic test accuracy systematic reviews. In: Joanna Briggs Institute re- viewer’s manual (Aromataris E, Munn Z, eds). The Joanna Briggs Institute, 2017. https://reviewersmanual.joannabriggs.org. Ac- cessed 13 April 2023. 4. Rutjes AW, Reitsma JB, Vandenbroucke JP, et al. Case–control and two-gate designs in diagnostic accuracy studies. Clin Chem. 2005;51:1335-1341. 5. Oxford Centre for Evidence-Based Medicine. The Oxford 2011 levels of evidence. https://www.cebm.net/wp-content /uploads/2014/06/CEBM-Levels-of-Evidence-2.1.pdf. Accessed 13 April 2023. 6. Bapu NG, Chandrashekar L, Munisamy M, Thappa DM, Mohanan S. Dermoscopic findings of alopecia areata in dark skinned individuals: an analysis of 116 cases. Int J Trichology. 2014;6:156-159. 7. Sahu VK, Datta A, Sarkar T, Gayen T, Chatterjee G. Role of Trichoscopy in Evaluation of Alopecia Areata: A Study in a Ter- tiary Care Referral Centre in the Eastern India. Indian J Derma- tol. 2022;67:127-132. 8. Mahajan R, Daroach M, De D, Handa S. Clinico-dermoscopic features and treatment responsiveness in pediatric alopecia – Experience from a tertiary care pediatric dermatology clinic. In- dian J Dermatol 2020;65:483-8. 9. Kibar M, Aktan Ş, Lebe B, Bilgin M. Trichoscopic findings in alopecia areata and their relation to disease activity, severity and clinical subtype in Turkish patients. Australas J Dermatol. 2015;56:e1-6. 10. Saqib NU, Bhat YJ, Shah IH, et al. Assessment, reliability, and validity of trichoscopy in the evaluation of alopecia in women. Int J Womens Dermatol. 2021;7:458-465. 11. Nikam VV, Mehta HH. A nonrandomized study of trichoscopy patterns using nonpolarized (contact) and polarized (noncon- tact) dermatoscopy in hair and shaft disorders. Int J Trichology. 2014;6:54-62. 12. Chiramel MJ, Sharma VK, Khandpur S, Sreenivas V. Relevance of trichoscopy in the differential diagnosis of alopecia: A cross- sectional study from North India. Indian J Dermatol Venereol Leprol. 2016;82:651-658. 13. Neema S, Vashisht D, Yadav AK, Sinha A, Radhakrishnan S. Trichoscopy of Pressure-Induced Alopecia and Alopecia Areata: A Comparative Study. Int J Trichology. 2022;14:17-20. were retrieved, for a total of 107 instances. Similarly to other cicatricial alopecias, loss of follicular openings was the most prevalent finding (98% of cases). Additionally, perifollicular scales, white areas and honeycomb pigment network were generally the main features (prevalence of 78%, 69% and 60%, respectively), followed by erythema (57% of cases) and blue-grey dots in a targetoid pattern (42% of cases). Less common findings are showed in Table 1/Supplemental table. Of note, even though blue-grey dots are a common fea- ture in both LPP and discoid lupus erythematosus, targetoid pattern arrangement were indicative of the former according to the study by Chiramel et al [12]. Similarly, Ankad et al found blue-grey dots in a target distribution along with per- ifollicular scaling to be characteristic of LPP [57]. Impor- tantly, Abedini et al found perifollicular scaling and follicular plugs in both LPP and discoid lupus erythematosus, yet a more tubular appearance of perifollicular scaling and white color/smaller size of the plugs would be in favor of LPP [52]. Pseudopelade of Brocq A total of 13 cases of pseudopelade of Brocq with trichoscopic description were available from the literature (five case-con- trol studies [8, 10-12, 53] and one single case-report [61]). Loss of follicular ostia was a constant finding, while other common features included white dots (eccrine openings) and cicatricial white patches (both observed in 46% of cases) as well as and perifollicular scales (39% of cases). Less com- mon findings are reported in Table 1/Supplemental table. Hair Shaft Disorders Monilethrix Based on the findings coming from two case-control stud- ies [8,12], one case-series [62], and three single case-reports [63-65] (for a total of eight patients), beaded hair with equi- distant nodes and internodes, broken hairs, and a tendency for the hair to bend and break at the internodes (referred to as the “regularly bended ribbon sign”) are the main hair shaft abnormalities seen on trichoscopy in monilethrix. Woolly Hair Syndrome We found a single case report on trichoscopy of woolly hair syndrome that reported hair shafts featuring short wave cir- cles with a “crawling snake” appearance [66]. Conclusions Trichoscopy of hair/scalp diseases have been extensively studied in skin of color, showing a relevant usefulness in highlighting diagnostic clues imperceptible to the unaided eye. Yet, there is still limited evidence on some conditions despite they are commonly encountered in clinical practice. Additionally, apart from few analyses, most of the published 13 Review | Dermatol Pract Concept. 2023;13(4)S1:e2023310S 32. Verma I, Madke B, Singh AL, Choudhary S. A Clinico-trichological Study of Female Androgenetic Alopecia. Int J Trichology. 2021;13:9-16. 33. Bhamla SA, Dhurat RS, Saraogi PP. Is Trichoscopy a reliable tool to diagnose early female pattern hair loss?. Int J Trichol. 2013;5:121-125. 34. Ummiti A, Priya PS, Chandravathi PL, Kumar CS. Correlation of Trichoscopic Findings in Androgenetic Alopecia and the Disease Severity. Int J Trichology. 2019;11:118-122. 35. Kumar P, Pandhi D, Bhattacharya SN, Das S. Trichoscopy as a Diagnostic Tool for Tinea Capitis: A Prospective, Observational Study. Int J Trichology. 2020;12:68-74. 36. Brasileiro A, Campos S, Cabete J, Galhardas C, Lencastre A, Serrão V. Trichoscopy as an additional tool for the differential diagnosis of tinea capitis: a prospective clinical study. Br J Der- matol. 2016;175:208-209. 37. Hughes R, Chiaverini C, Bahadoran P, Lacour JP. Corkscrew hair: a new dermoscopic sign for diagnosis of tinea capitis in black children. Arch Dermatol. 2011;147:355-356. 38. Michelle V, Shilpa K, Leelavathy B, Asha GS. Telephone handle hair: A novel trichoscopic finding in black dot tinea capitis. Int J Trichol. 2019;11:181-183. 39. Pinheiro AM, Lobato LA, Varella TC. Dermoscopy findings in tinea capitis: case report and literature review. An Bras Derma- tol. 2012;87:313-314. 40. Sonthalia S, Jha AK, Gupta V, Lallas A. A tricky case of hair loss in a child: Trichoscopy saves the day. Indian Dermatol Online J. 2018;9:203-204. 41. Vazquez-Lopez F, Palacios-Garcia L, Argenziano G. Dermoscopic corkscrew hairs dissolve after successful therapy of Trichophyton violaceum tinea capitis: a case report. Australas J Dermatol. 2012;53:118-119. 42. Campos S, Brasileiro A, Galhardas C, et al. Follow-up of tinea capitis with trichoscopy: a prospective clinical study. J Eur Acad Dermatol Venereol. 2017;31:e478-e480. 43. Tosti A, Miteva M, Torres F, Vincenzi C, Romanelli P. Hair casts are a dermoscopic clue for the diagnosis of traction alopecia. Br J Dermatol. 2010;163:1353-1335. 44. Ankad BS, Naidu MV, Beergouder SL, Sujana L. Trichoscopy in trichotillomania: a useful diagnostic tool. Int J Trichology. 2014;6:160-163. 45. Malakar S, Mukherjee SS. Burnt matchstick sign ‐ A new trichoscopic finding in trichotillomania. Int J Trichol. 2017;9:44-46. 46. Thakur BK, Verma S, Raphael V, Khonglah Y. Extensive tonsure pattern trichotillomania-trichoscopy and histopathology aid to the diagnosis. Int J Trichol. 2013;5:196-198. 47. Lal M, Saini AK, Kumar R, Jain SK. Early-onset trichotillomania with habit disorder in a 5-year-old girl – With trichoscopic find- ings. Int J Trichol. 2020;12:241-242. 48. Pinto AC, Andrade TC, Brito FF, Silva GV, Cavalcante ML, Martelli AC. 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