A Clinico-trichological Study of Female Androgenetic Alopecia.

BACKGROUND: Female Androgenetic Alopecia (FAGA) is one of the most common cause of diffuse scalp hair loss in women. FAGA is insidious in onset, gradually progressive, non scarring alopecia. Trichoscopy is a newly developed non invasive, objective, bed side analytical method of hair imaging based on video dermoscopy of scalp. The objective of this study is to study the clinical features of female androgenetic alopecia, to study the trichoscopic features in patients of female androgenetic alopecia and to correlate the trichoscopic features according to clinical grade of female androgenetic alopecia.
METHODS: Study enrolled 50 females with FAGA and 50 normal females. FAGA cases were divided into subgroups according to sinclair scale. Laboratory investigations including hemoglobin level, triiodothyronine (T3), thyroxine (T4) thyroid stimulating hormone (TSH) and serum ferritin level were carried out in both cases and controls. After clinical diagnosis, trichoscopic examination was done and categorised using Diagnostic Criteria set by Rakowska A. et al and trichoscopic findings were coorelated with clinical grades.
RESULTS: >4 yellow dots in frontal area , >2:1 ratio of single hair units (frontal: occiput) & >3:1 ratio of hair with perifollicular discoloration (frontal: occiput) are mainly seen in late stages of FAGA i.e. grade 4 & 5 and >1.5:1 ratio of vellus hairs (frontal :occiput) in early stages i.e. grade 2 & 3 while lower mean hair thickness in frontal area & > 10% thin hairs in frontal area are seen in all stages of FAGA
Conclusion: Trichoscopy not only confirms the diagnosis by assessing the trichoscopic features of FAGA but also coorelates them with clinical severity. And as the age increases, grade of clinical severity increases. Not necessarily hemoglobin, thyroid and serum ferritin levels will be dearranged in FAGA cases. LIMITATION: The study is done on few number of patients. Further studies needs to be done to validate results. Copyright:

INTRODUCTION

Female androgenetic alopecia (FAGA) is one of the most common causes of diffuse scalp hair loss in women. It has a significant psychological and psychosocial impact in the affected patients. FAGA is insidious in onset, gradually progressive, nonscarring alopecia. It mostly involves the frontal-parietal area resulting in central thinning with intact frontal hairline, or broadening of central parting line. Sometimes, few cases have frontal-temporal or bitemporal involvement. Incidence of FAGA increases with age and has a reported a 12% incidence in females around 30 years and 30%–40% incidence in the female population between 60 and 69 years of age.[1]

With the help of adequate history, clinical examination using various global scales such as Ludwig Scale, Sinclair Scale, Modified Norwood Hamilton Scale, and Oslen Scale, it is possible to study the patterns of hair loss in FAGA according to grade of severity. Diagnosis of FAGA can be done by techniques such as trichogram (semi-invasive), scalp biopsy (invasive), and trichoscopy (noninvasive). However, trichogram is a poor diagnostic tool for FAGA and its grades,[2] and biopsy is an invasive procedure and has limitations in everyday practice. Trichoscopy is a newly developed noninvasive, objective, bed side analytical method of hair imaging based on video dermoscopy of the scalp.[2] It is a quick, easy, novel efficient noninvasive device which saves time and money and also increases clinician's diagnostic accuracy.[3] Hence, this office procedure may sometimes obviate the need for a skin biopsy for the diagnosis and for follow-up.

The objective of this study is to study the clinical features of FAGA, to study the trichoscopic features in patients of FAGA, and to correlate the trichoscopic features according to clinical grade of FAGA.

MATERIALS AND METHODS

Written informed consent was obtained from all patients and participants for voluntary participation and photographs and the protocol was approved by the Institutional Ethics Committee.

The present study enrolled 50 females with FAGA and 50 normal females, i.e., controls from August 2016 to September 2018 at the Department of Dermatology, Venerology and Leprosy, Jawaharlal Nehru Medical College, Sawangi, Wardha, Maharashtra, India. Cases eligible for study were of age range 18–69 years and diagnosed clinically with FAGA based on clinical feature of slowly progressive, nonscarring alopecia of the scalp, predominantly affecting the frontal-parietal area resulting in central thinning with intact frontal hairline, or broadening of central parting line and who were not on any treatment for scalp alopecia. Cases with abrupt onset of hair loss, suffering from any febrile infection or endocrine disorders or malignancy or any chronic illness, had any major surgery, were on any crash diet, on any drugs such as anti-thyroid drugs and anti-epileptics which result in hair loss and were pregnant or were in the postpartum period or lactating were excluded. Controls were healthy females with no complaint of hair loss with age range 18–69 years. FAGA cases were divided into subgroups based on stage of hair loss according to Sinclair scale 2–5 (Sinclair Grade 1 not included as it represents normal scalp).

Laboratory investigations, including hemoglobin level, triiodothyronine (T3), thyroxine (T4) thyroid-stimulating hormone (TSH), and serum ferritin level, were carried out in both cases and controls.

After clinical diagnosis, trichoscopic examination was done and photographs were taken using a videodermoscope (denolite equipped with software which analyses hair in magnified images and provided results in millimeters) at 58 × (covers an area of 9 mm2 similar to area covered by 70 × in study by Rakowska et al.), and 4 images were taken of each area of scalp i.e., frontal, occipital, and left temporal after parting of hairs with comb in both cases and controls. The trichoscopic findings of FAGA were categorized using the diagnostic criteria set by Rakowska et al. To the best of our knowledge, no study has correlated clinical severity of FAGA with trichoscopic diagnostic criteria laid down by Rakowska et al.

Statistical analysis

The Chi-square test and student's unpaired t-test were used for the statistical analysis. The softwares used were SPSS 22.0 version (IBM, Armonk, New York, USA) and GraphPad Prism 6.0 version (San Diego, California, USA). The level of statistical significance was considered as P < 0.05.

RESULTS

Demographic data

The mean age in FAGA cases was 41.20 ± 14.25 years (19–68 years) and in control group was 42.08 ± 15.10 years (20–68 years), and this difference was statistically not significant (P = 0.85), and therefore, these groups were compatible. The mean duration of hair fall in cases was 3.42 ± 2.23 years ranging from 0.5 to 8.5 years.

Clinical staging of androgenetic alopecia patients

The distribution of cases according to Sinclar scale, majority of cases 50% (25) were of Grade 2, followed by Grade 3, 4, and 5 with 22% (11), 18% (9), and 10% (5) of cases, respectively. The mean age in cases significantly increased with increasing grade of Sinclair grade, highest of Grade 5 (59.00 ± 8.12 years) and lowest of Grade 2 (36.00 ± 12.20 years, respectively, (P = 0.003) [Table 1, Figures 1a–5a].

Table 1

Distribution of cases according to Sinclair scale

Sinclair scale	Number of patients (%)
Grade 1* (normal scalp)	0 (0)
Grade 2	25 (50)
Grade 3	11 (22)
Grade 4	9 (18)
Grade 5	5 (10)
Total	50 (100)

* (normal scalp)

Figure 1

(a) Clinical picture of normal scalp (frontal area). (b) Trichoscopic picture of normal scalp (frontal area)

Figure 5

(a) Clinical picture of Sinclair Grade 5 (frontal area). (b) Trichoscopic picture of Sinclair grade 5 (frontal area)

(a) Clinical picture of Sinclair Grade 2 (frontal area). (b) Trichoscopic picture of Sinclair grade 2 (frontal area)

(a) Clinical picture of Sinclair Grade 3 (frontal area). (b) Trichoscopic picture of Sinclair grade 3 (frontal area)

(a) Clinical picture of Sinclair Grade 4 (frontal area). (b) Trichoscopic picture of Sinclair grade 4 (frontal area)

Laboratory results

Majority of cases 31 (62%) and controls 35 (70%) had normal Hb (Hb >12 gm%), 17 (34%) cases and 15 (30%) controls were found moderately anemic (Hb 10–11.99 gm%), and 2 (4%) cases were mildly anemic (Hb 7–9.99 gm%). Distribution of participants according to Hb level in both groups was statistically nonsignificant (P = 0.30). All cases and controls had normal T3, T4, and TSH level. Majority cases 45 (90%) and 46 (92%) controls were iron deficient (serum ferritin <70 ng/ml). Moreover, 5 (10%) cases and 4 (8%) controls had normal Sr. Ferritin. Distribution of participants according to Sr. Ferritin level in both groups was nonsignificant (P = 0.72). In FAGA cases and controls, the differences in the mean hemoglobin (12.15 ± 1.22 gm% and 12.37 ± 1.09 g %, respectively), mean triidothyronine T3 (0.98 ± 0.15 ng/ml and 1.03 ± 0.16 ng/ml, respectively), mean tetraiodothyronine T4 (8.52 ± 1.61 μg/dl, 8.40 ± 1.60 μg/dl, respectively), mean TSH (2.06 ± 0.98 μIU/ml, 2.18 ± 1.12 μIU/ml, respectively) and mean serum ferritin (42.63 ± 29.28 ng/ml, 43.76 ± 21.08 ng/ml, respectively) was found statistically nonsignificant (P > 0.05). Moreover, there was no significant difference (P > 0.05) between the Grade 2, Grade 3, Grade 4, and Grade 5 of Sinclair scale with respect to mean hemoglobin (Hb), triidothyronine (T3), tetraiodothyronine (T4), TSH, and Sr. ferritin.

Trichoscopic features

Yellow dots: The mean number of yellow dots was highly significant (P < 0.05) in frontal region (3.40 ± 2.71) compared to occipital area (1.18 ± 1.10) and left temporal (1.92 ± 1.61) in FAGA cases. The mean number of yellow dots in the present study in the control group (frontal-0.10 ± 0.36, occiput-0.02 ± 0.14, and left temporal-0.02 ± 0.14). In the present study, the mean number of yellow dots in all the three areas (frontal, occipital, and left temporal) was statistically significantly higher (P = 0.0001) in cases as compared to the control group.

In frontal area, the mean number of yellow dots in Grade 2, 3, 4, and 5 of Sinclair scale was 1.32, 3.54, 6.44, and 8.00, respectively. Similarly, in occiput area, the respective values were 0.40, 1.36, 2.22, and 2.80. In the left temporal area, the respective values were 1.00, 2.09, 3.22, and 3.80. The mean number of yellow dots was significantly increasing (P = 0.0001) with increasing grade, highest in frontal area, followed by left temporal and occipital area.

Mean hair thickness: In cases, smallest mean hair thickness was seen in the frontal region with 0.050 ± 0.005 mm in comparison to 0.055 ± 0.005 mm in the occipital region (P = 0.0001, S) and 0.052 ± 0.005 mm in the left temporal region. Mean hair thickness in the control group was 0.062 ± 0.004 mm in the frontal region, 0.059 ± 0.004 mm in occiput area, and 0.061 ± 0.004 mm in left temporal area. In all the three areas assessed, the mean hair thickness was found to be significantly less in frontal, occiput, and left temporal area in FAGA cases as compared to the control group.(P = 0.0001, S).

The mean hair thickness in frontal area in Grade 2, 3, 4, and 5 was 0.0551, 0.0498, 0.0453, and 0.0395 mm, respectively. In occipital area, the values were 0.0593, 0.0538, 0.0493, and 0.0473 mm, respectively. Similarly, in left temporal area, the respective values were 0.0573, 0.0519, 0.0471, and 0.0437 mm. Significant decrease in mean hair thickness with increasing Sinclair scale was observed, lowest in frontal area, followed by temporal and then occipital area (P = 0.0001) [Figures 1–5].

Thin (<0.03 mm), medium (0.03–0.05 mm), and thick hairs (>0.05 mm): In cases, the highest mean number of thin and medium hairs was observed in frontal area 10.56 ± 4.69 and 16.14 ± 1.89, respectively, compared to 7.40 ± 3.75 and 14.34 ± 1.69 in occipital area, respectively, and 8.84 ± 4.29 and 15.30 ± 1.37 in left temporal area, respectively. Mean number of thick hairs was 23.30 ± 5.82 in frontal area, 28.30 ± 2.21 in occipital area, and 25.62 ± 4.56 in left temporal area. In controls, in frontal area, the mean number of thin, medium, and thick hairs was 3.22 ± 1.40, 11.64 ± 2.73, and 35.15 ± 3.52, respectively ; in occiput area, the respective values were 3.36 ± 1.35, 13.32 ± 4.99, and 33.46 ± 6.34 ; in left temporal area, the respective values were 3.54 ± 1.55, 13.10 ± 5.28, and 33.50 ± 6.35.

In frontal area, the mean number of thin and medium hairs was significantly higher and mean number of thick hairs was significantly lower in cases as compared to controls (P = 0.0001). In occiput area, the mean number of thin hairs was significantly higher and mean number of thick hairs was significantly lower in cases as compared to controls (P = 0.0001), while the mean number of medium hairs was statistically nonsignificant (P = 0.17) in both groups. In temporal area, the mean number of thin and medium hairs was significantly higher (P = 0.0001; P = 0.005) and mean number of thick hairs was significantly lower (P = 0.0001) in cases as compared to controls.

In frontal area, the mean number of thin hair in Grade 2, 3, 4, and 5 was 6.60 ± 0.86, 11.36 ± 1.56, 15.77 ± 1.39, and 19.20 ± 0.83 respectively. Similarly, the mean number of medium hair was 15.28 ± 1.79, 16.00 ± 1.34, 17.55 ± 1.33, and 18.20 ± 1.48, respectively. The respective values of mean number of thick hair were 28.12 ± 1.78, 22.63 ± 1.20, 16.66 ± 1.00, and 12.60 ± 1.34. There was statistically significant (P = 0.0001) increase in mean number of thin hair and medium hair with increasing Sinclair grade and statistically significant (P = 0.0001) decrease in mean number of thick hair with increasing Sinclair scale.

In occipital area, the mean number of thin hair in Grade 2, 3, 4, and 5 was 4.56 ± 1.00, 7.27 ± 1.10, 11.00 ± 0.86 and 15.40 ± 1.67, respectively. Similarly, the mean number of medium hair was 15.56 ± 0.76, 14.36 ± 0.67, 12.88 ± 0.33, and 10.80 ± 0.83, respectively. The respective values of mean number of thick hair were 29.92 ± 0.86, 28.36 ± 0.67, 26.22 ± 1.09, and 23.80 ± 0.83.Significant increase in mean number of thin hair and significant decrease in mean number of medium and thick hair with increasing Sinclair scale.(P = 0.0001).

Hair units: In cases, the mean number of single hair units was found to be highest in frontal area (30.90 ± 6.35) followed by left temporal area (23.78 ± 3.30) and occiput area (15.30 ± 2.21), and this was significantly more (P = 0.0001) than controls which had mean number of single hair unit 9.88 ± 3.39 in frontal area, 13.28 ± 4.36 in left temporal area, and 7.96 ± 3.25 in occiput area. The mean number of two hairs units in cases was lowest in frontal area (15.82 ± 4.52) followed by left temporal area (22.06 ± 2.46) and occiput area (28.50 ± 1.41) which was significantly lower as compared to the mean number of 29.40 ± 3.60 in frontal area, 30.26 ± 4.20 in left temporal area and 30.42 ± 4.21 in occiput area of the controls. Furthermore, in cases, the mean number of three hair units was found to be lowest in frontal area (3.38 ± 1.92) followed by left temporal area (4.18 ± 2.40) and occiput area (6.14 ± 3.05), and this was significantly lower (P = 0.0001) than the controls which had the mean number of three hair unit 10.70 ± 2.68 in frontal area, 6.80 ± 1.62 in left temporal area, and 11.64 ± 3.98 in occiput area. The mean ratio of single hair units (frontal: Occiput) area was statistically significantly (P = 0.0001) higher in cases (1.99 ± 0.19) as compared to controls (1.43 ± 0.75).

In frontal area, the mean number of single hair unit in Grade 2, 3, 4, and 5 was 25.48 ± 2.27, 32.36 ± 1.80, 38.33 ± 1.41, and 41.40 ± 0.54, respectively. Similarly, the mean number of two hair units was 19.52 ± 1.85, 15.09 ± 1.70, 10.55 ± 1.50, and 8.40 ± 0.54, respectively. The respective values of mean number of three hair units were 5.00 ± 0.64, 3.00 ± 0.77, 1.11 ± 0.33, and 0.20 ± 0.44. Significant increase in mean number of single hair unit and statistically significant decrease in mean number of two hair and three hair units with increasing Sinclair scale (P = 0.0001).

In occiput area, the mean number of single hair units in Grade 2, 3, 4, and 5 was 13.52 ± 1.04, 15.91 ± 0.83, 17.77 ± 0.83, and 18.40 ± 1.94, respectively. Similarly, the mean number of two hair units was 27.80 ± 1.32, 28.81 ± 1.07, 29.11 ± 1.26, and 30.20 ± 0.44, respectively. The respective values of mean number of three hair units were 8.72 ± 1.13, 5.27 ± 0.78, 3.11 ± 0.92. and 0.60 ± 0.54. Significant increase in mean number of single and two hair units and significant decrease in mean number of three hair units with increasing Sinclair scale.(P = 0.0001; P = 0.001; P = 0.0001).

The ratio of single hair units (frontal: Occiput) in Grade 2, 3, 4, and 5 was 1.87, 2.03, 2.16, and 2.18, respectively, and significant increase in ratio of single hair units (frontal: Occiput) with increasing scale (P = 0.0001).

Vellus hairs: In cases, highest mean number of vellus hairs was observed in frontal area with 10.56 ± 4.69 compared to 7.40 ± 3.75 in occiput area and 8.84 ± 4.29 in left temporal area. In controls, mean number of vellus hairs was 3.22 ± 1.40 in frontal area 3.36 ± 1.35 in occiput area and 3.54 ± 1.55 in temporal area. In all the three areas assessed, the mean number of vellus hairs was found to be significantly more in frontal, occiput, and left temporal area, in cases as compared to controls (P = 0.0001).

The mean number of vellus hairs in frontal area in Grade 2, 3, 4, and 5 was 6.60, 11.36, 15.77, and 19.20, respectively. In occipital area, the values were 4.56, 7.27, 11.00, and 15.40, respectively. Similarly, in left temporal area, the respective values were 5.36, 9.36, 13.55, and 17.20. Significant (P = 0.0001) increase in mean number of vellus hairs with increasing Sinclair grade in frontal, occiput, and temporal area.

Hair follicles with perifollicular discoloration: In cases, the highest mean number of hair follicles with perifollicular discoloration was observed in frontal area with 16.90 ± 2.43 compared 5.54 ± 1.88 in occipital area and 10.58 ± 2.19 in left temporal area. In controls, the highest mean number of hair follicles with perifollicular discoloration was 9.82 ± 2.28 in frontal, 7.22 ± 1.14 in occiput, and 7.50 ± 1.69 in left temporal area. In all the three areas assessed, the values were found to be significantly more in frontal and temporal area and significantly less in occiput area in cases as compared to controls (P = 0.0001, S). The mean ratio of hair follicles with perifollicular discoloration (frontal: Occiput) was significantly more (P = 0.0001) in cases (3.24 ± 1.00) as compared to controls (1.36 ± 0.28).

The mean number of hairs with perifollicular discoloration in frontal area in Grade 2, 3, 4, and 5 was 19.00 ± 0.95, 16.09 ± 0.83, 14.00 ± 0.86, and 13.40 ± 0.54, respectively. In occipital area, the values were 7.00 ± 0.86, 4.90 ± 0.83, 4.00 ± 1.58, and 2.40 ± 0.54, respectively. Similarly, in left temporal area, the respective values were 12.04 ± 1.64, 10.63 ± 1.12, 8.11 ± 0.78, and 7.60 ± 0.54, respectively. Significant decrease in mean number of hairs with perifollicular discoloration with increasing Sinclair grade in frontal, occiput, and left temporal area (P = 0.0001). The ratio of hairs with perifollicular discoloration in Grade 2, 3, 4, and 5 was 2.73, 3.03, 3.22, and 4.78, respectively. There is statistically significant (P = 0.0001) increase in ratio of hairs with perifollicular discoloration (Frontal: Occiput) with increasing Sinclair scale.

FAGA cases and trichoscopic criteria laid down by Rakowska et al.: The criteria of lower mean hair thickness in frontal area was seen in all 50 (100%) cases followed by >10% thin hairs in frontal area in 48 (96%), >2:1 single hair units (frontal: Occiput) in 23 (46%), >3:1 hair follicles with perifollicular discoloration (frontal: Occiput) in 19 (38%), >4 yellow dots in frontal area in 16 (32%), and >1.5:1 vellus hair (frontal: Occiput) in 15 (30%) cases, respectively [Table 2].

Table 2

Number of cases fulfilling each female androgenetic alopecia criteria laid down by Raowska et al.

	Criterias	Cases (%)
Major criteria	>4 yellow dots in frontal area	16 (32)
	Lower mean hair thickness in frontal area	50 (100)
	>10% thin hairs in frontal area	48 (96)
Minor criteria	>2:1 single hair units, frontal: occiput	23 (46)
	>1.5:1 vellus hair, frontal: occiput	15 (30)
	>3:1 hair follicles with perifollicular discoloration, frontal: occiput	19 (38)

Ninety-six percent (48) cases fulfilled two major criteria, 2% (1) fulfilled 1 major and two minor criteria, i. e., 98% (49) cases out of 100%(50) cases fulfilled trichoscopic diagnostic criteria of FAGA laid down by Raowska et al. (2) >4 yellow dots in frontal area was present in 0% (0/25), 18.18% (2/11), 100% (9/9), and 100% (5/5) cases of Grade 2, 3, 4, and 5, respectively. Lower mean hair thickness in frontal area was seen in 100% cases of Grade 2, 3, 4, and 5. >10% thin hairs in frontal area in 92% (23/25) of Grade 2 and 100% cases of Grade 3, 4, and 5 respectively. >2:1 single hair units (frontal : Occiput) was present in 20%(5/25), 45.45%(5/11), 100%(9/9), and 100%(5/5) cases of Grade 2, 3, 4, and 5, respectively. >1.5:1 vellus hair (frontal: Occiput) in 32% (8/25), 63.63% (7/11), 0% (0), and 0% (0) cases of Grade 2, 3, 4, and 5, respectively. >3:1 hair follicles with perifollicular discoloration (frontal: Occiput) was seen in 4% (1/25), 54.54% (6/11), 77.77% (7/9), and 80% (4/5) cases in Grade 2, 3, 4, and 5, respectively [Table 3].

Table 3

Percentage of cases fulfilling each female androgenetic alopecia criteria according to Sinclair scale

	FAGA criterias	Grade 2 (n=25), n (%)	Grade 3 (n=11), n (%)	Grade 4 (n=9), n (%)	Grade 5 (n=5), n (%)	x 2	P
Major criteria	>4 yellow dots in frontal area	0 (0)	2 (18.18)	9 (100)	5 (100)	42.48	0.0001 (S)
	Lower mean hair thickness in frontal area	25 (100)	11 (100)	9 (100)	5 (100)	-	-
	>10%thin hairs in frontal area	23 (92)	11 (100)	9 (100)	5 (100)	2.08	0.05 (NS)
Minor criteria	>2:1 single hair units, frontal: occiput	5 (20)	5 (45.45)	9 (100)	5 (100)	43.41	0.0001 (S)
	>1.5:1 vellus hair, frontal : occiput	8 (32)	7 (63.63)	0 (0)	0 (0)	11.97	0.007 (S)
	>3:1 hair follicles with perifollicular discoloration, frontal: occiput	1 (4)	6 (54.54)	7 (77.77)	4 (80)	27.18	0.0001 (S)

FAGA: Female Androgenetic Alopecia, S: Significant, NS: Not significant

DISCUSSION

The present study was conducted in the Department of Dermatology, Acharya Vinoba Bhave Rural Hospital, Jawaharlal Nehru Medical College Sawangi (Meghe), Wardha. This study was aimed at studying clinical pattern, grade of severity, and trichoscopic features in patients of FAGA along with the correlation of the trichoscopic features with clinical grade of FAGA.

A total of 100 subjects, i. e., 50 cases fulfilling the inclusion and exclusion criteria and 50 normal controls were enrolled into this observational case–control study. All the subjects, both cases and controls were clinically and trichoscopically assessed.

The distribution of cases according to Sinclar scale, majority of cases 50% (25) were of grade 2, followed by Grade 3, 4, and 5 with 22% (11), 18% (9), and 10% (5) of cases, respectively. The findings of the present study were in concordance with Tawfik et al.[4] who also found majority number of cases, i.e., 44 of Grade 2 followed by Grade 3, 4, and 5 with 25, 5, and 3 cases, respectively.

The distribution of cases according to individual trichoscopic criteria given by Rakowska et al.[2] Maximum 50 (100%) cases showed lower mean hair thickness in frontal area and 48 (96%) had >10% thin hairs in the frontal region. Twenty-three (46%) cases had >2:1 ratio of single hair units (frontal: Occiput), 19 (38%) fulfilled >3:1 ratio of hair follicles with perifollicular discoloration (frontal: Occiput), 16 (32%) fulfilled >4 yellow dots in frontal area, and 15 (30%) fulfilled >1.5:1 ratio of vellus hair (frontal: Occiput). As no direct studies were available which used FAGA trichoscopic criteria laid down by Rakowska et al.,[2] therefore studies fulfilling trichoscopic features of FAGA cases were compared.

Hu et al.[5] in their study found that 100% (200/200) FAGA cases had hair shaft thickness heterogeneity, 44.5% (89/200) cases had Brown peripilar sign, i. e., perifollicular discoloration, and 24% (48/200) had yellow dots. Kiber et al.[6] in their study found that 100% (134/134) FAGA cases had hair diameter diversity, 64.9% (87/134) had perifollicular discoloration, and 18.7% (25/134) had yellow dots Tawfik et al.[4] in their study found that 97.4% (77/79) had hair diameter diversity and predominant single hair follicle, 32.9% (26/79) had brown peripilar sign, and 15.2% (12/79) had yellow dots. Inui et al.[7] in their study found that 100% (10/10) cases had hair diameter diversity, 20% (2/10) had peripilar sign or perifollicular discoloration, and 10% (1/10) had yellow dots. The above-mentioned studies focused on the trichoscopic features in FAGA rather than trichoscopic diagnostic criteria. To the best of our knowledge, ours is the first study to assess incidence of cases complying with individual trichoscopic criteria for FAGA.

Less than four yellow dots in frontal area, >2:1 ratio of single hair units (frontal: Occiput), and >3:1 ratio of hair with perifollicular discoloration (frontal: Occiput) are mainly seen in late stages of FAGA, i.e., Grade 4 and 5 and >1.5:1 ratio of vellus hairs (frontal : occiput) in early stages, i.e., Grade 2 and 3 while lower mean hair thickness in frontal area and >10% thin hairs in frontal area are seen in all stages of FAGA. To the best of our knowledge, ours is the first study to correlate trichoscopic criteria laid down by Rakowska et al.[2] with FAGA cases of variable clinical severity.

CONCLUSION

Trichoscopy being a noninvasive bedside diagnostic tool is useful in day to day clinical practice and is a safe, faster way to diagnose various scalp disorders including FAGA. It not only confirms the diagnosis by assessing the trichoscopic features of FAGA but also correlates them with clinical severity. Moreover, as the age increases, grade of clinical severity increases. Not necessarily hemoglobin, thyroid and serum ferritin levels will be dearranged in FAGA cases.

Recommendation

Routinely in day to day practice trichoscopy should be done for diagnostic purpose in FAGA and also to assess the severity of the disease. It can further be used in monitoring efficacy of various modalities in FAGA.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.