Trichoscopy of Non-Cicatricial Alopecia.

MAIN FINDINGS

Alopecia areata
Micro-eclamation mark hairs, tapered hairs, black dots, yellow dots, upright regrowing hairs, pigtail regrowing hairs, vellus hairs and broken hairs.

Androgenetic alopecia
Increased proportion of thin and vellus hairs, hair shaft thickness heterogeneity, perifollicular discoloration (hiperpigmentation), and presence of variable number of yellow dots

Telogen effluvium
Upright regrowing hairs and predominance of hair follicle openings with only one emerging hair shaft.

Psoriasis 
Silver-white scales, red dots and globules, twisted red loops, and glomerular vessels.

Seborrheic dermatitis
Yellowish scales, arborizing vessels and atypical red vessels.

Tinea capitis
Comma hairs, corckscrew hairs, broken hairs, damaged hairs, black dots, zigzag hairs and interrupted hairs.


ALGORITHM

- Yellow dots: Numerous: Alopecia areata (AA)
                      A few:  Other alopecia: hypotrichosis congenita, Kerion celsie..
                                  Hair diameter diversity (≥20%), perifollicular pigmentation ⁄peripilar sign: AGA

- Black dots and/or broken hairs:  Tapering hairs (exclamation mark hairs): AA
                                                      Short vellus hairs: AA
                                                      Curled hairs: Trichotillomania                                               
                                                      No findings: AA and/or trichotillomania

                                                      Others: Tinea capitis, chemotherapy - induced alopecia, after laser depilation or trichogram.
- Others:  Perifollicular scale/sebum: Seborrheic alopecia
                Short vellus hairs, many: AA remitting
                Comma hairs: tinea capitis
                No findings: Telogen effluvium
              

UpToDate: Management of SJS/TEN.

• Early recognition and immediate withdrawal of any potentially causative agents are critical first steps in the management of SJS/TEN.
• Multiple specialists should be involved in the care of patients with SJS/TEN when possible, including experts in critical care, plastic surgery, dermatology, infectious disease, ophthalmology, and nutrition.
• For patients with extensive desquamation, we suggest transfer to a burn unit if possible (Grade 2C).
• The optimal approach to wound care has not been determined. Success has been reported with both repeated debridement of exfoliating skin, and "anti-shear" wound care, in which the necrotic skin is left in place to act as a biologic dressing.
• Sepsis is the major cause of death. Sterile handling, infection control measures, topical antibiotic agents, and surveillance cultures of possible sites of superinfection are important components of prevention. Prophylactic systemic antibiotics are not utilized by the majority of burn centers, although antimicrobials should be administered at the first sign of infection, and choice of agent should be guided by specific culture data.
• Supportive care should be the primary focus of management of SJS/TEN. Beyond this, there is insufficient evidence to establish the benefit of any adjunctive therapies (table 1). Systemic glucocorticoids and intravenous gammaglobulin (IVIG) are commonly used at many centers, although not all. Our approach is described below.
• For children (aged 16 years and younger) with SJS, we suggest NOT administering glucocorticoids (Grade 2C).
• For adult patients with mild to moderate SJS, in whom the diagnosis has been made within a few days of symptom onset, we suggest high dose, short-term systemic glucocorticoids (Grade 2C). We typically use prednisone, 2 mg per kg daily or an equivalent amount of prednisolone or methylprednisolone, initiated as soon as possible after diagnosis. Glucocorticoids are discontinued after four to seven days or at the first sign of infection.
• For pediatric and adult patients with severe SJS and TEN, we suggest IVIG (Grade 2C). We administer a dose of 1 gram/kg daily for three consecutive days. We do not administer glucocorticoids, due to concern about increasing the risk of sepsis, or employ plasmapheresis in the treatment of TEN.
• The mortality of SJS is 1 to 3 percent, while the mortality of TEN ranges from 25 to 35 percent. Predictors of mortality include older age at onset and greater extent of skin involvement. Long-term sequelae of the skin and eyes are common among survivors.

For more information:

Stevens-Johnson syndrome and toxic epidermal necrolysis: Management, prognosis, and long-term sequelae
Whitney A High, MD Milton H Nirken, MD	UpToDate

Hair Transplantation and Cicatricial Alopecia.

Unger W, Unger R & Wesley C. The surgical treatment of cicatricial alopecia. Dermatologic Therapy 2008: 21: 295–311.

Do not miss this book: Unger WP, Shapiro R. Hair Transplantation, 4th edn. New York: Marcel Dekker, 2004.


Availability of donor hair 
The long-term donor-recipient area ratio – that is, the ratio of “permanent” donor hair relative to the ultimate size of present, as well as future areas of alopecia that might develop – is perhaps the most important factor to consider. In many patients, however, the ratio is inadequate to satisfactorily treat both the current and possibly future areas of cicatricial alopecia, in addition to addressing surrounding areas that are likely to develop male pattern baldness (MPB) or female pattern hair loss (FPHL). Furthermore, if donor hair is taken from an area that is eventually destined to lose its hair secondary to MPB/FPHL or some of the diseases that cause unstable cicatricial alopecias (UCAs), it will also be lost in the recipient area.
Given the difficulty in accurately estimating this ratio, excision is generally preferable to hair transplanting. This is especially true with respect to larger alopecic regions in younger individuals, while older patients with small areas of scarring may often be appropriately treated with hair transplantation.

Scalp laxity
The less scalp laxity, the more preferable hair transplantation is to excision.

Patient’s healing characteristics 
Hypertrophic or keloid scars, less or greater than average scalp laxity (especially those with Elhers–Danlos syndrome), and individuals who have experienced inexplicable excessive postoperative bleeding in the past favor a decision to utilize hair transplantation as opposed to excision.

Vascular circulation
Grafts in the center of a large scar are most distant from a good blood supply. To test the blood supply of a large area, it is recommended that one first anesthetize a portion of the area with a 2% lidocaine solution without epinephrine. Then a 19-G needle can be used to make several incisions. There should be evidence of bleeding when this is done. If not, the area would be best treated with surgical excision.

Area of involvement
Hair transplantation is preferable in sites such as the hairline and eyebrow. If excision is employed, ideally the surgeon should use a “trichophytic” closure in which a narrow zone of the epidermis of one flap of the wound is removed and the wound is closed in such a way as to result in hair which grows through the scar itself.