The role of scalp dermoscopy in the diagnosis of

alopecia areata incognita

Antonella Tosti, MD,a David Whiting, MD,b Matilde Iorizzo, MD,a Massimiliano Pazzaglia, MD,a
Cosimo Misciali, MD,a Colombina Vincenzi, MD,a and Giuseppe Micali, MDc
Bologna and Catania, Italy; and Dallas, Texas

Background: Alopecia areata incognita is a variety of alopecia areata characterized by acute diffuse
shedding of telogen hairs without typical patches.

Objective: We sought to report the clinical, pathological, and dermoscopic features of alopecia areata
incognita.

Methods: Seventy patients with alopecia areata incognita were evaluated clinically and with video-
dermoscopy during the period of 2002 to 2006. Pathology was performed in 50 patients.

Results: The presence of numerous, diffuse, round or polycyclic yellow dots, different in size and uniform
in color and distribution, was a typical dermoscopic feature in all patients. Short regrowing hairs were also
present. The dermoscopic findings were correlated and supported by the histologic features of the scalp
specimens.

Limitations: Scalp biopsy was performed only in 50 patients.

Conclusion: Videodermoscopy is a first step before performing a biopsy. It can help the clinician to find
the right place to take the sample, but can also avoid unnecessary biopsies. ( J Am Acad Dermatol
2008;59:64-7.)

A lopecia areata incognita (AAI), first described
by Rebora1 in 1987, is a variety of alopecia
areata characterized by acute diffuse shed-
ding of telogen hairs in the absence of typical
patches. Clinically it has the features of telogen
effluvium, but it could also be misdiagnosed as
alopecia androgenetica. This is the reason why the
scalp biopsy is often required to confirm the clinical
diagnosis. Prevalence of AAI is unknown, but the
disease seems to be more common in women.
Recently it has been shown how dermoscopy of
the scalp could improve diagnostic skills in hair
disorders.2,3
From the Department of Dermatology, University of Bolognaa;
Baylor Hair Research and Treatment Center, Dallasb; and
Department of Dermatology, University of Catania.c
Funding sources: None.
Conflicts of interest: None declared.
Accepted for publication March 21, 2008.
Reprints not available from the authors.
Correspondence to: Antonella Tosti, MD, Department of
Dermatology, University of Bologna, Via Massarenti 1e40138
Bologna, Italy. E-mail: antonella.tosti@unibo.it.
Published online April 28, 2008.
0190-9622/$34.00
ª 2008 by the American Academy of Dermatology, Inc.
doi:10.1016/j.jaad.2008.03.031
In typical alopecia areata, dermoscopy allows
evaluation of disease activity by detecting dystrophic
hairs, exclamation point hairs, and cadaverized hair.
The presence of yellow dots within the follicular
ostium of both empty and hair-bearing follicles is a
characteristic feature that is helpful in the diagnosis.
We report 70 patients with AAI diagnosed thanks
to the presence of the yellow dot pattern at video-
dermoscopy. The diagnosis was confirmed by his-
topathology in 50 cases.
CASE REPORTS
All patients, 58 female and 12 male (mean age
33.37 years), presented with severe and diffuse hair
loss, lasting from 2 weeks to 2 months before our
examination. The patients were seen at the Depart-
ment of Dermatology of the Universities of Bologna
(50 patients) and Catania (20 patients), Italy, during
the period of 2002 to 2006. All patients had severe
hair thinning, often with a sudden loss of more than
60% of their scalp hairs. Clinical examination re-
vealed diffuse hair thinning in all cases (Fig 1). In 23
patients the hair thinning was more severe on the
androgen-dependent scalp. Examination of skin,
mucosae, and nails revealed normal findings in all
patients. None of our patients had history of

64
J AM ACAD DERMATOL
VOLUME 59, NUMBER 1
Fig 1. A 36-year-old woman with severe and diffuse hair
loss at first visit.
Fig 2. Pull test showing telogen roots at different stage of
maturation.
psychologic stress, systemic diseases, nutritional
deficiency, or taking drugs capable of causing a
telogen effluvium. No patients reported scalp pain or
burning sensation (trichodynia). Laboratory examina-
tions showed positive antibodies to thyroglobulin and
thyroperoxidase, but normal thyroid function, in 15
patients; ferritin levels were below 70 ng/mL (15-62) in
32 patients, but iron levels were normal in all cases.
The pull test was strongly positive in all patients
with easy extraction of tufts of hair. Microscopic
examination of the extracted hairs revealed telogen
roots at different degrees of maturation with a high
prevalence of early telogen roots (Fig 2).
The scalp examination was performed by com-
puterized polarized-light videomicroscopy (FotoFin-
derdermoscope, Teachscreen Software, Bad Birnbach,
Germany). Lenses with 320 to 370 factors of magni-
fication, at 310 increments, were used for viewing.
Probed images were digitalized and displayed on a
Tosti et al 65
Fig 3. A, Scalp dermoscopy showing yellow dots and
numerous short regrowing hairs. B, Regrowing hairs are
more evident. (A and B, Original magnification: A, 320; B,
340.)
high-resolution monitor in real time and stored for
future use.
A 4-mm punch biopsy specimen for horizontal
sections and a 3-mm biopsy specimen for vertical
sections were taken in the 50 patients who signed a
written informed consent. The biopsy specimens
were taken from a scalp area selected with the aid of
the videodermoscope. Biopsy specimens were fixed
in 10% formalin, paraffin-embedded, and routinely
processed. Horizontal and vertical sections were cut
and stained with hematoxylin-eosin.
RESULTS
The dermoscopic features of the scalp were sim-
ilar in all patients. Using the epiluminescent mode of
operation, the scalp showed many diffuse, round or
polycyclic yellow dots, which varied in size and were
uniform in color and distribution. The yellow dots
were evident within the follicular ostium of both
empty and hair-bearing follicles and affected about
70% of the follicles. A large number of regrowing,
tapered, terminal hairs (2-4 mm long) was also
evident in the entire scalp (Fig 3). Dystrophic hairs,
exclamation point hairs, and cadaverized hair were
present in 20 patients.
The biopsies were performed in a scalp area of
hair loss with numerous yellow dots selected by the
66 Tosti et al J AM ACAD DERMATOL
JULY 2008

Table I. Alopecia areata incognita hair counts and

histopathologic findings
Total biopsied cases 50
Male 1
Female 49
Male:female ratio 0.02:1
Mean age male, y 15
Mean age female, y 37.2 6 10.6*
Terminal hair follicles 17.8 6 9.8
Vellus hair follicles 10.5 6 7.6
Total hair follicles 28.7 6 14.1
Follicular units 14.4 6 4.1
Follicular stelae 9.9 6 6.2
Terminal:vellus ratio 1.6:1
Anagen:telogen ratio 86.5:13.5
Telogen germinal units 2.9 6 2.1
Mild peribulbar and intrabulbar 0.56 6 0.54 Fig 4. Horizontal section at mid dermis level showing
lymphocytic infiltrate peribulbar lymphocytic infiltrate around anagen follicles.
Infundibular dilatation 25 (cases) (Hematoxylin-eosin stain; original magnification: 38.)

*Mean 6 SD.

videodermoscope. The histologic features of the

scalp specimens were similar in all patients and
correlated to the videodermoscopy findings.
Vertical sections showed several small infundibu-
lar dilatations of the follicle, lined of stratified squa-
mous epithelium and cornified cells within their
cavities. The granular zone was still present. Bacteria
and yeasts were often observed.
The counts obtained by horizontal sections (Table
I) demonstrated an increased number of vellus hair
follicles and telogen follicles. Follicular streamers
often contained lymphocytes. Telogen germinal
units were present. Subtle peribulbar lymphocytic
infiltrate was often seen only around vellus anagen
Fig 5. Horizontal section at hypodermis level showing
hair follicles in the papillary and mid dermis (Figs
mild peribulbar lymphocytic infiltrate. (Hematoxylin-eosin
4 and 5). stain; original magnification: 38.)

DISCUSSION
AAI is a variety of alopecia areata that mimics
telogen effluvium. AAI has an acute onset and
produces diffuse and severe hair thinning in a few
months. Women are most commonly affected. Clin-
ical history is negative for events known as possible
causes of telogen effluvium.
From a pathological point of view, AAI should be
suspected when high percentages of telogen hairs
and/or miniaturized hairs are present even in the
absence of a peribulbar lymphocytic infiltrate. The
presence of a subtle lymphocytic infiltrate around
miniaturized hairs in the papillary dermis strongly
suggests the diagnosis.
According to Rebora,1 AAI occurs when alopecia
areata affects those people with high percentages of
telogen hairs on the scalp.
In these cases, early anagen VI hairs (the ones
with the highest mitotic rate and, therefore, vulner-
able to damage by a noxious event) are scarce and
then only isolated anagen hairs can be damaged. A
diffuse hair loss rather than patches will be the result.
Sato-Kawamura et al4 reported in a recent study
a new type of diffuse hair loss with a favorable
prognosis. The authors studied 9 female patients
with acute and diffuse hair loss that they named
‘‘acute diffuse and total alopecia of the female scalp
(ADTAFS).’’ Eight of the 9 patients had a cosmetically
acceptable hair regrowth after steroid administra-
tion. The histology of the lesions was indistinguish-
able from that of alopecia areata except for a
remarkable eosinophilic infiltrate. In our cases, how-
ever, we did not find eosinophils at pathology.
J AM ACAD DERMATOL
VOLUME 59, NUMBER 1
Fig 6. Vertical section: several small infundibular dilata-
tions of follicle, lined by stratified squamous epithelium
and containing cornified cells. (Hematoxylin-eosin stain;
original magnification: 310.)
The presence of numerous yellow dots and short
regrowing hairs was a constant feature easily ob-
served at videodermoscopy at all magnifications
(320-370).
The yellow dots are a specific feature of alopecia
areata occurring in 95% of patients in all stages of the
disease. The only other condition where they may
occasionally be seen is the bald scalp of men with
advanced androgenetic alopecia, but we never
Tosti et al 67
found this sign in female pattern hair loss, telogen
effluvium, or scarring alopecia.3,5
Our pathological data indicate that the yellow
dots correspond to degenerated follicular keratino-
cytes and sebum contained within the dilated ostium
of nanogen and miniaturized hair follicles (Fig 6).
The videodermoscopy findings were correlated
and supported by the histologic features of the scalp
specimens.
Our study shows how videodermoscopy could be
useful in helping the clinician in performing the
diagnosis of AAI.
Videodermoscopy is a first step before performing
a biopsy and can help the clinician to find the right
site for it, but can also avoid unnecessary biopsies.
REFERENCES
1. Rebora A. Alopecia areata incognita: a hypothesis. Dermato-
logica 1987;174:214-8.
2. Lacarrubba F, Dall’Oglio F, Rita Nasca M, Micali G. Video-
dermatoscopy enhances diagnostic capability in some forms of
hair loss. Am J Clin Dermatol 2004;5:205-8.
3. Ross EK, Vincenzi C, Tosti A. Videodermoscopy in the evaluation
of hair and scalp disorders. J Am Acad Dermatol 2006;55:799-806.
4. Sato-Kawamura M, Aiba S, Tagami H. Acute diffuse and total alopecia
of the female scalp: a new subtype of diffuse alopecia areata that
has a favorable prognosis. Dermatology 2002;205:367-73.
5. Tosti A. Dermoscopy of hair and scalp disorders. London:
Informa Healthcare; 2007.