TECHNIQUE FOR TOTS Pediatric Dermatology Vol. 25 No. 6 652–654, 2008
Videodermoscopy: A Useful Tool for Diagnosing Congenital Triangular Alopecia Matilde Iorizzo, M.D.,* Massimiliano Pazzaglia, M.D.,* Michela Starace, M.D.,* Giuseppe Militello, M.D., and Antonella Tosti, M.D.* *Department of Dermatology, University of Bologna, Bologna, Italy, Department of Dermatology, Columbia University, New York, New York, USA
Abstract: Congenital triangular alopecia, despite its name, usually presents in children between 3 and 6 years of age, but adult patients have been reported. It is not uncommon for triangular alopecia to be misdiagnosed as alopecia areata and treated for such. This is especially true when a lesion of triangular alopecia presents in an area of the scalp other than the typical fronto-temporal hairline or later in adulthood. Videodermoscopy may serve as a useful tool to perform the right diagnosis as it can highlight signs not seen by the unaided eye and may be able to spare the patient from a biopsy.
INTRODUCTION Congenital triangular alopecia, despite its name, usually presents in children between 3 and 6 years of age, but adult patients have been reported (1,2). It presents as a nonscarring triangular or lancet shaped patch of alopecia involving the fronto-temporal hairline and characterized by vellus hairs. Lesions can be unilateral or bilateral. It can be associated with other skin or systemic abnormalities (3–5). Happle (6) has recently suggested that this disorder may be inherited as a para-dominant trait where a postzygotic loss of the wildtype allele in a heterozygotic state leads to the disease. This disorder is marked histopathologically by a normal number of follicular units, the majority being of the vellus and indeterminate type (7). As far as we know, the etiology of the disorder is unknown and there is no specific treatment. The differential diagnosis of such focal lesions
includes alopecia areata, trichotillomania, traction alopecia, and, in some cases, even a focal scarring disorder, such as aplasia cutis congenita. It is not uncommon for congenital triangular alopecia to be misdiagnosed as alopecia areata and treated for such. This is especially true when a lesion presents in an area of the scalp other than the typical fronto-temporal hairline or later in adulthood. In these cases, we believe that video-dermoscopy might be a useful tool to help the clinician in the diagnosis thus sparing the patient with unnecessary biopsies or treatments. METHODS Figure 1 shows the typical clinical presentation of a patient with congenital triangular alopecia. The scalp examination was performed by a computerized polarized-light videomicroscopy (FotoFinderdermoscope; Teachscreen Software, Bad Birnbach, Germany). Lenses
Address correspondence to Matilde Iorizzo, M.D., Department of Dermatology, University of Bologna, Via Massarenti 1, 40138 Bologna, Italy, or e-mail:
[email protected]. DOI: 10.1111/j.1525-1470.2008.00811.x
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2008 The Authors. Journal compilation 2008 Wiley Periodicals, Inc.
Iorizzo et al: Videodermoscopy: A Useful Tool
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Figure 1. Typical patient with congenital triangular alopecia. Figure 3. Typical dermoscopic image of alopecia areata.
with 20· to 70· factors of magnification, at 10· increments, were used for viewing. Probed images were digitalized and displayed on a high-resolution monitor in real time and stored for later use. Alcohol was the interface solution (Kodan spray; Schulke and Mayr, Vienna, Austria). The videodermoscope revealed normal follicular openings with vellus hairs surrounded by normal terminal hair (Fig. 2). For comparison, a dermoscopic image of a patient with a diagnosis of alopecia areata is shown in Fig. 3. In this case, dermoscopy allows evaluation of disease 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. DISCUSSION Congenital triangular alopecia is a common disorder, even more than reported. We believe that patients are not
bothered by their illness and therefore do not present to a dermatologist or the disorder is misdiagnosed. In atypical cases, it can in fact be misdiagnosed with other forms of focal alopecia. In this case, we have found the videodermoscopy to be a useful adjunctive diagnostic tool to differentiate triangular alopecia from other scalp disorders, such as alopecia areata. A correct diagnosis would, in these cases, save the patient from unnecessary interventions, such as intralesional steroids or punch biopsies. CONFLICT OF INTEREST STATEMENT We certify that any affiliations with, or involvement in, any organization, or entity with any financial interest in the subject matter or materials discussed in this manuscript currently and over the past 5 years are disclosed. ACKNOWLEDGMENT This study was possible, thanks to a grant from the Women Dermatological Society. Giuseppe Militello, M.D., received a grant from the Women Dermatological Society. REFERENCES
Figure 2. Videodermoscopic image of congenital triangular alopecia.
1. Tosti A. Congenital triangular alopecia. Report of fourteen cases. J Am Acad Dermatol 1987;16:991–993. 2. Trakimas CA, Sperling LC. Temporal triangular alopecia acquired in adulthood. J Am Acad Dermatol 1999;40:842– 844. 3. Park SW, Choi YD, Wang HY. Congenital triangular alopecia in association with congenital heart diseases, bone and teeth abnormalities, multiple lentigines and cafe´-au-lait patches. Int J Dermatol 2004;43:366–367.
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