Images in Dermatology
Trichoscopic stages of dissecting cellulitis: a potential complementary tool to clinical assessment
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A, black dots; B, yellow dots; C, broken hair.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Dissecting cellulitis (DC) is a rare, chronic, progressive, and relapsing inflammatory disease, with a predominance of histopathological neutrophilic infiltrate. It is more frequent in young Afro-descendent men in the vertex and occipital area,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> with papules and pustules that can develop into nodules and interconnecting abscesses, or even cicatricial alopecia. Clinical findings vary according to the extent and severity of the disease. Recently, Lee et al. proposed a disease severity-based classification for DC, dividing it in three different clinical-pathological stages: stage I and II being non-scarring, and stage III representing cicatricial alopecia, without contemplating their trichoscopic findings.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Trichoscopy has shown to be useful in the diagnosis, prognostic evaluation, and treatment monitoring of scalp disorders.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Regarding DC, Verzi et al. reinforced that trichoscopy allows magnification of structures barely visible to the naked eye, clarifying clinical examination uncertainties, and therefore could be a valuable tool for both diagnosis and treatment choice in this still poorly elucidated disorder.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> The present article illustrates trichoscopic features of DC, correlating their images to the clinical stages of disease progression.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In earlier stages of the disease, the trichoscopic picture of DC may simulate that of alopecia areata. The presence of follicular and perifollicular lymphocytic infiltrates on the lower parts of terminal follicles<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5,6</span></a> explains the trichoscopic resemblance to alopecia areata, a condition in which the intense peribulbar inflammatory infiltrate is often referred to as a swarm of bees. Involvement of the lower portions of the follicle may lead to telogen and consequent hair loss. The follicle is unable to start a new anagen phase and remains empty, accumulating sebum and keratin, thus justifying yellow dots in trichoscopy. Alternatively, inflammation may impair adequate hair shaft formation.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Weakened shafts break, leading to the formation of broken hairs and black dots. Recently, exclamation mark hairs,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> a trichoscopic feature typically associated to alopecia areata, have been described in early DC (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Importantly, such features indicate that this stage is still non-scarring and that hair regrowth is possible with adequate treatment. This non-scarring aspect is represented by Lee et al. in clinical stages I and II.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Nevertheless, it is pointed in the conclusion of their article that DC underdiagnosis is possible, especially at early stages. Thus, the inclusion of trichoscopy in the criteria would be of great value for better diagnostic accuracy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Non-treated DC progresses to the abscedens stage, which presents with severe inflammation and is characterized by the presence of pustules, nodules, and abscesses. In this phase, it is possible to observe three-dimensional yellow dots, which may or may not be imposed over dystrophic hairs, as well as yellow structureless areas.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8,9</span></a> These yellow dots are larger than those described in nonscarring alopecia and in the earlier stage of DC. They have also been described as having a “soap bubble”-like appearance.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8,9</span></a> The yellow structureless areas are “lakes of pus” easily found around hair follicles and are typical of DC (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Pinpoint-like vessels with a whitish halo can also be observed, even though they are not uncommon in other scalp diseases.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> In the authors’ experience, if patients are properly treated at this stage, they might recover much of their hair. However, progression to scarring seems inevitable in some areas.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">With the progression of the disease to the fibrotic stage, it is possible to identify extensive dermal fibrosis and destruction of sebaceous glands in histopathology. The fibrotic stage has trichoscopic features that are similar to the end phases of others scarring alopecias, like white areas lacking follicular openings that represent tissue fibrosis, clinically described as shiny patches of alopecia. Another feature that is quite characteristic of advanced DC is the formation of cutaneous clefts. Hair shafts may emerge from such clefts organized into hair tufts with different sizes (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion, this article highlights the trichoscopic features of DC focusing on demonstrating their evolutive stages, which could be associated with the clinical criteria proposed by Lee et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> and enhance trichoscopy's role in diagnosis, treatment choice, and follow-up. This is a suggestion of an additional didactic classification based on the authors’ experience, and some overlap of stages is possible.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> The authors emphasize that further investigations are needed in order to confirm the observations. Nonetheless, it is believed that adoption of trichoscopy by dermatologists will refine care of patients with DC, particularly for monitoring patients while on treatment.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Financial support</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Authors’ contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Daniel Fernandes Melo: Approval of final version on the manuscript; conception and planning of study; drafting and editing of manuscript.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Luciana Rodino Lemes: Drafting and editing of manuscript.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Bruna Duque-Estrada: Drafting and editing of manuscript.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Rodrigo Pirmez: Drafting and editing of manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:3 [ "identificador" => "xres1370013" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1259085" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0010" "titulo" => "Financial support" ] 3 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contributions" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 5 => array:2 [ "identificador" => "xack475736" "titulo" => "Acknowledgment" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-03-19" "fechaAceptado" => "2019-10-29" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1259085" "palabras" => array:3 [ 0 => "Alopecia" 1 => "Dermoscopy" 2 => "Folliculitis" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dissecting cellulitis is a chronic, progressive, and relapsing inflammatory disease that predominantly affects the vertex and occiput of young Afro-descendent men. It starts with papules and pustules that evolve to nodules, abscesses, and cicatricial alopecia. This article illustrates the evolutive trichoscopy of dissecting cellulitis, from its early phase, through the abscess phase, to the fibrotic cicatricial phase. Trichoscopy complements clinical-pathological classification, representing a complementary tool useful in early diagnosis and monitoring of the patient during treatment.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Melo DF, Lemes LR, Pirmez R, Duque-Estrada B. Trichoscopic stages of dissecting cellulitis: a potential complementary tool to clinical assessment. An Bras Dermatol. 2020;95:514–7.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Hospital Naval Marcílio Dias, Rio de Janeiro, RJ, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1117 "Ancho" => 1674 "Tamanyo" => 325147 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Early stage of dissecting cellulitis, with trichoscopy findings on alopecia areata. A, black dots; B, yellow dots; C, broken hair.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1120 "Ancho" => 1674 "Tamanyo" => 355700 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Abscedens stage of dissecting cellulitis. A, yellow structureless area; B, three-dimensional yellow dots.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1091 "Ancho" => 1674 "Tamanyo" => 368448 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Fibrotic stage of dissecting cellulitis. A, lack of follicular openings; B, cutaneous clefts with emerging hairs.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dissecting cellulitis of the scalp: a restrospective study of 51 patients and review of literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Badaoui" 1 => "P. Reygagne" 2 => "B. Cavelier-Balloy" 3 => "L. Pinquier" 4 => "L. Deschamps" 5 => "B. 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Slowinska" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3315/jdcr.2011.1083" "Revista" => array:6 [ "tituloSerie" => "J Dermatol Case Rep" "fecha" => "2011" "volumen" => "5" "paginaInicial" => "82" "paginaFinal" => "88" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22408709" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0090" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Yellow dots in trichoscopy: relevance, clinical significance and peculiarities" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.S. Lima" 1 => "L.R. Lemes" 2 => "D.F. Melo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1590/abd1806-4841.20176157" "Revista" => array:6 [ "tituloSerie" => "An Bras Dermatol" "fecha" => "2017" "volumen" => "92" "paginaInicial" => "724" "paginaFinal" => "726" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29166518" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack475736" "titulo" => "Acknowledgment" "texto" => "<p id="par0060" class="elsevierStylePara elsevierViewall">The authors would like to thank Dr. Taynara Barreto and Dr. Violeta Tortelly for their scientific contributions.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009500000004/v3_202008041755/S0365059620301410/v3_202008041755/en/main.assets" "Apartado" => array:4 [ "identificador" => "80631" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Images in Dermatology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009500000004/v3_202008041755/S0365059620301410/v3_202008041755/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620301410?idApp=UINPBA00008Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 21 | 11 | 32 |
| 2024 October | 96 | 73 | 169 |
| 2024 September | 137 | 90 | 227 |
| 2024 August | 163 | 106 | 269 |
| 2024 July | 140 | 134 | 274 |
| 2024 June | 118 | 119 | 237 |
| 2024 May | 134 | 74 | 208 |
| 2024 April | 93 | 91 | 184 |
| 2024 March | 82 | 60 | 142 |
| 2024 February | 122 | 102 | 224 |
| 2024 January | 71 | 77 | 148 |
| 2023 December | 99 | 57 | 156 |
| 2023 November | 165 | 83 | 248 |
| 2023 October | 94 | 82 | 176 |
| 2023 September | 87 | 70 | 157 |
| 2023 August | 70 | 33 | 103 |
| 2023 July | 67 | 44 | 111 |
| 2023 June | 86 | 51 | 137 |
| 2023 May | 89 | 32 | 121 |
| 2023 April | 70 | 18 | 88 |
| 2023 March | 90 | 42 | 132 |
| 2023 February | 79 | 36 | 115 |
| 2023 January | 45 | 31 | 76 |
| 2022 December | 63 | 27 | 90 |
| 2022 November | 88 | 58 | 146 |
| 2022 October | 119 | 61 | 180 |
| 2022 September | 50 | 53 | 103 |
| 2022 August | 55 | 49 | 104 |
| 2022 July | 44 | 58 | 102 |
| 2022 June | 48 | 62 | 110 |
| 2022 May | 43 | 67 | 110 |
| 2022 April | 52 | 47 | 99 |
| 2022 March | 63 | 72 | 135 |
| 2022 February | 53 | 35 | 88 |
| 2022 January | 58 | 79 | 137 |
| 2021 December | 53 | 62 | 115 |
| 2021 November | 55 | 70 | 125 |
| 2021 October | 64 | 73 | 137 |
| 2021 September | 39 | 54 | 93 |
| 2021 August | 47 | 49 | 96 |
| 2021 July | 36 | 51 | 87 |
| 2021 June | 45 | 55 | 100 |
| 2021 May | 61 | 99 | 160 |
| 2021 April | 109 | 313 | 422 |
| 2021 March | 67 | 47 | 114 |
| 2021 February | 27 | 29 | 56 |
| 2021 January | 32 | 26 | 58 |
| 2020 December | 30 | 23 | 53 |
| 2020 November | 54 | 15 | 69 |
| 2020 October | 96 | 16 | 112 |
| 2020 September | 86 | 16 | 102 |
| 2020 August | 11 | 12 | 23 |
| 2020 July | 42 | 16 | 58 |
| 2020 June | 18 | 11 | 29 |
| 2020 May | 5 | 7 | 12 |
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