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which had not improved with topical corticosteroids&#46; Hairs with different lengths&#44; hemorrhagic areas&#44; split hairs&#44; question mark hairs&#44; broken hairs&#44; flame hairs&#44; and black dots were observed on trcihoscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A e B&#41;&#46; Trichomalacia&#44; ectopic&#44; pigmented cortical cells&#44; pigment casts in inner root sheath and in follicles were seen on histopathology &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; She was diagnosed with Trichotillomania &#40;TTM&#41;&#44; consulted with a psychiatrist&#44; and was diagnosed as a generalized anxiety disorder&#46; Fluoxetin and risperidone were prescribed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span class="elsevierStyleEnunciation" id="enun0010"><span class="elsevierStyleLabel">Case 2</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 32-year-old woman presented with her third episode of eyebrow loss during one year period&#46; Vellus hairs&#44; yellow dots&#44; and anisotrichosis were detected on trichoscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; There was lymphocyte invasion of the outer root sheath&#44; and a lymphocytic infiltrate with peribulbar fibrosis on histopathology &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; The patient was diagnosed with Alopecia Areata &#40;AA&#41;&#46; 5&#8239;mg&#47;ml triamcinolone acetonide was injected intralesionally per month three times&#46; At the end of the third month&#44; the hairs regrew&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span class="elsevierStyleEnunciation" id="enun0015"><span class="elsevierStyleLabel">Case 3</span><p id="par0025" class="elsevierStylePara elsevierViewall">An 18-year-old man applied to the outpatient clinic with eyebrow loss for five months&#46; He had had hair loss on the scalp six months ago that spontaneously regrew up&#46; There were alopecic areas on the right eyebrow&#59; and numerous yellow dots&#44; empty follicular openings&#44; and a few black dots on trichoscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The patient was diagnosed with AA&#46; Intralesional triamcinolone acetonide &#40;5 mg&#47;ml&#41; was injected once&#44; and the follow-up continues&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span class="elsevierStyleEnunciation" id="enun0020"><span class="elsevierStyleLabel">Case 4</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 31-year-old woman was presented with a five-month-history of eyebrow loss&#46; Spontaneous regrowth of eyebrow hairs happened after a complete loss&#46; She denied any emotional stress or conflict on her job and persistently refused to consult the psychiatrist&#46; On trichoscopy&#59; hairs of different lengths&#44; empty follicles&#44; broken hairs&#44; question mark hairs &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A&#8211;B&#41; were observed&#46; The patient was diagnosed with TTM then quit the follow-up&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span class="elsevierStyleEnunciation" id="enun0025"><span class="elsevierStyleLabel">Case 5</span><p id="par0035" class="elsevierStylePara elsevierViewall">A 10-year-old girl presented with eyebrow loss for two months&#44; which begun after she had had a serious emotional stress&#46; Her mother mentioned seeing her daughter pulling her eyebrows&#46; Her eyebrow hairs were sparse&#59; and broken hairs&#44; comma hairs&#44; tulip hairs&#44; and black dots were observed on trichoscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>A&#8211;B&#41;&#46; The patient was diagnosed with TTM and referred to a child and adolescent psychiatrist&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Trichotillomania is characterized by pulling one&#8217;s own hair repetitively in a compulsive manner&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is classified inside the obsessive-compulsive disorder and related disorders in the Diagnostic and Statistical Manual of Mental Disorder-Fifth Edition &#40;DSM-5&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Before pulling their hair out&#44; patients experience anxiety&#59; and feel relaxed thereafter&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Patients with TTM are usually misdiagnosed as AA due to their episodic nature&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Therefore&#44; they are treated unsuccessfully as the study&#8217;s first case&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Alopecia areata is characterized by T-cell infiltration of the hair bulb&#46; It rarely represents isolated eyebrow involvement<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and may rarely appear as an initial finding of AA&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Although trichoscopic features of TTM on the scalp were well described&#44; trichoscopy of eyebrow TTM were discussed in limited reports&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> On trichoscopy of eyebrows&#44; the authors observed hairs with different lengths&#44; split hair&#44; question mark hair&#44; broken hair&#44; flame hair&#44; comma hair&#44; tulip hairs&#44; black dots&#44; hyperpigmented and hemorrhagic areas on the surface&#46; Yellow dots are one of the common features in AA and show a regular distribution&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> but rare in TTM&#44; and the distribution is irregular&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In the AA patients&#44; the authors observed a few irregularly distributed yellow dots&#44; but the authors didn&#39;t detect them in TTM patients&#46; It may be due to insufficient space for trichoscopic examination in alopecic areas of the eyebrows which may justify the absence in the presented case with TTM&#46; Empty follicles are also one of the trichoscopic features of AA and are more common on eyebrows&#46; This might be associated with the brevity of the eyebrow hair cycle&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The authors think that washing the face more frequently than the scalp may contribute to this situation&#46; Sebum&#44; keratin&#44; and broken hairs inside the follicle openings might be removed by washing&#46; In one of the study&#8217;s AA patients&#44; the authors observed numerous empty follicles&#46; Also&#44; the evaluation of multiple trichoscopic images together contributes to define the diagnosis&#46; Khunkhet et al&#46; observed trichoscopic features of TTM and AA on the scalp and they evaluated five images for each patients&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In a study&#44; exclamation mark hairs and tapered hairs are claimed as common features of the eyebrow AA&#46; However&#44; they are observed less common than scalp AA&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Despite that&#44; the authors did not observe exclamation marks or tapered hairs in the AA patients&#46; It may be due to a low number of cases&#46; Vellus hairs are asserted as a common feature of eyebrow AA&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The authors detected vellus hairs in one of the AA patients&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Broken hairs&#44; are transverse fractures of the terminal hair shaft due to inflammation or rapid regrowth of black dots&#46; Broken hairs and black dots are also common features of both scalp and eyebrow AA&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The authors observed those in both of the AA patients&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion&#44; although trichoscopic features of AA and TTM of the eyebrows are similar to those of the scalp&#44; there are some minor differences&#46; It should be remembered that trichoscopy is very useful in distinguishing AA and TTM on the eyebrows&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#39; contributions</span><p id="par0075" class="elsevierStylePara elsevierViewall">G&#252;ldehan At&#305;&#351;&#58; Approval of the final version of the manuscript&#59; critical literature review&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; &#305;ntellectual participation in propaedeutic and&#47;or therapeutic management of studied cases&#59; critical manuscript review&#59; preparation and writing of the manuscript&#59; study conception and planning&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Ay&#351;enur &#350;am Sar&#305;&#58; Approval of the final version of the manuscript&#59; critical literature review&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; &#305;ntellectual participation in propaedeutic and&#47;or therapeutic management of studied cases&#59; critical manuscript review&#59; preparation and writing of the manuscript&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Pembeg&#252;l G&#252;ne&#351;&#58; Approval of the final version of the manuscript&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; critical manuscript review&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Cansu S&#246;nmez&#58; Approval of the final version of the manuscript&#59; effective participation in research orientation&#59; critical manuscript review&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Images in Dermatology
Isolated hair loss on the eyebrow: five cases with trichoscopic features
Güldehan Atışa,
Autor para correspondência
guldehan.atis@gmail.com

Corresponding author.
, Ayşenur Şam Sarıa, Pembegül Güneşb, Cansu Sönmezc
a Department of Dermatology, Haydarpaşa Numune Training and Research Hospital, Hamidiye Medicine Faculty, University of Health Sciences, İstanbul, Turkey
b Department of Pathology, Memorial Hospital, İstanbul, Turkey
c Department of Pathology, Haydarpaşa Numune Training and Research Hospital, Hamidiye Medicine Faculty, University of Health Sciences, İstanbul, Turkey
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which had not improved with topical corticosteroids&#46; Hairs with different lengths&#44; hemorrhagic areas&#44; split hairs&#44; question mark hairs&#44; broken hairs&#44; flame hairs&#44; and black dots were observed on trcihoscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A e B&#41;&#46; Trichomalacia&#44; ectopic&#44; pigmented cortical cells&#44; pigment casts in inner root sheath and in follicles were seen on histopathology &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; She was diagnosed with Trichotillomania &#40;TTM&#41;&#44; consulted with a psychiatrist&#44; and was diagnosed as a generalized anxiety disorder&#46; Fluoxetin and risperidone were prescribed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span class="elsevierStyleEnunciation" id="enun0010"><span class="elsevierStyleLabel">Case 2</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 32-year-old woman presented with her third episode of eyebrow loss during one year period&#46; Vellus hairs&#44; yellow dots&#44; and anisotrichosis were detected on trichoscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; There was lymphocyte invasion of the outer root sheath&#44; and a lymphocytic infiltrate with peribulbar fibrosis on histopathology &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; The patient was diagnosed with Alopecia Areata &#40;AA&#41;&#46; 5&#8239;mg&#47;ml triamcinolone acetonide was injected intralesionally per month three times&#46; At the end of the third month&#44; the hairs regrew&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span class="elsevierStyleEnunciation" id="enun0015"><span class="elsevierStyleLabel">Case 3</span><p id="par0025" class="elsevierStylePara elsevierViewall">An 18-year-old man applied to the outpatient clinic with eyebrow loss for five months&#46; He had had hair loss on the scalp six months ago that spontaneously regrew up&#46; There were alopecic areas on the right eyebrow&#59; and numerous yellow dots&#44; empty follicular openings&#44; and a few black dots on trichoscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The patient was diagnosed with AA&#46; Intralesional triamcinolone acetonide &#40;5 mg&#47;ml&#41; was injected once&#44; and the follow-up continues&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span class="elsevierStyleEnunciation" id="enun0020"><span class="elsevierStyleLabel">Case 4</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 31-year-old woman was presented with a five-month-history of eyebrow loss&#46; Spontaneous regrowth of eyebrow hairs happened after a complete loss&#46; She denied any emotional stress or conflict on her job and persistently refused to consult the psychiatrist&#46; On trichoscopy&#59; hairs of different lengths&#44; empty follicles&#44; broken hairs&#44; question mark hairs &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A&#8211;B&#41; were observed&#46; The patient was diagnosed with TTM then quit the follow-up&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span class="elsevierStyleEnunciation" id="enun0025"><span class="elsevierStyleLabel">Case 5</span><p id="par0035" class="elsevierStylePara elsevierViewall">A 10-year-old girl presented with eyebrow loss for two months&#44; which begun after she had had a serious emotional stress&#46; Her mother mentioned seeing her daughter pulling her eyebrows&#46; Her eyebrow hairs were sparse&#59; and broken hairs&#44; comma hairs&#44; tulip hairs&#44; and black dots were observed on trichoscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>A&#8211;B&#41;&#46; The patient was diagnosed with TTM and referred to a child and adolescent psychiatrist&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Trichotillomania is characterized by pulling one&#8217;s own hair repetitively in a compulsive manner&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is classified inside the obsessive-compulsive disorder and related disorders in the Diagnostic and Statistical Manual of Mental Disorder-Fifth Edition &#40;DSM-5&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Before pulling their hair out&#44; patients experience anxiety&#59; and feel relaxed thereafter&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Patients with TTM are usually misdiagnosed as AA due to their episodic nature&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Therefore&#44; they are treated unsuccessfully as the study&#8217;s first case&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Alopecia areata is characterized by T-cell infiltration of the hair bulb&#46; It rarely represents isolated eyebrow involvement<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and may rarely appear as an initial finding of AA&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Although trichoscopic features of TTM on the scalp were well described&#44; trichoscopy of eyebrow TTM were discussed in limited reports&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> On trichoscopy of eyebrows&#44; the authors observed hairs with different lengths&#44; split hair&#44; question mark hair&#44; broken hair&#44; flame hair&#44; comma hair&#44; tulip hairs&#44; black dots&#44; hyperpigmented and hemorrhagic areas on the surface&#46; Yellow dots are one of the common features in AA and show a regular distribution&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> but rare in TTM&#44; and the distribution is irregular&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In the AA patients&#44; the authors observed a few irregularly distributed yellow dots&#44; but the authors didn&#39;t detect them in TTM patients&#46; It may be due to insufficient space for trichoscopic examination in alopecic areas of the eyebrows which may justify the absence in the presented case with TTM&#46; Empty follicles are also one of the trichoscopic features of AA and are more common on eyebrows&#46; This might be associated with the brevity of the eyebrow hair cycle&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The authors think that washing the face more frequently than the scalp may contribute to this situation&#46; Sebum&#44; keratin&#44; and broken hairs inside the follicle openings might be removed by washing&#46; In one of the study&#8217;s AA patients&#44; the authors observed numerous empty follicles&#46; Also&#44; the evaluation of multiple trichoscopic images together contributes to define the diagnosis&#46; Khunkhet et al&#46; observed trichoscopic features of TTM and AA on the scalp and they evaluated five images for each patients&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In a study&#44; exclamation mark hairs and tapered hairs are claimed as common features of the eyebrow AA&#46; However&#44; they are observed less common than scalp AA&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Despite that&#44; the authors did not observe exclamation marks or tapered hairs in the AA patients&#46; It may be due to a low number of cases&#46; Vellus hairs are asserted as a common feature of eyebrow AA&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The authors detected vellus hairs in one of the AA patients&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Broken hairs&#44; are transverse fractures of the terminal hair shaft due to inflammation or rapid regrowth of black dots&#46; Broken hairs and black dots are also common features of both scalp and eyebrow AA&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The authors observed those in both of the AA patients&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion&#44; although trichoscopic features of AA and TTM of the eyebrows are similar to those of the scalp&#44; there are some minor differences&#46; It should be remembered that trichoscopy is very useful in distinguishing AA and TTM on the eyebrows&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#39; contributions</span><p id="par0075" class="elsevierStylePara elsevierViewall">G&#252;ldehan At&#305;&#351;&#58; Approval of the final version of the manuscript&#59; critical literature review&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; &#305;ntellectual participation in propaedeutic and&#47;or therapeutic management of studied cases&#59; critical manuscript review&#59; preparation and writing of the manuscript&#59; study conception and planning&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Ay&#351;enur &#350;am Sar&#305;&#58; Approval of the final version of the manuscript&#59; critical literature review&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; &#305;ntellectual participation in propaedeutic and&#47;or therapeutic management of studied cases&#59; critical manuscript review&#59; preparation and writing of the manuscript&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Pembeg&#252;l G&#252;ne&#351;&#58; Approval of the final version of the manuscript&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; critical manuscript review&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Cansu S&#246;nmez&#58; Approval of the final version of the manuscript&#59; effective participation in research orientation&#59; critical manuscript review&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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ISSN: 03650596
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