International Journal of Trichology International Journal of Trichology
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 Table of Contents  
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 73-75  

Alopecia areata on vertex as a potential pitfall for misdiagnosis of central centrifugal cicatricial alopecia in African-American women

1 Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, RI, USA
2 Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA

Date of Web Publication21-Jul-2017

Correspondence Address:
Courtney M Johnson
Warren Alpert Medical School, Brown University, Box G-9999; 222 Richmond Street, Providence, RI 02912
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijt.ijt_107_16

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Trichoscopy is a noninvasive visualization tool used to more accurately diagnose hair and scalp disorders. Alopecia areata (AA) in the patient of African descent can mimic the early signs of central centrifugal cicatricial alopecia (CCCA), especially if the initial presentation of hair loss occurs on the central scalp. Two African-American women presented with singular round-ovoid patches of decreased hair loss on the central scalp. Given the clinical presentation, CCCA was the working diagnosis. However, using dermoscopy, the patients were found to have exclamation hairs and short broken hairs on a background of honeycomb-like pigmented network and regular pinpoint white dots consistent with AA. The diagnosis was confirmed on biopsy. We demonstrate the role of dermoscopy for diagnosing AA in the patient of African descent.

Keywords: African-American, alopecia areata, central centrifugal cicatricial alopecia, exclamation hair

How to cite this article:
Johnson CM, Miteva M. Alopecia areata on vertex as a potential pitfall for misdiagnosis of central centrifugal cicatricial alopecia in African-American women. Int J Trichol 2017;9:73-5

How to cite this URL:
Johnson CM, Miteva M. Alopecia areata on vertex as a potential pitfall for misdiagnosis of central centrifugal cicatricial alopecia in African-American women. Int J Trichol [serial online] 2017 [cited 2023 Feb 7];9:73-5. Available from: https://www.ijtrichology.com/text.asp?2017/9/2/73/211311

   Introduction Top

Trichoscopy is a noninvasive technique helpful in the management of hair and scalp disorders.[1],[2] Alopecia areata (AA) is the most common cause of inflammatory-induced alopecia in the US, occurring equally in African-Americans and Caucasians.[3],[4] It presents with round patches of hair loss on clinical examination and with short broken hairs, yellow dots, black dots, exclamation mark hairs, and fine vellus hairs on trichoscopy.[4],[5] To date, no trichoscopic studies of AA in African-American patients exist. A few articles comment on the absence of yellow dots, the presence of diffuse pigmented network with increased pinpoint white dots, and broken hairs.[3],[5] Central centrifugal cicatricial alopecia (CCCA), the most common type of scarring alopecia in African-American women, is characterized by progressive irreversible hair loss involving the central scalp.[6],[7] Trichoscopy shows peripilar white halos, loss of follicular openings, disrupted pigmented network, irregular distributed pinpoint white dots, and individual broken hairs.[7]

We describe two African-American women with a round alopecic patch on the vertex that clinically resembled CCCA and we highlight the trichoscopic features of AA in African-American patients.

   Case Report Top

A 27-year-old woman and a 36-year-old woman, both Fitzpatrick skin Type V, presented with a recent onset of decreased hair density on the central scalp. One patient reported wearing braids and the other reported wearing a natural style.

Both physical examinations demonstrated a single round patch on the vertex of decreased hair density [Figure 1]a and [Figure 1]b. Given the pattern, location and the prevalence of CCCA in African-American women, the working diagnosis was CCCA. Trichoscopy demonstrated honeycomb pigmented network and regular pinpoint white dots across the affected scalp. Short broken hairs with tapered proximal portion and thicker compact or frayed distal tip resembled exclamation hairs [Figure 2]a. Pathology confirmed acute-stage AA [Figure 2]b.
Figure 1: Photographs of two African-American women with a patch of hair loss on the central scalp. (a) A single patch of alopecia with short hairs involving the vertex scalp among braided hair extensions. (b) A single patch of alopecia on the vertex scalp with some vellus hairs

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Figure 2: Representative trichoscopy and pathology image. (a) Trichoscopy shows preserved follicular openings, honeycomb pigmented network, and pinpoint white dots. Note the presence of exclamation point hairs, which emerge together with other hairs from the same follicular opening (red arrows) (Handyscope, FotoFinder Systems, Bad Birnbach, Germany). (b) A horizontal section of a scalp biopsy reveals a nonscarring pattern, with decreased follicular density of 8 follicles. Two anagen follicles reveal a swarm-of-bees like infiltrate at the bulb level. There are also 4 telogen follicles and 2 nanogen follicles (H and E, ×4)

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   Discussion Top

A diagnosis of CCCA should be suspected in the African patient with hair breakage or thinning on the central scalp.[2],[7],[8],[9] Trichoscopy can be helpful to distinguish patches of AA from CCCA [Table 1]. Yellow dots are not detected in black skin, possibly due to the difficulty in distinguishing this color on a pigmented scalp.[5]
Table 1: Trichoscopy findings in alopecia areata and central centrifugal cicatricial alopecia

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The pathognomonic finding for AA is the presence of exclamation mark hairs, which are short hairs with wider diameter distally.[4],[5] They arise from follicles that are prematurely precipitated into catagen during anagen Stages III or IV and their shafts break when reaching the surface.[10] On pathology, they correspond to telogen follicles. In African-American hair, the exclamation mark hairs are rarely identified as single hairs as afro-textured hairs usually presents as pairs of emerging hairs at the surface.[11] Thus, exclamation hairs emerge together with one or two intact or broken terminal hairs. The shape of the exclamation hair tip is not rounded as compared to Causation hair as Afro-textured hair has a kidney-shaped hair shaft causing exclamation hairs to curve and acquire an angulated distal end. As hair breakage can be an early sign of CCCA, careful recognition of exclamation hairs can help in the diagnosis of AA in patients of African descent.[8]

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Conflicts of interest

There are no conflicts of interest.

   References Top

Tosti A, Torres F. Dermoscopy in the diagnosis of hair and scalp disorders. Actas Dermosifiliogr 2009;100 Suppl 1:114-9.  Back to cited text no. 1
Miteva M, Tosti A. Hair and scalp dermatoscopy. J Am Acad Dermatol 2012;67:1040-8.  Back to cited text no. 2
Yin NC, Tosti A. A systematic approach to Afro-textured hair disorders: Dermatoscopy and when to biopsy. Dermatol Clin 2014;32:145-51.  Back to cited text no. 3
Alkhalifah A. Alopecia areata update. Dermatol Clin 2013;31:93-108.  Back to cited text no. 4
de Moura LH, Duque-Estrada B, Abraham LS, Barcaui CB, Sodre CT. Dermoscopy findings of alopecia areata in an African-American patient. J Dermatol Case Rep 2008;2:52-4.  Back to cited text no. 5
Ogunleye TA, McMichael A, Olsen EA. Central centrifugal cicatricial alopecia: What has been achieved, current clues for future research. Dermatol Clin 2014;32:173-81.  Back to cited text no. 6
Miteva M, Tosti A. Dermatoscopic features of central centrifugal cicatricial alopecia. J Am Acad Dermatol 2014;71:443-9.  Back to cited text no. 7
Callender VD, Wright DR, Davis EC, Sperling LC. Hair breakage as a presenting sign of early or occult central centrifugal cicatricial alopecia: Clinicopathologic findings in 9 patients. Arch Dermatol 2012;148:1047-52.  Back to cited text no. 8
Miteva M, Tosti A. Pathologic diagnosis of central centrifugal cicatricial alopecia on horizontal sections. Am J Dermatopathol 2014;36:859-64.  Back to cited text no. 9
Tobin DJ, Fenton DA, Kendall MD. Ultrastructural study of exclamation-mark hair shafts in alopecia areata. J Cutan Pathol 1990;17:348-54.  Back to cited text no. 10
Miteva M, Tosti A. 'A detective look' at hair biopsies from African-American patients. Br J Dermatol 2012;166:1289-94.  Back to cited text no. 11


  [Figure 1], [Figure 2]

  [Table 1]


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