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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 14
| Issue : 6 | Page : 204-206 |
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The association between the number of follicular stelae and severity and treatment response of alopecia areata cases: A retrospective study
Güllü Gencebay1, Özge Aşkın2, Övgü Aydın3, Server Serdaroğlu2
1 Department of Dermatology, Şırnak State Hospital, Şırnak, Turkey
2 Department of Dermatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
3 Department of Pathology, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
| Date of Submission | 31-May-2019 |
| Date of Decision | 23-Aug-2019 |
| Date of Acceptance | 20-Jul-2021 |
| Date of Web Publication | 31-Jan-2023 |
Correspondence Address:
Güllü Gencebay
Bahçelievler mah. Esin Cd. No:26, 73000 Yoğurtçular/ Merkez/Şırnak
Turkey
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijt.ijt_48_19
 Abstract | | |
Background: Alopecia areata (AA) is an autoimmune disease characterized by peribulbar lymphocytic infiltration, follicular miniaturization, catagen/telogen follicles, and increased follicular stelae (streamers) in skin biopsies. Objectives: Our aim was to assess the number of follicular stelae of patients with AA and to evaluate their association with clinical type and severity and treatment response of AA. Materials and Methods: Histopathologic features including number of follicular stelae were recorded in skin biopsies taken from lesions of AA in 142 patients who attended our dermatology clinic from 2011 to 2017. Results: There was a statistically significant correlation between the patient age and the number of follicular stelae (P = 0.001). There was a statistically significant correlation between the severity of disease and the number of follicular stelae (P = 0.005). AA subtypes (0%–25% scalp hair loss) had a significantly lower number of follicular stelae than 75%–100% scalp hair loss and alopecia universalis (7.92 ± 4.21 vs. 13.23 ± 7.28). There was no statistically significant correlation between the treatment response and the number of follicular stelae (P = 0.75). Conclusion: Our results showed that number of follicular stelae varied among AA clinical types and correlated with severity. This study was the first to evaluate the correlation between the number of follicular stelae and severity of AA.
Keywords: Alopecia areata, follicular stelae, histopathology
How to cite this article:
Gencebay G, Aşkın &, Aydın &, Serdaroğlu S. The association between the number of follicular stelae and severity and treatment response of alopecia areata cases: A retrospective study. Int J Trichol 2022;14:204-6 |
How to cite this URL:
Gencebay G, Aşkın &, Aydın &, Serdaroğlu S. The association between the number of follicular stelae and severity and treatment response of alopecia areata cases: A retrospective study. Int J Trichol [serial online] 2022 [cited 2023 Mar 22];14:204-6. Available from: https://www.ijtrichology.com/text.asp?2022/14/6/204/368907 |
| Introduction | |  |
Alopecia areata (AA) is an autoimmune disease presenting with nonscarring alopecia that affects patients of all ages, although it is more common in children and young adults.[1] The prevalence of AA is approximately 0.1%–0.2% of the general population.[2] The prevalence may vary from 0.9% to 6.9% in different races and ethnic groups.[3] The characteristic lesions of AA are small, well-limited, noncicatricial bald lesions. It can affect all hair follicles in the body, but the most commonly affected site is scalp hair which may progress to the total loss of hair follicles.[1]
Histopathologically, peribulbar lymphocytic inflammation is the diagnostic clue of AA. The lymphocytic infiltration is rich in T-cells, suggesting evidence of an autoimmune process.[4] In addition to peribulbar lymphocytic infiltration, catagen/telogen follicles, follicular miniaturization, pigment deposition, especially in the catagen follicles, lymphocyte and eosinophil infiltration, and melanin deposition in fibrous tracts are among the other findings found in the skin biopsies.[5]
The most important factor affecting the histopathological features is the duration of the episode of AA. Lymphocytes surround terminal hairs in early episodes and miniaturized hairs in repeated episodes in the acute phase. In the subacute phase, anagen follicles decrease and the number of catagen and telogen hairs increase. The presence of reduced terminal hairs and increased miniaturized hairs with variable inflammation is characteristic in the chronic phase. In the recovery period, the number of terminal anagen hairs from the regrowth of miniaturized hairs increases and no inflammation is observed.[4]
Follicular stelae (follicular streamers or fibrous tracts) are follicular remnants that are located within the bulbar region of the hair follicle. They have two possible functions. The first one is to stimulate the formation of new follicles via the differentiation of telogen germinal epithelium. The second one is to guide a tract for the growing anagen follicle within the reticular dermis. When the follicular stelae are lost, the life cycle of the hair follicle and secondary follicle formation is disturbed. Follicular stelae are especially increased in nonscarring alopecias. Follicular stelae are also increased in AA and androgenetic alopecia patients; the conditions in which catagen/telogen proportion is increased.[6] This study aims at evaluating retrospectively the relationship between the number of follicular stelae and the severity of AA, and the treatment responses of these patients.
| Materials and Methods | | |
Patients diagnosed and treated as AA or alopecia totalis (AT)/universalis by a histopathological diagnosis and a clinical examination, who attended our dermatology clinic from 2011 to 2017, were enrolled in the study. All patients selected from the clinical database were clinically diagnosed by dermatologists. Cases with diagnostic uncertainty were excluded from the study. The clinicopathological and demographic data of all included cases were recorded including age, gender, total duration of the disease, disease severity, and response of any therapy. The type of alopecia was classified as AA, AT, and alopecia universalis (AU) (scalp hair loss %100). AA patients were classified as 0%–25%, 25%–50%, 50%–75%, and 75%–100% according to the percentage of scalp hair loss. Treatment responses were defined as no response, 0%–25%, 25%–50%, 50%–75%, and 75%–100%.
The histopathologic features such as total follicular units, presence of anagen follicles, presence of catagen/telogen follicles, and follicular stelae (streamers) were recorded for each patient.
| Results | | |
In this study, we enrolled a total of 142 alopecia patients who used a treatment for at least 4 months. There were 60 women (42.2%) and 82 men (57.8%), with a median age of 24.2 years at the time of treatment. The disease duration was assessed based on three categories: ≤5 years, 6–10 years, and >10 years and ranged from 3 months to 32 years. The disease duration of 67 patients (47%) was ≤5 years, while the disease duration of 39 patients (27%) was >10 years. Fifty-three percent of patients had AA or AT, while 67 patients (47%) had alopecia universalis. Baseline characteristics of patients are listed in [Table 1]. | Table 1: Baseline characteristics of patients with alopecia areata, alopecia totalis, or alopecia universalis (n=142)
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We found a statistically significant correlation between women and men in the number of follicular stelae. Women had higher follicular stelae than men (13.35 ± 6.92 vs. 11.11 ± 7.25, P = 0.031) There was a statistically significant correlation between the patient age and the number of follicular stelae (P = 0.001). There was a statistically significant negative correlation between the severity of disease and the number of follicular stelae (P = 0.005). AA subtypes (0%–25% scalp hair loss) had a significantly lower number of follicular stelae than 75%–100% scalp hair loss and AU (7.92 ± 4.21 vs. 13.23 ± 7.28). Clinical pictures and histopathological images of two patients with 0%–25% and 100% loss of scalp hair are shown in [Figure 1] and [Figure 2]. | Figure 1: Patchy alopecia areata in the vertex (a), a few follicular stelae in skin biopsy H and E, ×40 (b)
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 | Figure 2: Alopecia totalis with a 100% loss of scalp hair (a), many follicular stelae in skin biopsy H and E, ×100 (b)
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We found no statistically significant correlation between the treatment response and the number of follicular stelae (P = 0.75).
| Discussion | | |
Identification of follicular stelae on scalp biopsy sections is important to differentiate between cicatricial and noncicatricial alopecias. Follicular stelae may be confused with follicular scars in nonoptimal specimens. The use of elastic tissue stains is a helpful tool to distinguish scarring from nonscarring alopecias.[7],[8]
Follicular stelae are increased predominantly in nonscarring alopecias.[6] Although peribulbar inflammation is the diagnostic clue of AA, it is not always present depending on the stage of the disease. The presence of eosinophils within the peribulbar infiltrate, and the follicular stelae is a useful diagnostic feature in these cases. Eosinophils are not present in androgenetic alopecia and trichotillomania in general.[5],[9] The another study demonstrated that the eosinophilic infiltrate is nonspecific feature and its diagnostic usefulness is limited. Follicular miniaturization, pigment deposition, and catagen/telogen follicles are more useful findings to diagnose AA.[10]
Fibrous tracts in nonscarring alopecias are increased as a result of increased catagen/telogen ratio and miniaturized follicles in the former. Follicular stelae are not assessed as additional hair follicles because they are downward prolongations of follicular structures. Therefore, follicular stelae are generally not counted as they may represent telogen follicles or vellus follicles.[6] In this study, the histopathologic specimens with counting follicular stelae were selected. The present study has demonstrated lower number of follicular stelae in patients with AU. Our results also showed that number of follicular stelae varied among AA clinical types and correlated with severity. However, the number of follicular stelae was not correlated with the total duration of AA. These data suggest that follicular stelae represent viable hairs if they are not fibrosed.
| Conclusion | | |
To our knowledge, this study was the first to evaluate the correlation between the number of follicular stelae and severity and treatment response of AA. In the current study, no significant relations were found between the number of follicular stelae and treatment response.
Statement of ethics
This study was performed according to the World Medical Association Declaration of Helsinki and was approved by Istanbul University Cerrahpaşa Medical Faculty Ethics Committee (07/02/2018-51403).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 6. | Horenstein MG, Jacob JS. Follicular streamers (stelae) in scarring and non-scarring alopecia. J Cutan Pathol 2008;35:1115-20. |
| 7. | Tan T, Guitart J, Gerami P, Yazdan P. Elastic staining in differentiating between follicular streamers and follicular scars in horizontal scalp biopsy sections. Am J Dermatopathol 2018;40:254-8. |
| 8. | Sellheyer K, Bergfeld WF. Histopathologic evaluation of alopecias. Am J Dermatopathol 2006;28:236-59. |
| 9. | Elston DM, McCollough ML, Bergfeld WF, Liranzo MO, Heibel M. Eosinophils in fibrous tracts and near hair bulbs: A helpful diagnostic feature of alopecia areata. J Am Acad Dermatol 1997;37:101-6. |
| 10. | Yoon TY, Lee DY, Kim YJ, Lee JY, Kim MK. Diagnostic usefulness of a peribulbar eosinophilic infiltrate in alopecia areata. JAMA Dermatol 2014;150:952-6. |
[Figure 1], [Figure 2]
[Table 1]
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