S023%Hair and Scalp Dermoscopy S023...Keratotic plugs Thick arborizing vessels ... Acuteandperipheryofchronic lesions. ... Milky red/Pink areas White patches. Trichoscopy ofDLE

S023 Hair and Scalp Dermoscopy

Discoid Lupus Erythematosus

Bruna Duque Estrada, M.D.

Instituto de Dermatologia Prof. Rubem David Azulay

Rio de Janeiro, Brazil.

Disclosure of Relationship with Industry

Bruna Duque-‐Estrada, MD

S023 Hair and Scalp Dermoscopy

Disclosures

I have no conflicts to disclosure

Discoid Lupus Erythematosus (DLE)

Primary Cicatricial AlopeciaAlthough the hair follicle is notthe primary target of inflammatory process

Onset 20-‐40s

Scalp involvement is often the presenting symptom

50-‐80% of patients with Chronic Cutaneous Lupus


Well-‐demarcated alopecic patch

Follicular plugging, adherent scale and erythema

Hypo-‐ or hyperpigmentation

Symptoms: itching, pain, burning and ternderness

Early diagnosis may avoid scarring and atrophy

Trichoscopy of DLE -‐ Objectives

• Diagnosis: present trichoscopic features of DLE

• Avoid scarring: call attention for early diagnosis

• Indicate biopsy sites

• Follow-‐up: differentiate active from non-‐active lesions

• Make differential diagnosis with scarring and non-‐scarring alopecias


Diagnostic features

Keratotic plugs

Thick arborizing vessels

Blue-‐grey dots

Red dots

Scattered brown discoloration

White patches

Ref Trabalho Ross, nosso, Lidia e Tosti


Keratotic plugs

”Large yellow dots”

Use dry dermoscopy

Dark yellow to yellow brown

Hyperkeratosis and plugging of the

follicular ostia with keratotic material

Acute and periphery of chronic lesions


Thick arborizing vessels

Deep plexus + Epidermal atrophy

+ 90% of DLE lesions

May last in late-‐stage disease

A. Rakowska et al. J Drugs Dermatol 2012


”Red spider in a yellow dot”

Yellow dots + thin arborizing vessels

Epidermal atrophy

Late stage DLE



Blue-‐grey dots

Speckled pattern

Melanin andmelanophages in the dermis

Interfollicular interface dermatitis

African descendents

Duque-‐Estrada B et al. An Bras Dermatol. 2010


Scattered browndiscoloration

Pigment incontinence

African descendents and Caucasians



Blue-‐white veil

Pigment incontinence + hyperkeratosis

Use immersion fluid

African descendents


Blue-‐white veil

Pigment incontinence + hyperkeratosis

Use immersion fluid

African descendents


Red dots

Early Diagnosis, active disease

Follicular opening surrounded by dilated vessels

Good prognostic factor for hair regrowth

Tosti A. et al. Arch Dermatol 2009

RosettesShiny whiteFour oval-‐shaped points

Optical effect between of crossed polarizationin the follicular and perifollicular structures

Narrowing of infundibulaor blockage by keratin

Early disease – follicle preserved


Perifollicular scaling

Dry Dermoscopy

”V sign” -‐ Compound structures

Lichenoid infiltrate and perifollicular fibrosis

Differential diagnosis: LPP

MitevaM., Tosti A. JEADV 2013


Interfollicular scaling

Hyperkeratosis

Differential: psoriasis, seb dermatitis


Milky red/Pink areas White patches

Trichoscopy of DLEActive featuresKeratotic plugsRed dotsThick arborizing vesselsBlue-‐gray dots

Scattered brown discolorationBlue-‐white veilPerifollicular scaleFine interfollicular scalingRosettes

Inactive (end-‐stage) features

Loss of follicular openingsPink areas

White patchesThin Arborizing vessels

Yellow dots with spider vessels

DLE & Frontal Fibrosing Alopecia

DLE may coexist with FFA

1: Trüeb RM, El Shabrawi-‐Caelen L, Kempf W. Cutaneous Lupus ErythematosusPresenting as Frontal Fibrosing Alopecia: Report of 2 Patients. Skin

Appendage Disord. 2017 Oct;3(4):205-‐210.

2: Contin LA, Martins da Costa Marques ER, Noriega L. Frontal Fibrosing Alopecia Coexisting with Lupus Erythematosus: Poor Response to

Hydroxychloroquine. SkinAppendage Disord. 2017 Jan;2(3-‐4):162-‐165

3: del Rei M, Pirmez R, Sodré CT, Tosti A. Coexistence of frontal fibrosingalopecia and discoid lupus erythematosus of the scalp in 7 patients: just a

coincidence? J Eur Acad Dermatol Venereol. 2016 Jan;30(1):151-‐3.

4: Khan S, Fenton DA, Stefanato CM. Frontal fibrosing alopecia and lupus overlap in a man: guilt by association? Int J Trichology. 2013 Oct;5(4):217-‐9.

5: Gaffney DC, Sinclair RD, Yong-‐Gee S. Discoid lupus alopecia complicated byf rontal fibrosing alopecia on a background of androgenetic alopecia. Br J

Dermatol. 2013 Jul;169(1):217-‐8

6: Duque-‐Estrada B, Tamler C, Sodré CT, Barcaui CB, Pereira FB. Dermoscopy patterns of cicatricial alopecia resulting from discoid lupus erythematosus

and lichen planopilaris. An Bras Dermatol. 2010 Mar-‐Apr;85(2):179-‐83.

Take home message

1. Early LesionsTrichoscopy helps you to be suspicious of DLE Keratotic plugs , Red dots, Rosettes – prefibrotic stage

Take home message

2. Clinically evident DLETrichoscopy confirms diagnosis, helps recognizing active/late stage areasand choosing biopsy sites

Take home message

3. Diffuse scaling may be a sign of DLERemove the scales before perfoming trichoscopy

Take home messageTake home message

Take home message

4. Try not miss late stage DLECicatricial alopeciaTrichoscopy will suggest DLE, and helps choosing biopsy sites

Thank [email protected]

S023%Hair and Scalp Dermoscopy S023...Keratotic plugs Thick arborizing vessels ... Acuteandperipheryofchronic lesions. ... Milky red/Pink areas White patches. Trichoscopy ofDLE

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