The value of dermoscopy in diagnosing eyebrow loss in patients with alopecia areata and frontal fibrosing alopecia

DOI: 10.1111/jdv.15279 JEADV ORIGINAL ARTICLE The value of dermoscopy in diagnosing eyebrow loss in patients with alopecia areata and frontal fibrosing alopecia A. Waskiel-Burnat, 1 A. Rakowska, 1, * M. Kurzeja, 2 J. Czuwara, 1 M. Sikora, 1 M. Olszewska, 1 L. Rudnicka 1 1 Department of Dermatology, Medical University of Warsaw, Warsaw, Poland 2 Specjalisci Dermatolodzy S.C., Warsaw, Poland *Correspondence: A. Rakowska. E-mail: adriana.rakowska@gmail.com Abstract Introduction Alopecia areata and frontal fibrosing alopecia are common causes of eyebrow loss (madarosis). Objective Assessment of trichoscopic markers of eyebrow loss in alopecia areata and frontal fibrosing alopecia. Materials and methods The analysis included 50 patients with scalp alopecia areata with madarosis, 50 patients with scalp frontal fibrosing alopecia with madarosis and 50 healthy controls. In every case, trichoscopy of the eyebrow area was performed. Results Empty follicular and eccrine duct openings were observed in all patients and presented predominantly as yellow dots. Exclamation mark hairs were only detected in patients with alopecia areata (30%). Tapered hairs, broken hair, black dots and Pohl Pinkus constrictions were observed in 14%, 36%, 26% and 4% of patients with alopecia areata, respectively, 4%, 16%, 2% and 0% of patients with frontal fibrosing alopecia, respectively, and they were not present in healthy controls. Dystrophic hairs and whitish areas were observed only in patients with frontal fibrosing alopecia (28% and 32%, respectively). Eyebrow regrowth in distinct directions was present in 32% of patients with frontal fibrosing alopecia, 8% of patients with alopecia areata and 4% of healthy controls. Diffuse erythema was detected in 60% of patients with alopecia areata and frontal fibrosing alopecia and 56% of healthy controls. Vellus hairs and upright regrowing hairs were observed in patients with alopecia areata (62% and 58%, respectively), frontal fibrosing alopecia (60% and 84%, respectively) and healthy controls (100% and 100%, respectively). Conclusion Trichoscopy of the eyebrow area is useful in diagnosing patients with isolated eyebrow loss. The most characteristic trichoscopic features of eyebrow loss in alopecia areata include exclamation mark hairs, tapered hairs, broken hairs and black dots. Frontal fibrosing alopecia of the eyebrows is characterized by the presence of dystrophic hairs, white areas and eyebrow regrowth in distinct directions. Received: 30 June 2018; Accepted: 19 September 2018 Conflict of Interests None. Funding Sources None. Introduction Eyebrows are short, thick terminal hairs situated above the orbital regions. They serve many important biological and aesthetic functions. Eyebrows grow as individual strands, not in multiplehair follicular units that are characteristic of scalp hair. The average length of eyebrows varies from 5 to 5.5 cm, with the width of 1.3 1.5 cm. 1 Similarly to other hair, the eyebrow hair cycle consists of three phases: anagen, catagen and telogen. 1 However, contrary to scalp hair, eyebrow anagen phase lasts only two to 4 weeks, which results in the growth of short hair. The catagen phase lasts two to 3 weeks, while the telogen phase continues for two to 3 months. The anagen phase comprises approximately 10%, while the telogen phase 90% of eyebrow hair follicles. 1 The term madarosis origins from the ancient Greek word madao meaning to fall off and is defined as eyebrow or eyelash loss. 2 It could be a symptom of various dermatological and non-dermatological conditions. Furthermore, madarosis may be associated with hair disorders such as alopecia areata and frontal fibrosing alopecia. 2 Trichoscopy hair and scalp dermoscopy is a non-invasive method useful in the diagnosis of scalp and hair diseases. 3,4 Numerous studies about trichoscopic findings of scalp alopecia areata and frontal fibrosing alopecia, as well as their relation to disease activity and severity have been published. 5 7 However, to date, no study has assessed trichoscopic markers of eyebrow loss in alopecia areata, and in only one study, trichoscopic features of eyebrow loss in frontal fibrosing alopecia were described. 8

214 Wa skiel-burnat et al. Objective The assessment of the trichoscopic features of eyebrow loss in alopecia areata and frontal fibrosing alopecia. Materials and methods The retrospective analysis included 50 patients with scalp alopecia areata and 50 patients with scalp frontal fibrosing alopecia with coexisting eyebrow loss (with no history of eyebrow plucking within the last month). The diagnoses of alopecia areata and frontal fibrosing alopecia were established on the basis of a detailed medical history, a clinical examination and scalp trichoscopy. Ambiguous cases were excluded from the study. In patients with alopecia areata, the severity of hair loss was assessed by severity of alopecia tool (SALT) and graded as S1 to S5 as follows: S0, no hair loss; S1, <25% hair loss; S2, 26 50% hair loss; S3, 51 75% hair loss; S4, 76 99% hair loss; S5, 100% hair loss. The clinical severity of frontal fibrosing alopecia was classified based on a clinical scale, measuring the area of cicatricial skin produced by the recession of the frontal and temporal hairline and graded as follows: I (>1 cm), II (1 2.99 cm), III (3 4.99 cm), IV (5 6.99 cm) and V ( 7 cm). The control group consisted of 50 healthy people with no history of eyebrow plucking within the last month. All the patients were examined at our outpatient department between 2015 and 2018. In every case, dry trichoscopy and trichoscopy with immersion fluid of eyebrow area using Fotofinder digital dermoscope (at 20- and 70-fold magnification) were performed. All trichoscopic photographs (a total of 1018 images) were analysed by two independent blinded evaluators for the presence of specific abnormalities in the hair shaft structure and skin surface. After the evaluation results were unblinded, compatible trichoscopic features (compatibility between evaluators calculated as percentage of identical dermoscopic findings and was 97.0%) were assigned to respective patients groups. The statistical analysis of the data was conducted using Statistica software, version 12.0. The differences in the incidence rate of various trichoscopic features amongst patients with alopecia areata, frontal fibrosing alopecia and healthy controls were examined with a chi-squared test. The results were considered statistically significant with P-values lower than 0.05. Figure 1 Trichoscopy of eyebrow loss in alopecia areata (970). Exclamation mark hairs (white arrow), yellow dots (blue arrow), eccrine duct openings (green arrow) and upright regrowing hairs (red arrow) may be noticed. Figure 2 Trichoscopy of eyebrow loss in alopecia areata (920). Tapered hairs (black arrows), exclamation mark hairs (white arrows), classic yellow dots (blue arrow), eccrine duct openings (green arrow), upright regrowing hairs (red arrow) and vellus hairs (yellow arrow) may be observed. Results The retrospective analysis included 50 patients with alopecia areata [36 women and 14 men; age range: 3 84; mean disease duration: 22.9 months (range: 1 70)] and 50 patients with frontal fibrosing alopecia [50 women; age range: 48 85; mean disease duration: 15.2 months (range: 1 30)]. In patients with alopecia areata, grade S1 affected 14/50 (28%) cases, grade S2 5/50 (10%) and grade S3 6/50 (12%). Grade S4 and S5 concerned 3/50 (6%) and 22/50 (44%) patients, respectively. In patients with frontal fibrosing alopecia, grade I, II, III and IV were identified in 14/50 (28%), 14/50 (28%), 13/50 (26%) and 10/50 (20%) Figure 3 Trichoscopy of eyebrow loss in alopecia areata (970). Pohl Pinkus constriction (violet arrow), classic yellow dots (blue arrow), eccrine duct openings (green arrow), black dots (orange arrow), upright regrowing hairs (red arrow) and vellus hairs (yellow arrow) may be detected.

Trichoscopy of eyebrows 215 Figure 4 Trichoscopy of eyebrow loss in frontal fibrosing alopecia (970). Dystrophic hair as a result of follicular fibrosis (pink arrow) may be observed in the centre of the image. Other trichoscopic features include classic yellow dots (blue arrow) and eccrine duct openings (green arrow). Figure 5 Trichoscopy of eyebrow loss in frontal fibrosing alopecia (920). Eyebrow regrowth in distinct directions is a characteristic feature. Other present trichoscopic features are upright regrowing hairs (red arrow), broken hairs (grey arrow), classic yellow dots (blue arrow), eccrine duct openings (green arrow) and diffuse erythema (violet arrow). cases, respectively. Eyebrow loss was an initial clinical manifestation of the disease in 18/50 (36%) patients with frontal fibrosing alopecia and 2/50 (4%) patients with alopecia areata. The control group consisted of 50 healthy people (34 women and 16 men; age range: 22 82). Follicular (Figs 1 5) and eccrine duct (Figs 1 6) openings were observed in all patients with alopecia areata, frontal fibrosing alopecia and healthy controls. In most cases, they were seen as yellow dots. Less commonly (mainly in patients with frontal fibrosing alopecia), they were reddish or greyish. Exclamation mark hairs (Figs 1 and 2) and tapered hairs (Fig. 2) were statistically significant more commonly detected in patients with alopecia areata (15/50, 30% and 7/50, 14%, respectively) compared to patients with frontal fibrosing alopecia (0/50, 0% and 2/50, 4%, respectively) and healthy Figure 6 Trichoscopy of eyebrow loss in frontal fibrosing alopecia (920). Whitish area with the absence of follicular openings and the presence of eccrine duct openings (green arrows) may be noticed. controls (0/50, 0% and 0/50, 0%, respectively; P < 0.001 and P < 0.01, respectively). Moreover, broken hair (Fig. 5) and black dots (Fig. 3) were statistically significant more commonly present in patients with alopecia areata (18/50, 36% and 13/50, 26%, respectively) compared to patients with frontal fibrosing alopecia (8/50, 16% and 1/50, 2%, respectively) and healthy controls (0/0, 0% and 0/0, 0%, respectively; P < 0.001 and P < 0.001, respectively). Pohl Pinkus constrictions (Fig. 3) were present only in patients with alopecia areata (2/50, 4%; P = 0.13). Dystrophic hairs (Fig. 4) and whitish areas with absence of follicular openings (Fig. 6) were detected in 14/50 (28%) and 16/50 (32%) patients with frontal fibrosing alopecia, and they were not observed in patients with alopecia areata and healthy controls (P < 0.001). Moreover, eyebrow regrowth in distinct directions (Fig. 5) was statistically significant more commonly present in patients with frontal fibrosing alopecia (16/50, 32%) compared to patients with alopecia areata (4/50, 8%) and healthy controls (2/50, 4%; P < 0.001). Vellus hairs (Figs 2 and 3) and upright regrowing hairs (Figs 1 3 and 5) were statistically significant less commonly detected in patients with alopecia areata (31/50, 62% and 29/50, 58%, respectively) and frontal fibrosing alopecia (30/50, 60% and 42/50, 84%, respectively) compared healthy controls (50/50, 100% and 50/50, 100%, respectively; P < 0.001). Diffuse erythema (Fig. 5) was observed in patients with alopecia areata (30/ 50, 60%), patients with frontal fibrosing alopecia (30/50, 60%) and healthy controls (28/50, 56%; P = 0.86). Detailed data are presented in Table 1. The limitations of the study are its retrospective form and no analysis of histological correlations. Discussion Alopecia areata is an autoimmune form of non-scarring hair loss that may affect any hair-bearing area. 9 Eyebrow loss might

216 Waskiel-Burnat et al. Table 1 Trichoscopic findings of eyebrow loss in alopecia areata and frontal fibrosing alopecia Trichoscopic findings Alopecia areata Number of patients (%) Frontal fibrosing alopecia Number of patients (%) Healthy controls Number of patients (%) Statistical significance (P value) Follicular openings 50/50 (100%) 50/50 (100%) 50/50 (100%) Eccrine duct openings 50/50 (100%) 50/50 (100%) 50/50 (100%) Black dots 13/50 (26%) 1/50 (2%) 0/50 (0%) <0.001 Exclamation mark hairs 15/50 (30%) 0/50 (0%) 0/50 (0%) <0.001 Broken hairs 18/50 (36%) 8/50 (16%) 0/50 (0%) <0.001 Tapered hairs 7/50 (14%) 2/50 (4%) 0/50 (0%) <0.01 Dystrophic hairs 0/50 (0%) 14/50 (28%) 0/50 (0%) <0.001 Vellus hairs 31/50 (62%) 30/50 (60%) 50/50 (100%) <0.001 Upright regrowing hairs 29/50 (58%) 42/50 (84%) 50/50 (100%) <0.001 Eyebrow regrowth in distinct directions 4/50 (8%) 16/50 (32%) 2/50 (4%) <0.001 Pohl Pinkus constrictions 2/50 (4%) 0/50 (0%) 0/50 (0%) 0.13 Diffuse erythema 30/50 (60%) 30/50 (60%) 28/50 (56%) 0.86 Whitish areas with absence of follicular openings 0/50 (0%) 16/50 (32%) 0/50 (0%) <0.001 coexist with patchy alopecia areata, as well as occur as an isolated involvement or as a part of alopecia universalis. 10 In the present study, eyebrow loss as initial clinical manifestation of alopecia areata was observed in 2/50 (4%) cases. The trichoscopic findings of scalp alopecia areata include yellow dots, vellus hairs, exclamation mark hairs, tapered hairs, Pohl Pinkus constrictions, black dots, broken hairs, upright regrowing hairs and pigtail (circle) hairs. 5 To date, there are no studies which address the trichoscopic features of eyebrow loss in alopecia areata. Partial or complete eyebrow loss is observed in 39% 11 to 100% 12 of patients with frontal fibrosing alopecia and is thought to precede scalp alopecia in 39% of cases. 11 In the present study, eyebrow loss as initial clinical manifestation of frontal fibrosing alopecia was observed in 18/50 (36%) cases. Clinically, eyebrow loss appears to be non-inflammatory and non-scarring. 12 However, the presence of fibrous tracts at the isthmus and the supraisthmic area in histopathological examination indicates a cicatricial form of eyebrow loss. 12 Trichoscopy features of frontal fibrosing alopecia are mild perifollicular scaling, absence of follicular openings, perifollicular erythema, white cicatricial areas, blue-grey and classic white dots. 6 To date, only one case series study has reported trichoscopic markers of eyebrow loss in frontal fibrosing alopecia. Anzai et al. 8 in 3/3 (100%) patients with eyebrow frontal fibrosing alopecia described the presence of black dots and broken hairs. Yellow dots and short regrowing hairs were observed in 2/3 (67%) cases, while diffuse erythema, red dots and pinpoint white dots in 1/3 (33%). Exclamation mark hairs (Figs 1 and 2) represent fractured hairs with a thin proximal end and a significantly thicker distal end. 5 They result from an inflammatory process that induces damage to the keratogenous zone of the rapidly growing, mitotically active anagen follicles. 13 In active alopecia areata of the scalp, an abundant amount of exclamation mark hairs, mainly at the hair-bearing margin is observed. In the present study, exclamation mark hairs occur as a characteristic trichoscopic feature of eyebrow loss in alopecia areata (P < 0.001). They were less commonly observed compared to scalp alopecia areata (30% vs. up to 71% according to literature data). 7 Moreover, contrary to the scalp, mainly solitary exclamation mark hairs were detected in eyebrow loss. This observation may be related to the fact that anagen follicles comprise only 10% of eyebrow hair and are rarely arranged between telogen follicles. By definition, tapered hairs have a thinner proximal end, while the distal end is outside of the field of view of a dermoscope. 5 They result from inflammatory damage to hair follicles in the late anagen phase with low mitotic activity. 13,14 The inflammatory process results in the reduction (no cessation) of mitotic activity. Indeed, hair follicles are still able to produce a thin hair shaft. If this inflammatory process is repeated in short time periods, Pohl Pinkus constrictions (zones of decreased hair thickness within the hair shaft) are observed. 13 According to the literature, tapered hairs are present in up to 81% of patients with scalp alopecia areata (mean value: 51%), and they are not observed in patients with scalp frontal fibrosing alopecia. 5,6 In the present study, tapered hairs occur as characteristic trichoscopic finding of alopecia areata. They were reported in 7/50 (14%) patients with alopecia areata and 2/50 (4%) patients with frontal fibrosing alopecia, and they were not observed in healthy controls (P < 0.01). It has to be emphasized that in short eyebrow hair, the distal end is always present in the field of view of a dermoscope. Thus, in this location, tapered hairs may be defined as hairs with proximal hair shaft thinning and tapered distal end (no thicker as in exclamation mark hairs; Fig. 2). According to the literature, Pohl Pinkus constrictions (Fig. 3) are observed in up to 10% (mean value: 4%) of patients with

Trichoscopy of eyebrows 217 scalp alopecia areata, and they are not reported in frontal fibrosing alopecia. 5,6 In this study, they were observed in 2/50 (4%) patients with alopecia areata and were not detected in patients with frontal fibrosing alopecia and healthy controls. However, their presence was not statistically significant (P = 0.13). Broken hairs (Fig. 5) are present in up to 71% of patients with scalp alopecia areata (mean value: 49%). They may be also occasionally observed in scalp frontal fibrosing alopecia. 15 Moreover, in the study performed by Anzai et al., 8 broken hairs were detected in 3/3 (100%) patients with eyebrow frontal fibrosing alopecia. In the present study, broken hairs were statistically significant more commonly observed in patients with alopecia areata (13/50, 36%) compared to patients with frontal fibrosing alopecia (8/50, 16%) and healthy controls (0/50, 0%; P < 0.001). According to the literature, the incidence of black dots (Fig. 3) in scalp alopecia areata are reported in up to 84% of patients (mean value: 58%). 5 They may be also occasionally observed in scalp frontal fibrosing alopecia. 16 Moreover, in the study conducted by Anzai et al., 8 black dots were presented in 3/ 3 (100%) patients with eyebrow frontal fibrosing alopecia. In this study, black dots were statistically significant more commonly detected in patients with alopecia areata (13/50, 26%) compared to patients with frontal fibrosing alopecia (1/50, 2%) and healthy controls (0/50, 0%; P < 0.001). Similarly to exclamation mark hairs, the less common presence of tapered hairs, Pohl-Pinkus constrictions, broken hairs and black dots in eyebrow compared to scalp alopecia areata may be associated with a lower percentage of hair follicles in the anagen phase in this location. In scalp area, empty follicular openings are mainly observed as yellow dots (yellow colour corresponds to sebum and/or keratotic material present within follicular infundibula). 5 In patients with alopecia areata, the incidence of yellow dots varies between 6% and 100% (mean value: 62%) of cases. 5 They are usually numerous and clustered (defined as three or more yellow dots in adjacent follicular units). 17 The lack of follicular opening is a characteristic trichoscopic finding of cicatricial alopecia such as frontal fibrosing alopecia. 6 Nevertheless, in the studies conducted by Fernandez-Crehuet et al. 18 and Toledo-Pastrana et al., 15 yellow dots were observed in 21.2% and 44.8% of patients with scalp frontal fibrosing alopecia. Moreover, in the study performed by Anzai et al., 8 yellow dots were detected in 2/ 3 (67%) patients with eyebrow frontal fibrosing alopecia. In the present study, solitary empty follicular openings (in most cases observed as yellow dots; Figs 1 5) were detected in the eyebrow area in all patients with alopecia areata, frontal fibrosing alopecia and healthy controls. However, contrary to patients with alopecia areata and healthy controls, follicular openings in frontal fibrosing alopecia tended to be more reddish or greyish. Reddish yellow dots in patients with frontal fibrosing alopecia have to be differentiated from true red dots that are the characteristics of discoid lupus erythematosus. 19 Unlike on the scalp, clustered yellow dots were not present because of the lack of multiple-hair follicular units in the eyebrow area. The high prevalence of empty follicular openings in the eyebrow area may be associated with a short eyebrow hair cycle. Frequent eyebrow shedding may indicate that many follicles are in the teloptosis/exogen phase (the moment at which the club hair is shed from the follicle that is already occupied by a new terminal anagen hair) or the kenogen phase ( latency period ), and thus, yellow dots are commonly observed in trichoscopic examination. Moreover, pinpoint yellow dots (Figs 1 6) that correspond to eccrine duct openings were observed in all patients with alopecia areata, frontal fibrosing alopecia and healthy controls. Other characteristic trichoscopic features of scalp alopecia areata vellus hairs (defined as thin and hypopigmented hairs shorter than 10 mm; Figs 2 and 3) were statistically significant more commonly reported in healthy controls (50/50, 100%) compared to patients with alopecia areata (31/50, 62%) and frontal fibrosing alopecia (30/50, 60%; P < 0.001). Furthermore, upright regrowing hairs (defined as short, regrowing hairs with a tapered distal end and a straight-up position; Figs 1 3 and 5) were detected in all healthy controls (50/ 50, 100%), and they were reported statistically significant less commonly in patients with alopecia areata (29/50, 58%) and patients with frontal fibrosing alopecia (42/50, 84%; P < 0.001). Indeed, presence of vellus hairs or upright regrowing hairs may not be considered as characteristic for any disease. The common presence of upright regrowing hairs in all patients group may be associated with short eyebrow hair cycle that results in frequent eyebrow shedding and new eyebrow regrowth. Diffuse erythema (Fig. 5) was observed in 30/50 (60%) patients with both alopecia areata and frontal fibrosing alopecia and 28/50 (56%) healthy controls (P = 0.86). Thus, it may not be considered as characteristic for any disease. Eyebrow regrowth in distinct directions (Fig. 5) was more commonly observed in patients with frontal fibrosing alopecia (16/50, 32%) compared to patients with alopecia areata (4/50, 8%) and healthy controls (2/50, 4%; P < 0.001). It may be hypothesized that eyebrow regrowth in distinct directions reflect fibrosing process, and thus, it is more commonly detected in patients with frontal fibrosing alopecia compared to patients with non-cicatricial eyebrow loss and healthy individuals. In patients with frontal fibrosing alopecia, dystrophic hairs (Fig. 4) and whitish areas with absence of follicular openings (Fig. 6) that reflect the fibrosing process 6 were detected (14/50, 28% and 16/50, 32%, respectively; P < 0.001). Nevertheless, eccrine duct openings were observed within whitish areas. This observation may be attributed to the fibrosing process limited to the perifollicular area. 12 Indeed, in frontal fibrosing alopecia, eccrine glands are spared. 20 It needs to be emphasized that misidentification of eccrine duct openings as follicular openings within whitish areas may falsely indicate non-scarring eyebrow loss.

218 Waskiel-Burnat et al. Eyebrow loss Exclamation mark hairs Dystrophic hairs Tapered hairs Whitish areas with absence of follicular openings Broken hairs Eyebrows regrowth in distinct directions Black dots Classic yellow dots Reddish/greyish yellow dots Alopecia areata Frontal fibrosing alopecia Figure 7 Trichoscopic features characteristic for eyebrow loss in alopecia areata and frontal fibrosing alopecia. The presence of empty follicular openings, vellus hairs and upright regrowing hairs in patients with eyebrow frontal fibrosing alopecia reported in this study, as well as eyebrow regrowth in some patients with frontal fibrosing alopecia treated with intralesional triamcinolone acetonide 21 indicates that eyebrow loss in frontal fibrosing alopecia may be reversible. Moreover, empty follicular openings, vellus hairs and upright regrowing hairs may be considered as favourable prognostic factors. On the contrary, the presence of dystrophic hairs, eyebrow regrowth in distinct directions and whitish areas with absence of follicular openings indicates cicatricial eyebrow loss. Thus, they may be considered as negative prognostic factors for eyebrow regrowth. Perifollicular erythema, perifollicular scaling and white dots typically seen in scalp frontal fibrosing alopecia were not observed in our study in eyebrow area. Similar to scalp alopecia areata, the presence of exclamation mark hairs, tapered hairs, broken hairs and black dots may be considered as markers of active eyebrow loss, while upright regrowing hairs as markers of eyebrow regrowth. Trichoscopic features characteristic for eyebrow loss in alopecia areata and frontal fibrosing alopecia are presented in Figure 7. Conclusion Trichoscopy (scalp and hair dermoscopy) is a useful method in diagnosing eyebrow loss in the course of alopecia areata and

Trichoscopy of eyebrows 219 frontal fibrosing alopecia and can be particularly helpful in isolated eyebrow loss in these diseases. The most characteristic trichoscopic features of eyebrow loss in alopecia areata include exclamation mark hairs, tapered hairs, broken hairs and black dots. The less common presence of these trichoscopic findings in eyebrow compared to scalp alopecia areata may be associated with a shorter eyebrow hair cycle in comparison with scalp hair. The short anagen phase of eyebrows results in a low percentage of anagen follicles that are affected by an inflammatory process in alopecia areata. Thus, these characteristic features of alopecia areata may not always be present in trichoscopic examination. Dystrophic hairs, whitish areas with absence of follicular openings and eyebrow regrowth in distinct directions are the most characteristic trichoscopic findings for eyebrow loss in frontal fibrosing alopecia. The presence of empty follicular openings, vellus hairs and upright regrowing hairs in patients with frontal fibrosing alopecia may be considered as favourable prognostic factors for eyebrow regrowth. On the contrary, dystrophic hairs, eyebrow regrowth in distinct directions and whitish areas with absence of follicular openings may be considered negative prognostic factors. References 1 Chanasumon N, Sriphojanart T, Suchonwanit P. Therapeutic potential of bimatoprost for the treatment of eyebrow hypotrichosis. Drug Des Devel Ther 2018; 12: 365 372. 2 Kumar A, Karthikeyan K. Madarosis: a marker of many maladies. Int J Trichol 2012; 4: 3 18. 3 Rudnicka L, Olszewska M, Majsterek M et al. Presence and future of dermoscopy. Exp Rev Dermatol 2006; 1: 769 772. 4 Lacarrubba F, Micali G, Tosti A. Scalp dermoscopy or trichoscopy. Curr Probl Dermatol 2015; 47: 21 32. 5 Waskiel A, Rakowska A, Sikora M et al. Trichoscopy of alopecia areata: An update. J Dermatol 2018; 45: 692 700. 6 Waskiel A, Rakowska A, Sikora M et al. Trichoscopy in lichen planopilaris: an update. Dermatol Rev 2018; 105:63 75. 7 Seo J, Lee JW, Choi MJ et al. Serial trichoscopy vs. modified hair pull test for monitoring the disease activity and treatment response of localized alopecia areata. J Eur Acad Dermatol Venereol 2017; 31: e149 e150. 8 Anzai A, Donati A, Valente NY et al. Isolated eyebrow loss in frontal fibrosing alopecia: relevance of early diagnosis and treatment. Br J Dermatol 2016; 175: 1099 1101. 9 Alkhalifah A. Alopecia areata update. Dermatol Clin 2013; 31: 93 108. 10 Barankin B, Taher M, Wasel N. Successful hair transplant of eyebrow alopecia areata. J Cutan Med Surg 2005; 9: 162 164. 11 Vano-Galvan S, Molina-Ruiz AM, Serrano-Falcon C et al. Frontal fibrosing alopecia: a multicenter review of 355 patients. J Am Acad Dermatol 2014; 70: 670 678. 12 Chew AL, Bashir SJ, Wain EM et al. Expanding the spectrum of frontal fibrosing alopecia: a unifying concept. J Am Acad Dermatol 2010; 63: 653 660. 13 Whiting DA. Histopathologic features of alopecia areata: a new look. Arch Dermatol 2003; 139: 1555 1559. 14 Pratt CH, King LE Jr, Messenger AG et al. Alopecia areata. Nat Rev Dis Primers 2017; 3: 17011. 15 Toledo-Pastrana T, Hernandez MJ, Camacho Martinez FM. Perifollicular erythema as a trichoscopy sign of progression in frontal fibrosing alopecia. Int J Trichol 2013; 5: 151 153. 16 Sonthalia S, Jha AK, Tiwary PK. A dermoscopic diagnosis and activity evaluation of frontal fibrosing alopecia in an Indian lady. Indian Dermatol Online J 2017; 8: 162 163. 17 Rakowska A, Zadurska M, Czuwara J et al. Trichoscopy findings in loose anagen hair syndrome: rectangular granular structures and solitary yellow dots. J Dermatol Case Rep 2015; 9: 1 5. 18 Fernandez-Crehuet P, Rodrigues-Barata AR, Vano-Galvan S et al. Trichoscopic features of frontal fibrosing alopecia: results in 249 patients. JAm Acad Dermatol 2015; 72: 357 359. 19 Rakowska A, Slowinska M, Kowalska-Oledzka E et al. Trichoscopy of cicatricial alopecia. J Drugs Dermatol 2012; 11: 753 758. 20 Busam K. Dermatopathology. Elsevier, Philadelphia, 2010. 21 Donovan JC, Samrao A, Ruben BS et al. Eyebrow regrowth in patients with frontal fibrosing alopecia treated with intralesional triamcinolone acetonide. Br J Dermatol 2010; 163: 1142 1144.