erosive pustular dermatitis of the scalp ( epds ) typically affects elderly people and is clinically characterized by pustules , erosions , and crusts , which heal with scarring alopecia . videodermoscopy ( vd ) of the scalp ( trichoscopy ) is a noninvasive tool used for the diagnosis and follow - up of different types of hair loss that , to the best of our knowledge , has never been assessed in the diagnosis of epds . to evaluate the trichoscopy features of epds , we carried out a retrospective analysis of vd images obtained in the scalp of ten patients who affected by histopathologically confirmed epds , seen over a period of 7 years at the outpatients consultation of hair diseases of dermatology of the university of bologna . the trichoscopy results obtained from the patients with epds were compared with those obtained from a series of thirty patients who affected by other type of scarring alopecia involving the scalp and clinically presenting with erosions , crusts , pustules , and atrophy . the most specific vd feature was thus represented by evident hair bulb in the scarring scalp , observed in all patients . epds , a rare chronic disorder of unknown etiology , was first described in 1979 by pye et al . epds typically affects elderly people and is clinically characterized by pustules , erosions , and crusts , which heal with scarring alopecia . usually , the diagnosis is pathologically confirmed . scalp pathology excludes other scarring diseases and reveals nonspecific features : massive fibrosis of the dermis with considerable reduction of the hair follicle density and absence of sebaceous glands with a neutrophilic infiltrate present around the hair follicles at the isthmus level . trichoscopy is a new diagnostic tool that permit diagnosing of different types of hair disorders and it has proved very useful in the management of epds , never seen before . we conducted a retrospective study of vd images obttained in the scalp of ten patient ( mean age 50.3 years , range from 8 to 95 ) with a pathological diagnosis of epds made at the outpatient consultation of hair diseases of the university of bologna seen over a period of 7 years . all medical records of patients with a diagnosis of epds made between january 2007 and january 2015 were reviewed . all patients were monitored by global photography and videodermatoscopy ( foto finder dermatoscope , touchscreen software , bad bimbach , germany ) . the clinical examination revealed in all cases areas of scarring alopecia with skin atrophy . the hair was sparse or absent and sometimes irregularly twisted and broken a few millimeters above emergency . the skin of the scalp was severely thin with eroded areas and in eight patients , it showed blood and seropurulent crusts [ figure 1a ] while in two patients , it was diffusely covered by oily scales . clinical ( a ) and videodermoscopy ( b ) of erosive pustular dermatitis of the scalp with evident hair bulb ( 20 ) trichoscopy was performed with high magnifications ( 2070 ) and in incident light , without the use of immersion oil ( dry vd ) . the following vd features were observed : ( a ) atrophic and thin scalp in 8/10 patients ; ( b ) lack of follicular ostia in 7/10 patients ; ( c ) evident superficial blood vessels in 5/10 patients ; ( d ) evident hair bulbs in all cases [ figure 1b ] . the most specific vd feature was thus represented by evident hair bulb in the scarring scalp , observed in all patients ( 100% ) . the presence of atrophic and thin scalp was observed in 8/10 of cases ; lack of follicular ostia was observed in 7/10 of patients while evident superficial blood vessels were observed in half of the patients . the trichoscopy results obtained from the patients with epds were compared with those obtained from a series of thirty patients , taken from our databases , affected by other type of scarring alopecia involving the scalp and clinically presenting with erosions , crusts , pustules , and atrophy . in folliculitis decalvans ( ten patients ) , vd showed the presence of tufted hair , perifollicular pustules , crusting , yellowish tubular scaling , and thin scalp without follicular ostia with twisted and elongated blood capillary loops [ figure 2a ] . in lichen planopilaris ( ten patients ) , vd showed the presence of peripilar casts , thin scalp without follicular ostia with enlarged and concentrically oriented blood vessels [ figure 2b ] . in discoid lupus erythematosus ( ten patients ) , vd showed keratotic plugs , red dots , and atrophic skin without follicular ostia with enlarged arborizing vessels [ figure 2c ] . ( c ) discoid lupus erythematosus ( 20 ) vd is an important diagnostic tool for hair diseases and should be utilized in all patients as it provides important information and may allow diagnosis , avoiding a biopsy . in our series of patients with epds , the clinical features were not always diagnostic , and other scalp disorders producing atrophy and scarring had to be excluded . trichoscopy might be useful in the diagnosis of epds as it shows atrophic and thin scalp , lack of follicular ostia , evident superficial blood vessels , and more specifically , visible hair follicle bulbs . the presence of evident hair bulb in epds has never been reported in the literature and seems unique and diagnostic of this disease . in conclusion , the finding of scarring alopecia with skin thinning and evident hair follicle bulbs is highly suggestive for epds and may avoid a biopsy . this is particularly interesting in epds as it typically affects elderly patients , where performing a biopsy is difficult due to comorbidities and drug intake .
erosive pustular dermatitis of the scalp ( epds ) typically affects elderly people with scarring alopecia . 
 videodermoscopy ( vd ) of the scalp has never been assessed in the diagnosis of epds . to evaluate the trichoscopy features of epds 
 , we carried out a retrospective analysis of vd images obtained in the scalp of ten patients who affected by epds and were compared with those obtained from a series of thirty patients who affected by other type of scarring alopecia . 
 the most specific vd feature was thus represented by evident hair bulb in the scarring scalp , observed in all patients .