PMC9910513_01
(a) Multiple skin-colored dome-shaped alopecic nodules on the vertex and occipital area of scalp in case 1 (yellow star showing site of biopsy, blue stars showing areas of trichoscopy). (b) Trichoscopy showing broken hair (red arrow), black dot (yellow arrow), and dilated follicular openings: "Eastern pancake sign" (blue arrows; DermLite DL3, polarized, 10x). (c) Trichoscopy showing broken hair (yellow arrow), black dots (green arrow), yellow dots (red arrows), and vellus hair (blue arrow), brown honeycomb pigment network (black arrows), and pinkish hue in the background (Dino-lite Edge, non-polarized, 70x). (d) Histopathology showing foreign-body giant cells (red arrows), pseudocyst (green arrow), mixed inflammatory infiltrate comprising neutrophils, plasma cells, and lymphocytes (blue arrows; 100x, hematoxylin and eosin)
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Cutaneous examination revealed multiple, nontender, firm, dome-shaped skin-colored nodules, sized 1.5 to 5 cm, involving vertex and occipital area of scalp [Figure 1a]. Trichoscopy showed black dots, yellow dots, broken hairs, vellus hair, and "Eastern pancake sign" corresponding to dilated follicular openings, honeycomb pigment network, and a pinkish hue in the background [Figure 1b and c]. It showed intact pilosebaceous units, with a total of 14 including 5 hair follicles in the telogen phase, without any evidence of scarring [Figure 1d].
PMC9910513_02
(a) Single skin-colored dome-shaped alopecic nodule on the vertex in case 2. (b) Trichoscopy showing black dots (yellow arrows), pili torti (blue arrow), white homogenous areas, and white lines (white arrows) against a pinkish background (DermLite DL3, polarized, 10x). (c) Trichoscopy showing multiple patulous follicular openings "the Eastern pancake sign" (yellow arrows), fine vellus hair (blue arrows) against a pinkish background (Dino-lite Edge, nonpolarized, 70x). (d) Histopathology showing perifollicular infiltrate comprising neutrophils, plasma cells, and lymphocytes (red arrows), intact pilosebaceous unit (yellow arrows) without any areas of fibrosis (100x, hematoxylin and eosin)
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Cutaneous examination revealed a single skin-colored dome-shaped, nontender, firm nodule varying from 1.5 to 3 cm in diameter, with few terminal hairs and creamy white exudate [Figure 2a]. Trichoscopy showed few black dots, dilated follicular openings, and twisting of hair shafts resembling pili torti [Figure 2b and c]. Histopathology revealed stratified squamous epithelium with no evidence of cyst formation, presence of perifollicular inflammatory infiltrate, intact pilosebaceous units without any areas of fibrosis [Figure 2d].
(a) Posttreatment clinical image of case 1 showing resolving alopecia and nodules. (b) Posttreatment trichoscopic image of case 1 showing upright regrowing hair (blue arrow) and absence of dilated follicular openings (DermLite DL3, polarized, 10x). (c) At 3-month follow-up after treatment, the nodular lesion subsided with increased hair growth (yellow circle) in case 2. (d) Posttreatment trichoscopy of case 2 showing circle hair (blue arrow), short vellus hair (yellow arrow), and absence of dilated follicular openings, indicating regrowth (DermLite DL3, polarized, 10x)
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Both the patients were prescribed doxycycline 100 mg twice daily for 3 months and showed resolution of alopecia and nodules [Figure 3a and c]. Trichoscopy showed circle hair, short vellus hair, and absence of dilated follicular openings indicating regrowth [Figure 3b and d].