Hair shaft abnormalities-clues to diagnosis treatment. Presented by

‫به نام خداوند جان و خرد‬
Hair shaft abnormalitiesclues to diagnosis treatment.
Presented by Dr . Anahita Vali
‫داستان زال و رودابه‬
‫بدان پرورا نيدم اين تار را‬
‫كه تا دستگيري كند يار را‬
‫تو اين را دروغ و فسانه مدان‬
‫استحكام عجيب موها‬
‫يك رشته مو توانائي بلند كردن وزنه‬
‫‪ 100‬گرمي را دارد بدون آنكه‬
‫پاره و گسسته شود و حتي ميتوان‬
‫ريسمان محكمي از موها بافت‪.‬‬
What is the similarities between hair & plants ?
The commonest causes of hair
fragility and breakage are cosmetic.
 Repeated physical injury
from overzealous grooming, Avoid/Avoid/Avoid
backcombing, braiding and
traction and long exposure
to heat and ultraviolet light
can cause weathering and
damage to the hair. Chemical
injury from perm lotions,
straighteners and hair dyes
can cause similar changes.
Rare inherited
conditions like monilethrix,
pili torti, trichorrhexis
nodosa, and
trichothiodystrophy and
trichorrhexis invaginata
cause brittle hair and
obvious hair loss from
Gentle hair care should be
the prime concern. Avoid
‫شكل ظاهري مو متاثر از پيوندهاي شيميائي داخل آن است‬
‫پيوندهاي دي سولفيدي‬
‫پيوندهاي هيدروژني‬
‫قوي ترو مستحكم تر‬
‫تنها راه تغئير آن ها مواد شيميائي‬
‫تعداد كمتر‬
‫ضعيف تر‬
‫تعداد بيشتر‬
‫مسئول انعطاف پذيري مو ها‬
‫درزمان خيس شدن مو باندهاي‬
‫هيدروژني به دفعات شكسته‬
‫ميشوند و در زمان خشك شدن آن‬
‫دوباره شكل ميگيرند‬
Hair shaft abnormalities are characterized
by changes in color, density, length and
Hair dysplasias
dry and looks lusterless.
easily broken, slow-growing, and seldom required
Office diagnosis of hair shaft
Good clinical history emphasizes other skin appendages such
as the nails, sweat and sebaceous glands.
Careful examination of the hair and scalp
Evaluation of affected hair shafts under , the light
microscope .
important note :To take representive hairs
of the scalp .
Different areas
Good Idea
Examine the Proximal 1-2 cm of the
affected shaft adjacent to scalp to
exclude the effects of Weathering .
Microscopic examination
 With
normal transmitted light or with polarized light.
 Hairs can be examined dry between two glass slide .
 Better and under higher magnification with a mounting medium
 The hairs placed side by side on slide without overlap under the
coverslip .
 The electron microscope (scanning or transmission)
Before making the diagnosis of a
Hair shaft abnormality , it is
Important to have a through
Knowledge of the
Variation in normal hairs .
It should be remembered that
normal hairs differ considerably in
length , diameter , cross section , color and
Cuticular pattern even in the
Same patient .
Normal hair variations
Curly ( helical )
Woolly or peppercorn
( spiral )
‫هركه در اين حلقه نيست فارغ از اين ماجراست‬
NO biochemical differences
Have been detected among the
Various forms of human hair . Physical
Properties of hairs are derived from
the central portion of the hair shaft , the
Cortex , which comprises 90% of the hair
shaft .
Variations among races
wide structural variability
even in normal hair
– Asiatic
hair : visually straight
– Caucasian hair : may be straight , wavy or
curly .
– Negroid hair : woolly or peppercorn .
Hair shaft Defects
Inherited eg . Trichorrhexis invaginata
Acquired eg . Trichoptilosis
Dermoscopy is a method based on epiluminescence
microscopy, which is used to visualize living skin in
magnification.Videodermoscopy of hair and scalp
(trichoscopy) is a new method, which allows viewing hair
shafts in vivo in many-fold magnification without the need
of pulling hair for diagnostic purposes of examination
Trichoscopy in genetic hair shaft
20-fold and 70-fold
magnification were analysed. In
selected cases 160-fold
magnification was used for
better visualization of hair
Several reports indicate the
usefulness of trichoscopy in
diagnosing hair and scalp
disorders, including
androgenic alopecia,
alopecia areata or
lipedematous alopecia.
Genetic hair shaft
abnormalities may be
diagnosed by trichoscopy
in a single diagnostic
session without the need
of plucking or cutting
them for diagnostic
Trichoscopy of hair shafts demonstrated a “crawling snake” appearance, with
short wave cycles under 20× magnification We liken this appearance to the head of the
mythical character Medusa, a character in Greek mythology, whose scalp hair was made of
living snakes. Apart from that, the examination demonstrated broken hair shafts.
Evenly pigmented, coarsetextured, and extremely curly
scalp hair
crawling snake”
Hair abnormalities are
extremely common in
genoder-matoses. Hair
changes may be a
significant finding or even
the initial presentation of
a syndrome giving the clue
to the diagnosis, in
diseases such as
Netherton syndrome, or
Woolly hair syndrome.
Most hair shaft abnormalities
Can be seen sporadically in
normal hair so need to be found
Consistently in different areas of the
Scalp to be of
Diagnostic importance
Hair Shaft Defects in Children
Children may be born with a good
head of hair, or relatively little hair,
or no hair at all. At birth, any of
these may be normal events,
but at 12 months of age, the
average child will have diffuse scalp
hair growth and by 2 years should
have normal scalp hair. If funnylooking hair is present, or if scalp
hair is totally absent in a child aged
1 years old, then that should cause
concern. Hair shaft defects in
children may only involve certain
areas such as the nape of the neck
and the temples, or may affect
much or all of the scalp hair.
The Netherton syndrome is
characterized by three major clinical
features: ichthyosiform dermatosis (nonbullous ichthyosiform erythroderma or as
ichthyosis linearis circumflexa), atopy and
a characteristic hair abnormality.
Clinically hair appears sparse, dull, brittle
and short. The hair shaft abnormality,
called bamboo hair or trichorhexis
invaginata is microscopically characterized
by an invagination of the distal portion of
the hair shaft into its proximal portion
forming a "ball in cup" appearance and is
considered pathognomonic for Netherton
Without fragility , have no functional
significance .
Pili annulati (ringed hair )
Woolly hair
Woolly hair nevus
Uncombable hair syndrome (cheveux
incoiffables )
Straight hair nevus
Hair shaft Defects
With fragility causing patchy hair loss
Bamboo hair ( nethertons syndrome )
Trichorrhexis nodosa
● Sun
● Wind
● Swimming
● Washing
● Friction
● Excessive
hair styling
Trichoclasis refers to the common “greenstick” fracture
of the hair shaft, consisting of a transverse fracture
splinted by an intact cuticle. There is no constant
abnormality of the cuticle or cortex in this
condition. Trichoclasis can be found in different hair shaft
abnormalities or simply following excessive hair care and
trauma. Usually when physical trauma accounts for
trichoclasis, the affected area shows sporadic and patchy
damage, which can be reversed with gentle hair care.
Pili Multigemini and Pili Bifurcati
In pili multigemini, hairs are formed from 2 to
8 hair papillae and matrices. The hair
shafts are surrounded by a common outer
root sheath but each hair has its own
inner root sheath, arising from one
follicular canal. Given this tight
arrangement, emerging hairs may look
flattened, triangular, or ovoid with possible
longitudinal grooves. In adults, pili multigemini
is usually found in the beard region,
sometimes in a linear distribution. In children,
the scalp is typically the affected area. Pili
bifurcati refers to hair shafts that
emerge from a single papilla but then
split into two shafts with their own
distinct cuticles which can then rejoin as
one shaft, even more than one time. It
represents a restricted from of pili multigemini
and occurs on the scalp rather than the beard.
‫آسيبهاي اكتسابي ساقه مو‬
‫فركردن يا صاف كردن موي سر‬
‫رنگ كردن يا رنگ بري موي سر‬
‫پوش دادن يا شانه كردن برعكس‬
‫استفاده نامناسب از اتو مويا سشوار‬
‫آفتاب گرفتن‬
‫استفاده زياد از استخر‬
‫دفترچه خاطرات هفت ساله‬
‫نرم كننده هاي مو يا حالت دهنده ها‬
‫نرم كننده هاي جديد‬
‫مشتقي از ويتامين ب‬
‫مولكولهاي بزرگ داراي بار‬
‫الكتريكي مثبت‬
‫به داخل تار مو جذب وباعث‬
‫رطوبت دهي آن ميشود‬
‫مو خود اندكي بار منفي دارد‬
‫چسبيدن مولكولها به لبه فلسهاي‬
‫به داخل پوست سر نيز نفوذ مي كند آسيب ديده كوتيكول‬
‫و باعث رطوبت رساني فوليكولها در نتيجه قابليت آراستن و براق‬
‫نيز ميشود‬
‫بودن مو افزايش مي يابد‪.‬‬
‫در نتيجه رطوبت مناسبي را در‬
‫زمان رويش مو در اختيار آن مي‬
‫‪PH‬موي انسان در حدود ‪ 6‬است‬
‫نقطه ايزوالكتريك موئي كه هيچ‬
‫تغئيري در آن ايجاد نشده ‪ 3/67‬است‬
‫در اين پي اچ تارهاي مو تمايلي‬
‫به انتقال بار الكتريكي ندارند‬
‫اثرات كلر بر روي موي سر‬
‫حتي در حضور مقادير بسيار كم كلر‬
‫كلر باعث تخريب پروتئين در سطح‬
‫اپي كوتيكول ميشود‬
‫بكار گيري شامپو در زمان استفاده‬
‫از آب حاوي كلر آسيب را كاهش‬
‫مي دهد‬
With light microscopy hair shaft
abnormalities can be divided into four
Categories , these includes :
1) Fractures of the hair shaft
2) Irregularities of the hair shaft
3) Hair shaft coiling and twisting
4) Exogenous matter on the hairshaft
Fractures of the hair shaft
Transverse ( Trichoschesis , Trichorrhexis nodosa )
Oblique ( Tapered fractured , eg anagen effluvium )
Longitudinal (Trichoptilosis )
Acquired trichorrexis nodosa (more
common )
Excessive weathering
Back combing
Stressed hair styles
Head rolling and banging
Habit tic
Perming and dyeing of hairs
Congenital trichorrhexis nodosa
May occur as an isolated entity
May occurs with a metabolic abnormality such as
Arginosuccinic aciduria
Menkes disease
Trichothiodystrophy .( hair sulfur <50% normal)
Heat is a great enemy to hair .
(the dryer must always be used with great
care and at a moderate setting )
‫هيچ درماني براي موهاي آسيب ديده از حرارت زياد وجود‬
‫بكار گيري منظم‪،‬مرتب و درست از‬
‫حالت دهنده ها‬
‫پوشش كامل مو بصورت بتونه‬
‫كردن ميتواند باعث كاهش بروز‬
‫مو خوره شود‬
Pili torti
regular twists of the hair shaft along the long axis
Hair Shaft Coiling and Twisting- Pili Torti
Pili torti refers to the hair shaft that is twisted on its own axis leading to
irregularly spaced beads from the twists, making the hair brittle and break
easily. Twisted hairs can be seen normally on a scalp, particularly the
pubic and axillary hair are normally twisted. Pili torti is usually a
congenital condition but can be acquired as well. Children with neural
hearing loss have been seen with pili torti which would lead the
investigator to insist on early auditory testing. Bjornstad’s syndrome is
a rare condition characterized by hearing loss and pili torti. Hypogonadism
can be present (Crandall’s syndrome) along with mental retardation. As
mentioned, Menkes’ kinky hair syndrome can have pili torti, trichorrhexis
nodosa, trichoclasis, and trichoptilosis, making the hair feel like steel
wool. A unique form of pili torti is known as corkscrew hair in which
many hairs are twisted in a double spiral, which can occur associated with
widely spaced teeth and joined fingers and toes (syndactyly).
autosomal dominant hair disorder periodic
thinning of hair shafts /tendency to
fracture at constricted points.
clinically in hair fragility and patchy
dystrophic alopecia Follicular
abnormalities seen in monilethrix range
from subtle perifollicular erythema and
hyperkeratosis to horny follicular papule
[Mutations in hair specific keratins,
especially hHb1 and hHb6, which
are primarily expressed in cortical
trichocytes, cause predominantly structure
abnormalities of hair cortex.
pili annulati showed a random pattern of intermittent abnormal cavities .Light bands
observed by clinical examination appeared as dark bands when imaged by light
microscopy, reflecting cortical spacers containing air in the light bands and fluid in the
dark bands.
Light microscopy showed hair shafts with an irregular, undulating contour and transverse
fractures through the hair shaft (trichoschisis). Polarized light microscopy showed
bright and dark .Hair shafts were notably flattened, folded most probably during the hair
mounting process.
Trichoscopy in trichotiodystrophy patients was non-specific. At a higher magnification
hairs showed a non-homogenous structure reassembling grains of sand within the hair
shaft and a slightly wavy contour
These features are visible in patients with
dark and light hairs. This has to be
distinguished from a symptom called
intermittent medulla, observed in
normal thick hair shafts, which may be
wrongly diagnosed as pili annulati. In these
cases, the medulla visible as light-colored
constitutes less than 50% of the hair shaft
width, the light bands are short and the
intervals between them are usually shorter
than the bands' own length. Our study
shows that this feature can be
distinguished by trichoscopy from the light
bands in pili annulati, which take up more
than a half of hair shaft width. The
boarders of bands are not clear-cut and the
intervals between these bands are usually
longer than the bands' own length.
Oblique Fractures- Tapered Fracture
Fractures of the hair that cause a pencil point
appearance are due to inhibition of nucleic acid and
protein synthesis and therefore mitosis during
anagen. Progresive narrowing of the emerging hair shaft
may lead to a detached fractured hair with the thinner
end near the scalp end. This is most commonly seen in
anagen effluvium from cytotoxic chemotherapy
drugs that disturb anagen hair shafts.
Trichostasis Spinulosa
Trichostasis spinulosa
refers to multiple hairs
that are present in one
Trichostasis spinulosa refers to multiple hairs that are present in one follicular canal with 5 to 50 vellus hairs that are embedded in a large comedo. Trichostasis is
follicular canal with 5 to
50 vellus hairs that are
embedded in a large
comedo. Trichostasis is
now regarded as a normal,
age-related process that is a
variant of a comedo. It
principally affects the chest
and back, especially the
scapular area and is less
common on the abdomen,
face, and neck. Topical
retinoic acid is the most
effective treatment.
Prophylaxis of acquired
hair shaft Defects
●Minimize damage from hair cosmetics
● Avoid
harsh shampoos
● To comb dry hair
( since friction is higher in wet hairs )
Hair dryers applied on
wet hair at high temperatures
may also provoke the well – known
phenomenon of Bubble
hair .
help to protect
hair .
Therapy of hair shaft disorders should focus
on the cause.
In addition, minimizing
traumatic influences to
hair shafts, such as drying
hair with an electric dryer
or permanent waves and
dyes, is important. A short
hairstyle is more suitable
for patients with hair shaft
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