{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T03:36:48Z","timestamp":1790653008948,"version":"4.1.0"},"reference-count":47,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2025,2,12]],"date-time":"2025-02-12T00:00:00Z","timestamp":1739318400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Alopecia is a common and distressing hair loss condition that poses a major diagnostic challenge. While histopathology is the gold standard, its invasive nature limits its routine use. Trichoscopy, a non-invasive imaging technique, has shown promises in diagnosing and differentiating the various alopecia subtypes. However, existing diagnostic algorithms primarily rely on dermoscopic findings. To address this, we developed a novel, three-step algorithm that integrates clinical and trichoscopic features and employs pattern analysis as a diagnostic tool. Methods: A comprehensive literature review was conducted to identify key trichoscopic features associated with different alopecia types. The gathered data were used as a base for the description of trichoscopic features and patterns for each subtype of alopecia, either scarring or non-scarring. Results: The proposed algorithm is analyzed into three steps. In the first step, alopecia is categorized by distribution into: patchy, patterned, or diffuse. In the second step, it distinguishes between scarring and non-scarring alopecia based on the absence or presence of follicular ostia, respectively. Lastly, in the third step, alopecias are distinguished based on specific trichoscopic clues, allowing for the identification of distinct trichoscopic patterns. Conclusions: The three-step diagnostic algorithm for alopecia, utilizing clinical and dermoscopic findings, performs a pattern analysis in trichoscopy, leading to a dermoscopic diagnosis with great confidence, and minimizing the need for invasive diagnostic procedures.<\/jats:p>","DOI":"10.3390\/jcm14041195","type":"journal-article","created":{"date-parts":[[2025,2,12]],"date-time":"2025-02-12T03:41:57Z","timestamp":1739331717000},"page":"1195","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":16,"title":["A Three-Step Diagnostic Algorithm for Alopecia: Pattern Analysis in Trichoscopy"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8189-7486","authenticated-orcid":false,"given":"Alexander C.","family":"Katoulis","sequence":"first","affiliation":[{"name":"2nd Department of Dermatology and Venereology, Medical School, National and Kapodistrian University of Athens, \u201cAttikon\u201d General University Hospital, 124 62 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6932-1441","authenticated-orcid":false,"given":"Georgia","family":"Pappa","sequence":"additional","affiliation":[{"name":"2nd Department of Dermatology and Venereology, Medical School, National and Kapodistrian University of Athens, \u201cAttikon\u201d General University Hospital, 124 62 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0009-8821","authenticated-orcid":false,"given":"Dimitrios","family":"Sgouros","sequence":"additional","affiliation":[{"name":"2nd Department of Dermatology and Venereology, Medical School, National and Kapodistrian University of Athens, \u201cAttikon\u201d General University Hospital, 124 62 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Effie","family":"Markou","sequence":"additional","affiliation":[{"name":"2nd Department of Dermatology and Venereology, Medical School, National and Kapodistrian University of Athens, \u201cAttikon\u201d General University Hospital, 124 62 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonios","family":"Kanelleas","sequence":"additional","affiliation":[{"name":"2nd Department of Dermatology and Venereology, Medical School, National and Kapodistrian University of Athens, \u201cAttikon\u201d General University Hospital, 124 62 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Evangelia","family":"Bozi","sequence":"additional","affiliation":[{"name":"2nd Department of Dermatology and Venereology, Medical School, National and Kapodistrian University of Athens, \u201cAttikon\u201d General University Hospital, 124 62 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Demetrios","family":"Ioannides","sequence":"additional","affiliation":[{"name":"1st Department of Dermatology and Venereology, Medical School, Aristotle University, 541 24 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8308-1023","authenticated-orcid":false,"given":"Lidia","family":"Rudnicka","sequence":"additional","affiliation":[{"name":"Department of Dermatology, Medical University of Warsaw, 02-091 Warsaw, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,2,12]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Marghoob, A.A., and Braun, R. (2013). Principles of dermoscopy and dermoscopic equipment. An Atlas of Dermoscopy, CRC Press. [2nd ed.]. Chapter 1.","DOI":"10.3109\/9781841847627.001"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Maloh, J., Engel, T., Natarelli, N., Nong, Y., Zufall, A., and Sivamani, R.K. (2023). Systematic review of psychological interventions for quality of life, mental health, and hair growth in alopecia areata and scarring alopecia. J. Clin. Med., 12.","DOI":"10.3390\/jcm12030964"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"260","DOI":"10.1016\/j.ad.2014.06.016","article-title":"Histologic features of alopecias: Part II: Scarring alopecias","volume":"106","author":"Requena","year":"2015","journal-title":"Actas Dermosifiliogr."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"T502","DOI":"10.1016\/j.ad.2023.05.014","article-title":"Histopathologic and trichoscopic correlations in nonscarring alopecias","volume":"114","author":"Cabo","year":"2023","journal-title":"Actas Dermosifiliogr."},{"key":"ref_5","first-page":"243","article-title":"Hair loss: Diagnosis and treatment","volume":"110","author":"Dakkak","year":"2024","journal-title":"Am. Fam. Physician"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"686","DOI":"10.1001\/jama.2022.12461","article-title":"Common causes of hair loss","volume":"328","author":"Walter","year":"2022","journal-title":"JAMA"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"399","DOI":"10.1055\/s-0041-1739240","article-title":"Practical approach to hair loss diagnosis","volume":"54","author":"Singh","year":"2021","journal-title":"Indian J. Plast. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Pomsoong, C., Sukanjanapong, S., Ratanapokasatit, Y., and Suchonwanit, P. (2022). Epidemiological, Clinical, and Trichoscopic Features of Syphilitic Alopecia: A Retrospective Analysis and Systematic Review. Front. Med., 9.","DOI":"10.3389\/fmed.2022.890206"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1007\/s12020-017-1280-y","article-title":"Androgenetic alopecia: A review","volume":"57","author":"Lolli","year":"2017","journal-title":"Endocrine"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1016\/j.clindermatol.2020.10.007","article-title":"Frontal fibrosing alopecia","volume":"39","author":"Kerkemeyer","year":"2021","journal-title":"Clin. Dermatol."},{"key":"ref_11","first-page":"e342","article-title":"keloidalis nuchae: An international multicentric review of 79 patients","volume":"38","author":"Courtney","year":"2024","journal-title":"J. Eur. Acad. Dermatol. Venereol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1127","DOI":"10.1016\/j.jaad.2023.09.053","article-title":"Central centrifugal cicatricial alopecia: Beyond the hot comb","volume":"89","author":"Heymann","year":"2023","journal-title":"J. Am. Acad. Dermatol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1557","DOI":"10.1016\/j.jaad.2019.12.056","article-title":"Fibrosing alopecia in a pattern distribution","volume":"85","author":"Griggs","year":"2021","journal-title":"J. Am. Acad. Dermatol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"215","DOI":"10.1007\/s10238-020-00673-w","article-title":"Alopecia areata: A review on diagnosis, immunological etiopathogenesis and treatment options","volume":"21","author":"Sterkens","year":"2021","journal-title":"Clin. Exp. Med."},{"key":"ref_15","first-page":"e8320","article-title":"Telogen effluvium: A review of the literature","volume":"12","author":"Asghar","year":"2020","journal-title":"Cureus"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"589","DOI":"10.1111\/ced.14982","article-title":"Anagen effluvium and the role of trichoscopy","volume":"47","author":"Starace","year":"2022","journal-title":"Clin. Exp. Dermatol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"272","DOI":"10.5826\/dpc.0904a05","article-title":"Alopecia areata incognita and diffuse alopecia areata: Clinical, trichoscopic, histopathological, and therapeutic features of a 5-year study","volume":"9","author":"Alessandrini","year":"2019","journal-title":"Dermatol. Pract. Concept."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"82","DOI":"10.3315\/jdcr.2011.1083","article-title":"Trichoscopy update 2011","volume":"5","author":"Rudnicka","year":"2011","journal-title":"J. Dermatol. Case Rep."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1040","DOI":"10.1016\/j.jaad.2012.02.013","article-title":"Hair and scalp dermatoscopy","volume":"67","author":"Miteva","year":"2012","journal-title":"J. Am. Acad. Dermatol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1016\/j.jaad.2014.10.039","article-title":"Trichoscopic features of frontal fibrosing alopecia: Results in 249 patients","volume":"72","author":"Grimalt","year":"2015","journal-title":"J. Am. Acad. Dermatol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1159\/000539385","article-title":"Trichoscopy of Frontal Fibrosing Alopecia in Caucasians: A Review","volume":"10","author":"Quadrelli","year":"2024","journal-title":"Skin Appendage Disord."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Rudnicka, L., Olszewska, M., and Rakowska, A. (2012). Frontal fibrosing alopecia. Atlas of Trichoscopy: Dermoscopy in Hair and Scalp Disease, Springer.","DOI":"10.1007\/978-1-4471-4486-1"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Katoulis, A.C., Ioannides, D., and Rigopoulos, D. (2021). Frontal fibrosing alopecia. Hair Disorders: Diagnosis and Management, CRC Press. [1st ed.].","DOI":"10.1201\/9780429465154"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"473","DOI":"10.1111\/jdv.15974","article-title":"Trichoscopy of primary cicatricial alopecias: An updated review","volume":"34","author":"Mathur","year":"2020","journal-title":"J. Eur. Acad. Dermatol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1406","DOI":"10.1001\/archdermatol.2009.277","article-title":"Follicular red dots: A novel dermoscopic pattern observed in scalp discoid lupus erythematosus","volume":"145","author":"Tosti","year":"2009","journal-title":"Arch. Dermatol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"818","DOI":"10.1111\/ijd.15365","article-title":"Dermoscopy of discoid lupus erythematosus\u2014A systematic review of the literature","volume":"60","year":"2021","journal-title":"Int. J. Dermatol."},{"key":"ref_27","first-page":"753","article-title":"Trichoscopy of cicatricial alopecia","volume":"11","author":"Rakowska","year":"2012","journal-title":"J. Drugs Dermatol."},{"key":"ref_28","first-page":"58","article-title":"Clinical and trichoscopic correlation of primary neutrophilic scarring alopecia: Folliculitis decalvans and dissecting cellulitis","volume":"153","author":"Rossi","year":"2018","journal-title":"G. Ital. Dermatol. Venereol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"993","DOI":"10.2147\/CCID.S365566","article-title":"Folliculitis Decalvans and Lichen Planopilaris Phenotypic Spectrum: A Case Report","volume":"15","author":"Zhang","year":"2022","journal-title":"Clin. Cosmet. Investig. Dermatol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"5","DOI":"10.4103\/ijd.ijd_591_21","article-title":"Implications of Dermoscopy and Histopathological Correlation in Discoid Lupus Erythematosus in Skin of Color","volume":"67","author":"Ankad","year":"2022","journal-title":"Indian J. Dermatol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"608","DOI":"10.1016\/j.abd.2019.09.006","article-title":"Trichoscopy findings in dissecting cellulitis","volume":"94","author":"Melo","year":"2019","journal-title":"An. Bras. Dermatol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"bcr2017222222","DOI":"10.1136\/bcr-2017-222222","article-title":"Acne keloidalis nuchae: Clinical and dermoscopic features","volume":"2017","author":"Chouk","year":"2017","journal-title":"BMJ Case Rep."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1353","DOI":"10.1111\/j.1365-2133.2010.09979.x","article-title":"Hair casts are a dermoscopic clue for the diagnosis of traction alopecia","volume":"163","author":"Tosti","year":"2010","journal-title":"Br. J. Dermatol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"415","DOI":"10.1159\/000538912","article-title":"Trichoscopy of central centrifugal cicatricial alopecia: A retrospective study and literature review","volume":"10","author":"Zogob","year":"2024","journal-title":"Skin Appendage Disord."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1111\/j.1529-8019.2008.00207.x","article-title":"Pseudopelade of Brocq","volume":"21","author":"Alzolibani","year":"2008","journal-title":"Dermatol. Ther."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1016\/j.ad.2022.08.018","article-title":"Trichoscopy in Alopecia Areata","volume":"114","year":"2023","journal-title":"Actas Dermosifiliogr."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"799","DOI":"10.1016\/j.jaad.2006.04.058","article-title":"Videodermoscopy in the evaluation of hair and scalp disorders","volume":"55","author":"Ross","year":"2006","journal-title":"J. Am. Acad. Dermatol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"629","DOI":"10.1111\/jdv.17079","article-title":"Common causes of hair loss\u2014Clinical manifestations, trichoscopy and therapy","volume":"35","author":"Alessandrini","year":"2021","journal-title":"J. Eur. Acad. Dermatol. Venereol."},{"key":"ref_39","first-page":"1","article-title":"The \u201cFringe Sign\u201d\u2014A useful clinical finding in traction alopecia of the marginal hairline","volume":"17","author":"Samrao","year":"2011","journal-title":"Dermatol. Online J."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"149","DOI":"10.2147\/CCID.S137296","article-title":"Traction alopecia: The root of the problem","volume":"11","author":"Billero","year":"2018","journal-title":"Clin. Cosmet. Investig. Dermatol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"S9","DOI":"10.1016\/j.jaad.2023.04.033","article-title":"The dermatoscope in the hair clinic: Trichoscopy of scarring and nonscarring alopecia","volume":"89","author":"Pirmez","year":"2023","journal-title":"J. Am. Acad. Dermatol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"786","DOI":"10.4103\/idoj.IDOJ_18_20","article-title":"Anagen effluvium: A trichoscopic analysis","volume":"12","author":"Gupta","year":"2020","journal-title":"Indian Dermatol. Online J."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1111\/pde.13756","article-title":"Trichoscopy features of trichotillomania","volume":"36","author":"Montesinos","year":"2019","journal-title":"Pediatr. Dermatol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1177\/12034754231152231","article-title":"Diagnostic Trichoscopy of Tinea Capitis","volume":"27","author":"Srivastava","year":"2023","journal-title":"J. Cutan Med. Surg."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1111\/j.1346-8138.2010.01119.x","article-title":"Trichoscopy for common hair loss diseases: Algorithmic method for diagnosis","volume":"38","author":"Inui","year":"2011","journal-title":"J. Dermatol."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Rudnicka, L., Olszewska, M., and Rakowska, A. (2012). Algorithms in trichoscopy. Atlas of Trichoscopy, Springer.","DOI":"10.1007\/978-1-4471-4486-1"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"e135","DOI":"10.1016\/j.jaad.2014.04.052","article-title":"Clinicopathologic lessons in distinguishing cicatricial alopecia: 7 cases of lichen planopilaris misdiagnosed as discoid lupus","volume":"71","author":"Nambudiri","year":"2014","journal-title":"J. Am. Acad. Dermatol."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/4\/1195\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T16:31:51Z","timestamp":1760027511000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/4\/1195"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,2,12]]},"references-count":47,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2025,2]]}},"alternative-id":["jcm14041195"],"URL":"https:\/\/doi.org\/10.3390\/jcm14041195","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,2,12]]}}}