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Trichostasis spinulosa: An entity with cosmetic concern

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Trichostasis spinulosa: An entity with cosmetic concern
Kavya Baddireddy1, Resham Vasani2
1Department of Dermatology, Venereology and Leprosy, Government Hospital for Mental Care, Visakhapatnam, AndhraPradesh, India, 2Department of
Dermatology, Venereology and Leprosy, Bhojani Clinic, Earth Classic, Mumbai, Maharashatra, India.
INTRODUCTION
e high prevalence of trichostasis spinulosa (TS) contrasts with the relative dearth of
recognition paid to it; TS is oen dismissed as a cosmetic entity. Moreover, the paucity of reports
indicates that TS is indeed underrecognized.[1] Treatment of TS continues to be a challenge to
this day, due to the scarcity of high-quality evidence. Suboptimal therapeutic regimens have
been guided largely by case reports, with the mainstay of treatment being keratolytics and topical
retinoids.[2] Recently, lasers have emerged as a promising treatment modality.[2,3] We present a
review of the pathogenesis, clinicopathologic features, associated conditions, dermoscopic
features, and treatment of TS.
HISTORY
TS is a distinct, benign, pilosebaceous unit disorder, stemming from the entrapment of bundle
of tiny vellus hairs encircled by a keratinous sheath in a dilated follicular infundibulum.[4] is
unique disorder was rst described in 1901 by the German dermatologist, Felix Franke under
the title of “das pincelhaar (“pincelhaar meaning paintbrush hair) and “thysanothrix” (thysanos
– meaning fringe). ereaer, dierent terminologies have been used such as “Lanugo
Komedonen, “Keratosis spinulosa cum trichostasi”, “Dysplasia pilorum thysanoformis” till the
time Noble coined the term “TS” in 1913.[5]
PATHOGENESIS
e pathogenesis of TS is not completely elucidated. Chief pathology lies in successive production
and retention of vellus telogen club hairs from a single hair matrix in a pilosebaceous follicle.
One hypothesis proposes that disturbance in the dynamics of hair papilla and subsequent
exaggerated papillary cyclical activity is the cause for the growth of vellus hairs within the
follicle.[6] Another hypothesis proposes that abnormal keratinization of follicular epithelium
and the resulting keratotic plugging caused by internal (congenital dysplasia of hair follicles) or
external factors (occlusive preparations such as oils, dust, heat, ultraviolet light, and industrial
irritants) might damage the follicles and prevent the extrusion of normal hair, leading to their
retention.[6,7]
Long-term topical corticosteroids are thought to instigate changes of TS by cornication of
the pilosebaceous duct and induction of hypertrichosis through the stimulation of vellus hair
www.cosmoderma.org
CosmoDerma
*Corresponding author:
Resham Vasani,
Department of Dermatology,
Venereology and Leprosy,
Bhojani Clinic, Earth Classic,
Mumbai, Maharashatra, India.
mailreshamvasani@gmail.com
Received : 31August 2021
Accepted : 05September 2021
Published : 27 September 2021
DOI
10.25259/CSDM_52_2021
Quick Response Code:
Baddireddy and Vasani: Trichostasis spinulosa
Cosmoderma 2021 • 1(48) | 2
growth.[8] Terminal hair TS following local application of
minoxidil is reported, minoxidil-induced transformation of
retained vellus to terminal hair is believed to be the reason.[9]
In addition to the above theories, actinic skin damage,
aging and abnormal angulation of isthmus at the level of
infundibulum have all been postulated to a play a role.
Increased prevalence of Cutibacterium acnes (formerly known
as Propionibacterium acnes) and Pityrosporum species is
reported by some authors.[10] ey have suggested that there is
a possible provocating and aggravating role of these microbes
in induction of follicular keratosis and favoured microbial
eradication for better results. However, studies in this respect
failed to deliver any conclusive evidence.
TS is described in association with space-occupying
lesions that constrict follicle infundibulae by tumor cells
or tumor-related brosis,[11] such as melanocytic nevi,[12]
collagenoma,[13] seborrheic keratosis,[14] syringomas,[14]
follicular sebaceomas (trichofolliculomas), or nodular basal
cell carcinomas.[15,16]
CLINICAL FEATURES
TS is a fairly common disorder than is presumed. However,
most oen it is underdiagnosed and under-reported owing
to the usual lack of any subjective symptoms, rather than its
ra rity.
Primary TS presents as isolated nding, spotted only as an
incidental discovery in cases attending for unrelated skin
problems.[15] Less commonly, it is observed in association
or found to develop within other cutaneous conditions as
mentioned above (secondary TS).[7,17] e onset is usually
aer adolescence, elderly being most aected perhaps due to
prolonged actinic damage. Childhood cases are rare.
Sexual predilection is absent though females are more
concerned and seek treatment. TS preferential involves body
areas with abundant sun exposure and pilosebaceous units,
commonly the face [Figure1], neck, chest, upper arms, and
interscapular regions [Figure 2].[4,18] Truncal distribution of
asymptomatic lesions is thought to be caused by continuous
pressure of garments.[8]
In the areas of aection, TS manifests as minimally keratotic
plugs that either project over the follicular orices containing
central, 5–80, dark short hairs (resembling the bristles of
paintbrush) or seen to be embedded within the orices
as small comedo-like dots. Hence, they are mistaken for
blackheads by the patients.[19,20] Normal appearing follicles are
found interspersed with those containing the hyperkeratotic
spinules in some cases while in others all the follicles of the
involved area are plugged.
Patients rarely complain of the roughness of the face, scaling,
or pruritus. Erythema, edema, and secondary pustulation are
noted around lesions that have been manipulated to express the
keratotic material. Psychological distress from the appearance
of the lesions usually prompts patients to seek care.[18]
Two variants are dened that are dierentiated based on
the age of onset, anatomic distribution, and the presence
or absence of pruritus.[21] e classical variant is the non-
pruritic type which is frequently seen in the elderly in a
localized distribution, commonly aecting the tip of the nose,
ala nasi, chin, cheeks, face, or the interscapular region.[21]
e pruritic type seen in young adults is the second variant
and is characterized by widespread distribution, extra-
facial involvement, and in association with other follicular
hyperkeratotic disorders, chronic renal failure, and benign
cutaneous tumors.[15,21,22]
Uncommon presentations include involvement of scalp
mimicking black dots of alopecia areata,[11,23] involvement of
Figure1: Clinical presentation of trichostasis spinulosa on the nasal
dorsum and ala nasii as dark dots.
Figure 2: Trichostasis spinulosa aecting back and presenting as
minimally keratotic follicular paupules with multiple hair bristles.
Baddireddy and Vasani: Trichostasis spinulosa
Cosmoderma 2021 • 1(48) | 3
axilla,[24] lower eyelid,[7] nevoid pattern[25], and generalized
distribution in a case with chronic renal failure.[22]
DIFFERENTIAL DIAGNOSIS
Dermatoses presenting as keratotic follicular papules may
be considered in the dierential diagnosis of TS. ese
include keratosis pilaris, lichen spinulosus, open comedones
of acne, eruptive vellus hair cysts, ichthyosis follicularis,
hypovitaminosis A, hypovitaminosis C, dyskeratosis
follicularis, Kyrle’s disease, keratosis pilaris atrophicans faciei,
atrichia with papular lesions, keratosis pilaris decalvans,
pityriasis rubra pilaris.[9,21] Pili multigemini, popularly
known as “compound hairs” is another close dierential and
is characterized by the presence of bifurcated or multiple
divided hair matrices and papillae in contrast to single
papillae of TS, giving rise to the formation of multiple hair
shas within the individual follicles.[9,26] Of the above list, acne
comedones, lichen spinulosus, keratosis pilaris, and eruptive
vellus hair cysts very closely simulate TS. Distinguishing
clinical, histological, and dermoscopic features of these
entities are summarized in [Table1].[18,19,27-32]
DIAGNOSIS
TS is oen missed upon gross naked eye examination. Close
observation with a handheld magnifying lens shows dark
grouped hair bristles projecting from the horny follicular plugs.
DERMOSCOPIC EXAMINATION
Dermoscopy enables accurate rapid diagnosis of TS
and also aids in monitoring response to treatment.[17]
e dermoscopic ndings are classied as signs of hair
retention seen as vellus hairs and tus of hairs [Figure3]
and signs of follicular keratoses described as dermoscopic
black dots [Figure4] and orangish-yellow plugs occupying
dierent sizes of dilated pores. Slight compression of the
lesions as in immersion contact dermoscopy helps separate
and spread the hairs, enabling visualization of each
hair sha tip.[33,34] Dermoscopic dierential diagnosis is
elaborated in Table1.
HAIR MOUNT AND TRICHOGRAM
Microscopic analysis makes the diagnosis easy. Mounting
the follicular contents expressed by gentle manual pressure
or hair pull or extraction by a pair of forceps, tweezers or
comedone extractor typically reveals a bunch of parallelly
arranged more than 6 vellus hairs glued together by a
gelatinous material in the midportion, the clear greasy
substance does not extend to the distal or proximal ends of
the hairs and leaves a portion of them uncovered at both ends
[Figure5]. ese retained hairs are usually more pigmented
and thinner at the distal end, the proximal intrafollicular
portion is lighter in color and bulbous indicating that they
are in the telogen phase of the hair cycle.[6,35]
HISTOLOPATHOLOGICAL EXAMINATION
A punch biopsy is usually not indicated or necessary to
establish a diagnosis of TS. Histologic features of TS include
acanthosis and hyperkeratosis of perifollicular epithelium,
mild inammatory inltrates, multiple thin vellus hair
shas, and increased amount of lamellar keratin inside the
infundibular region of follicles, corresponding to the retained
hairs and keratin plug, respectively.[6,10,26]
TREATMENT
TS, while otherwise being medically harmless, runs a chronic
refractory course with lesions usually reappearing aer
treatment discontinuation.[1]
Figure 3: Dermoscopic examination (Dermlite DL4N, polarised
mode, x10). Hair retention seen as tus of tiny dark hair emerging
from follicular ostia.
Figure 4: Dermoscopic examination (Dermlite DL4N, polarised
mode, x10). Follicular keratosis seen as dermoscopic blackheads.
Baddireddy and Vasani: Trichostasis spinulosa
Cosmoderma 2021 • 1(48) | 4
(Contd...)
Characteristic Trichostasis spinulosa Acne open
comedones
Keratosis pilaris Eruptive vellus hair
cysts
Lichen spinulosus
Anatomical
distribution
Common
Others
Face, especially the nose,
neck, chin, interscapular
region[18]
Chest, back, especially
abdomen and extremities,
scalp
Face, back
Neck, upper
chest, shoulders
Extensor and
lateral aspects of the
proximal
extremities, cheeks.
Neck, torso, and
buttocks[28,32]
Chest, Sternal area,
abdomen
Anterior exures of
limbs, trunk, buttocks
forehead and face
Trunk, extensor
surfaces of the
upper
extremities
Neck, buttocks,
abdomen,
knees cheeks[32]
Age All age, mostly elderly[29] All ages,
mostly
adolescents
All ages, most oen
early childhood[29]
Children and young
adults[29]
Children and
adolescents[18]
Sex No predilection Males slightly
more aected
No predilection No predilection Male
preponderance
Clinical features Horny plugs within
dilated follicles with
protruding hairs
Comedo like impacted
plugs[28,29]
Solid, horny
impactions that
distend hair
follicle[18]
Spiny grouped/
scattered keratotic
papules with subtle
perifollicular
erythema[28,32]
1 to 5 mm so to
rm skin coloured
or hyperpigmented,
dome-shaped papules
topped with central
puncta, umbilicated or a
hyperkeratotic crust[28,30]
Skin coloured
asymptomatic or
mildly pruritic
follicular spiny
papules in
patches[18]
Dislodgement
of keratotic
plug
Eortlessly
dislodged[29]
Dicult to
dislodge
Eortlessly
dislodged[29]
Removal not possible
due to dermal location
of pathology[29]
Removed with
diculty
Microscopic
analysis/
Hair mount
of removed
follicular plug
Bunch of vellus hairs
enclosed by a keratinous
sheath[28,29]
Very few three
to six vellus
hairs per
comedone are
sometimes
present and are
usually coiled
within the
horny plug[17]
Single coiled vellus hair
surrounded by keratin
material[15,28,29]
Not possible as plug
cannot be removed[28,29]
Keratinous material
with no hairs
Histology Acanthotic epidermis
enclosing a dilated
follicle containing several
vellus hairs glued together
by a keratin plug.
Perifollicular inltrate and
inltrate around
arrector pili muscle may
be seen[28,29]
Plugging of the
pilosebaceous
orice by
sebum on the
skin surface[34]
Dilated follicle with
single coiled hair,
infundibular plugging
mild perifollicular
inammation and
brosis[28,29]
Cystic spaces lined by
stratied squamous
epithelium containing
variable quantity of
laminated keratin and
several vellus hair
located in mid or upper
dermis[28,30]
Dilated follicular
ostia with compact
hyperkeratosis,
focally associated
with a perifollicular
and perivascular
lichenoid
inltrate[33]
Dermoscopy Vellus hairs, tus of hairs
Dermoscopic black dots
Yellowish orange
horny plugs – follicular
keratosis[28]
Brown- Yellow
hard central
plug[30]
Mostly single,
sometimes 2 or 3
vellus hairs that are
frequently coiled,
semi-circular or
looped, peri-follicular
erythema, peri-pilar
casts, and vascular
ectasias. Pigmented
globules suggest
postinammatory
hyperpigmentation[28,32]
1. Brownish, round-to-
oval structures - cysts
with laminated keratin
2. Brownish halo-
inammation
3. Central/eccentric pores
– opening of cysts into
the epidermis
4. Blue homogenous
areas- Tyndall eect
of keratin
5. Peripherally arranged
radial capillaries
(may or may not be
present)[28,30]
Round-to-oval
yellowish areas
with keratotic
follicular plugs
surrounded by mild
erythema
Table 1: Dierential Diagnosis of Trichostasis Spinulosa.
Baddireddy and Vasani: Trichostasis spinulosa
Cosmoderma 2021 • 1(48) | 5
e existing treatment modalities that have been explored
with varying success range from simple minimally invasive
oce-based procedures such as needle evacuation,
hydroactive adhesive tape stripping, keratolytics to laser and
energy based interventions.[1,18]
Needle evacuation and extraction with the help of forceps,
tweezers, or comedone extractor is painful and can be
complicated by scarring and recurrences.[6,36,37] A modication of
cyanoacrylate skin surface stripping (used to harvest a thin layer
of stratum corneum) was also described to mechanically debride
the spiny projections. Adrop of cyanoacrylate liquid adhesive is
placed on a transparent glass slide, which is then pressed rmly
onto the target site of the skin for 15–30 s. e horny plugs along
with the hairs of TS get attached and subsequently removed when
the slide is rocked from side to side with little force. Erosions and
oozing can occur with this method.[37]
Depilatory wax and removal of hairs by depilatory cellulose
lacquer provide temporary relief.[6] Hydroactive adhesive
tape (Biore), a deep cleaning pad can be applied on wet
skin for 10min and then carefully peeled o. It contains a
cationic (positively charged) hydrocolloid with active agent
polyquaternium 37 that binds to comedonal plugs which
are rich in acidic amino acids (negatively charged). Instant
removal of few plugs with hairs can be noticed.[1,38]
KERATOLYTICS
Keratolytics like lactic acid, urea, ammonium lactate, salicylic
acid, Whiteld’s ointment have all been tried and found to be
only temporarily and minimally eective.[6] Favorable results
were seen when used aer depilatory agents.[19] Salicylism,
contact dermatitis, postinammatory pigmentation are the
rare probable side eects.
TOPICAL RETINOIDS
Tretinoin 0.025%, 0.05%, and adapalene 0.1% by virtue
of their comedolytic, antiproliferative, anti-inammatory
properties normalize the defective epidermal turnover,
correct the hyperkeratosis and relieve the obstruction in
TS.[6] Adapalene, when compared to tretinoin causes less
irritation and is better tolerated. Higher concentrations of
tretinoin and tazarotene may be used for extra facial lesions.
CHEMICAL PEELS
Repeated capryloyl salicylic acid peelings at concentrations
between 20% and 30% decrease sebum secretion, disrupts
intercorneocyte cohesion, leading to desquamation and
good improvement of TS. Its lipophilic nature permits better
penetration up to the mid-portion of the follicular canal
where excessive keratinization, the initial event in keratotic
plug formation, takes place.[39] Glycolic acid and Jessner’s
peels known to be eective in treating other follicular
keratosis,[40] can be given a try.
LASER HAIR REMOVAL
Selective permanent destruction of pigmented hair using
lasers (694-nm ruby laser, 755-nm alexandrite, 810-nm
Figure5: Hair mount of the plucked hairs showing multiple vellus
hairs bundled together by a keratinous sheath with characteristic
paintbrush appearance.
Characteristic Trichostasis spinulosa Acne open
comedones
Keratosis pilaris Eruptive vellus hair
cysts
Lichen spinulosus
Treatment Keratolytics, tretinoin not
eective
Treatment-resistant
Long remission possible
with lasers[28][29]
Topical
retinoids,
Azelaic acid
Benzoyl
peroxide
Salicylic acid
and glycolic
acid peels[17]
Keratolytics, topical
retinoids eective
Oral retinoids and
lasers like PDL, KTPL,
alexandrite laser, long-
pulsed diode laser,
Q-switched Nd:YAG
laser, and fractional
carbon dioxide laser
are eective[28,29]
Spontaneous resolution
via transepidermal
elimination may occur
Needle evacuation,
topical and oral
retinoids, dermabrasion
and lasers[28,29]
Spontaneous
resolution may be
seen
Keratolytics
Topical and oral
retinoids
Vitamin D
analogous
Sometimes
persistent with
relapsing course[32]
Table 1: (Continued)
Baddireddy and Vasani: Trichostasis spinulosa
Cosmoderma 2021 • 1(48) | 6
diode lasers, long pulse1064-nm ND: YAG laser) is found
to be safe and successful in slowing hair regrowth in TS,
oering a denitive curative option.[3,2,40-43] Improvement
in the skin texture, appreciated as reduction in roughness
is an added cosmetic advantage besides complete clearance
of the comedo-like plugs. Areas with thinner skin such as
the face and axilla allow better penetration and delivery of
laser energy and respond better than back and extremities.
e best long-term results are achieved with the alexandrite
and diode hair removal lasers with no statistically signicant
dierence in ecacy and tolerability between the two.[3,42]
Anagen hairs are chiey amenable to laser ablation. TS, as
is a disorder resulting from retention of telogen hairs may
not respond comparable with terminal hairs and there is a
possibility of recurrence of lesions requiring longer periods
of follow-up.[2,3,43] Nevertheless, data on laser type, device
parameters, number and interval between sessions and
follow-up period for any recurrence is lacking.
CONCLUSION
TS is a common though underrecognised entity which can
be easily mistaken when the distribution is atypical. Careful
examination with dermoscopic evaluation is necessary for
the correct diagnosis. Future large randomized control trials
are required to compare laser modalities with each other
and combination therapies with non-laser options, and to
establish optimal treatment protocols.
Declaration of patient consent
Patients consent not required as patients identity is not
disclosed or compromised.
Financial support and sponsorship
Nil.
Conict of interest
ere are no conict of interest.
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Trichostasis spinulosa (TS) is a common yet underdignosed condition affecting hair follicles. Diagnosis is based on the clinical features, hair mount, and dermoscopy. Here, the authors describe a case of TS in a nevoid distribution wherein dermoscopy aided the diagnosis. How to cite this article Ankad BS, Shah S, Mallapur AA. Nevoid Trichostasis Spinulosa: Dermoscopic Point of View. Int J Dermoscop 2017;1(2):65-66.
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Introduction: Keratosis pilaris (KP) is a common, benign skin condition of follicular hyperkeratosis. Although KP is asymptomatic, the cosmetic appearance of KP can lead to psychosocial distress among patients. New emerging treatments are increasingly being utilized. Yet, there is little to no summative data on the treatments of KP and its subtypes. Objective: To summarize existing literature on treatments for KP and its subtypes. Methods: A comprehensive systematic review was performed using Pubmed/MEDLINE, Embase and Web of Science databases. The search identified 1,150 non-duplicated articles, and 47 articles were included in the review. The primary outcomes measured were KP treatment type and the degree of improvement following therapy. Findings: Our findings show that the most supported form of treatment for KP is laser therapy, particularly the QS:Nd YAG laser. Topical treatments- including Mineral Oil-Hydrophil Petrolat, tacrolimus, azelaic acid, and salicylic acid- are also effective at least for improving the appearance of KP. Conclusion: While the measured treatment outcomes varied among studies, laser therapy appeared most efficacious in the treatment of KP and its subtypes. Usage of topical treatments also improved KP lesions.
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Laser hair removal since its availability has been primarily used for aesthetic purposes. Over the years, it has emerged as an important therapeutic modality in various dermatological and surgical disorders, both as an adjuvant and as a monotherapy. Depending on the skin type, all laser hair removal systems have been used with good results and minimal complications. We hereby review the diverse range of unconventional indications of laser hair removal.
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Context Trichostasis spinulosa (TS) is a common but underdiagnosed follicular disorder involving retention of successive telogen hair in the hair follicle. Laser hair removal is a newer treatment modality for TS with promising results. Aims This study aims to evaluate the efficacy of 800 nm diode laser to treat TS in Asian patients. Subjects and Methods We treated 50 Indian subjects (Fitzpatrick skin phototype IV–V) with untreated trichostasis spinulosa on the nose with 800 nm diode laser at fluence ranging from 22 to 30 J/cm² and pulse width of 30 ms. The patients were given two sittings at 8 week intervals. The evaluation was done by blinded assessment of photographs by independent dermatologists. Results Totally 45 (90%) patients had complete clearance of the lesions at the end of treatment. Five (10%) subjects needed one-third sitting for complete clearance. 45 patients had complete resolution and no recurrence even at 2 years follow-up visit. 5 patients had partial recurrence after 8–9 months and needed an extra laser session. Conclusions Laser hair reduction in patients with TS targets and removes the hair follicles which are responsible for the plugged appearance. Due to permanent ablation of the hair bulb and bulge, the recurrence which is often seen with other modalities of treatment for TS is not observed here.
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Trichostasis spinulosa is a rarely diagnosed disorder of the pilosebaceous unit, characterized by retention of telogen hairs within the dilated follicles. A hair tuft can be seen protruding from the follicles. We present a case of trichostasis spinulosa associated with intradermal melanocytic nevi, where dermoscopy helps to identify this entity.