JEADV

LETTER TO THE EDITOR

Dermatoscopicpathologic (a)

correlation of lichen simplex

chronicus on the scalp: broom
bres, gear wheels and
hamburgers
Editor
Lichen simplex chronicus (LSC) is a chronic condition charac-
terized by lichenified plaques, that occur as a result of constant
scratching or rubbing of the skin1 and the scalp is one of the
most common locations.2 LSC on the scalp presents as a single
or several irregular, oval or polycyclic demarcated lesions with
possible scaling, hair loss or hair breakage.2,3 It can mimic psori-
asis, a localized hair shaft disorder, tinea capitis or trichotilloma-
(b)
nia. No data on dermatoscopy of LSC on the scalp exist. We
show here that dermatoscopy can be a useful tool to the diagno-
sis and also correlate the dermatoscopic signs with the patholog-
ical features observed in transversely sectioned scalp biopsies
from affected scalp.
Three women (Caucasian, African American and Hispanic)
ageing from 51 to 65 years presented with 8 months to 5 years
history of localized paroxysmal scalp itching and associated hair
loss. The scalp examination revealed patches of lichenified skin
with broken short hairs.
Dermatoscopic examination using a hand held dermatoscope,
revealed red and scaly scalp with hair breakage. The abnormal Figure 1 (a) Lichen simplex chronicus. Dermatoscopy of the
hairs were two types: (i) short hair shafts emerging as a single scalp shows the broom hair bres: numerous short hairs split into
stem from a follicular opening which show proximal split into two or three hairs of similar thickness at the level of their emer-
two or three hairs of similar thickness at the level of the surface gence of the follicular opening (red arrows) and additionally split
and (ii) hair shafts of same characteristics but with additional into two or three tiny hair endings at the distal tips (blue arrows)
(Handyscope, FotoFinder Systems, Bad Birnbach, Germany, 920).
distal split of the hair tips into two or three tiny hair endings (b) Lichen simplex chronicus after treatment: Note the absence of
(Fig. 1a). This hair shaft abnormality has been described as scalp erythema and licheniciation as well as the improved hair
broom hair fibers.4 The dermatoscopic findings showed signifi- density with normal short hair shafts (DermLite II PRO HR, 3Gen,
cant improvement after 3 months of treatment with clobetasol California, USA, 912).
cream under occlusion and moisturizing shampoo (Fig. 1b).
All biopsies were processed as horizontal sections and also as
vertical sections in one case. There was preserved follicular archi- blood cells (Fig. 2b) (the hamburger sign).5 In one case several
tecture with normal number of terminal follicles and preserved hair shafts were fragmented in three pieces. In the uppermost
terminal: vellus ratio. The sebaceous glands were diminished in sections, the epidermis was visible and showed thick layers of
size and number. At the level of the infundibulum the outer root orthokeratosis and hyperkeratosis.
sheath formed jagged acanthotic projections, which together The broom hairs identified on dermatoscopy have been
with the hair canal in the middle resembled a gear wheel on hori- reported in trichotillomania.4 The presence of broken hairs at
zontal sections (Fig. 2a). The infundibular ostium showed different lengths, amorphous hair residues and black dots, irreg-
hyperkeratosis with hair shafts split in two by a layer of red ular coiled hairs and yellow dots,4,6,7 as well as the absence of

JEADV 2014 2014 European Academy of Dermatology and Venereology

2 Letter to the Editor
(a)
(b)
Figure 2 (a) Lichen simplex chronicus. Horizontal sections at the
level of the infundibulum reveal the outer root sheath of the follicles
forming serrated acanthotic projections, which together with the
hair canal in the middle resemble gear wheel structures (Haemat-
oxylin and Eosin, 910). (b) Lichen simplex chronicus. Horizontal
sections at the level of the infundibulum reveal the hamburger sign
of a split hair shaft (the bun) with a layer of red blood cells in the
middle (the meat). Note the infundibular hyperkeratosis (Hematoxy-
lin and Eosin, 940).
lichenification distinguishes trichotillomania from LSC. Broom
hair fibres have not been described in psoriasis or tinea capitis,
which is also our experience.
The broom hair fibres correspond on pathology to hair shafts
split into two or rarely into three pieces at the level of infundibu-
lum, which resemble a hamburger. The hamburger sign was
originally reported in trichotillomania as an auxiliary diagnostic
JEADV 2014
finding.7 We detected it in all our biopsies from LSC and we
consider it a result of the traumatic splitting of the hair shafts
from the constant rubbing and scratching to the scalp. Other
pathological findings of LSC observed in our horizontal sections
include the gear wheel sign representing the jagged acanthotic
projections of the outer root sheaths around the hair canal at the
level of the infundibulum. Irregular acanthosis and hyperkerato-
sis is the hallmark of LSC on pathology on vertical sections.
In conclusion, the recognition of the broom hair fibres on
dermatoscopy and the hamburger sign and the gear wheel sign
on pathology provide an additional tool for the diagnosis of LSC
in the scalp.
~o Alvarez,2 M. Miteva3
M.V. Quaresma,1,* A.M. Marin
1
Department of Dermatology, Professor Rubem David Azulay Institute of
n
Dermatology, Rio de Janeiro, Brazil, 2University of Los Andes, Fundacio
 de Bogota
Santa Fe , Bogota
, Colombia, 3Department of Dermatology and
Cutaneous Surgery, University of Miami Miller School of Medicine, Miami,
FL, USA
*Correspondence: M.V. Quaresma. E-mail: mavi@mavictoria.com.br
References
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2 Stillians AW. Lichen simplex of the scalp. Arch Derm Syphilol 1926; 13:
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3 Bernardin RM, Altman CE, Meffert JJ. What is your diagnosis? Lichen
simplex chronicus. Cutis 2006; 78: 96, 101102.
4 Rudnicka L, Rakowska A, Olszewska M et al. Hair shafts. In Rudnicka L,
Olszewska M, Rakowska A, eds. Atlas of Trichoscopy Dermoscopy in Hair
and Scalp Disease. Springer, London, UK, 2012: 1146.
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6 Lee DY, Lee JH, Yang JM, Lee ES. The use of dermatoscopy for the
diagnosis of trichotillomania. J Eur Acad Dermatol Venereol 2009; 23:
731732.
7 Miteva M, Tosti A. Dermatoscopy of hair shaft disorders. J Am Acad
Dermatol 2013; 68: 473481.
DOI: 10.1111/jdv.12748
2014 European Academy of Dermatology and Venereology