January 17, 2011

Reflectance Confocal Microscopy of the Yellow Dot Pattern in Alopecia Areata

Author Affiliations

Author Affiliations: San Gallicano Dermatologic Institute–IRCCS, Rome, Italy (Drs Ardigò, Cameli, and Berardesca); Department of Dermatology & Cutaneous Surgery, Miller Medical School University of Miami, Miami, Florida (Dr Tosti); and Department of Dermatology, University of Bologna, Bologna, Italy (Drs Vincenzi and Misciali).


Copyright 2011 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2011

Arch Dermatol. 2011;147(1):61-64. doi:10.1001/archdermatol.2010.288

Background  The presence of yellow dots is a characteristic dermoscopic finding in alopecia areata. The aim of this study was to investigate the yellow dot pattern observed at dermoscopy in alopecia areata with reflectance confocal microscopy (RCM) and correlate RCM findings with pathological features.

Observations  Six patients affected by alopecia totalis entered the study. Patients were first submitted to scalp dermoscopy, which was followed by RCM examination of the same area. After RCM, a 5-mm punch biopsy specimen was also taken. Dermoscopic findings showed the yellow dot pattern in all patients, with round or polycyclic yellow-pink dots often containing miniaturized or broken hair shafts. At RCM, a Vivablock mosaic taken at the level of the spinous layer showed striking reduction of follicular adnexal structures and empty lumina containing highly refractile material corresponding to the yellow dots seen on dermoscopy. The pathological features showed that the yellow dots correspond to the dilated infundibula of the velluslike anagen and telogen follicles that characterize the chronic phase of alopecia areata.

Conclusion  The RCM study of the yellow dot pattern showed a good correlation with the dermoscopic and pathological findings and confirms that the yellow dots correspond to inefficient follicular structures that often contain hair remnants.

In vivo reflectance confocal microscopy (RCM) is a noninvasive technique for real-time en face imaging of the superficial layers of the skin down to the superficial reticular dermis, with cellular-level resolution close to conventional histopathological analysis.1 Contrast is provided by differences in the refractive index and size of different cellular organelles as well as the extracellular microstructures within the tissue.2,3 Reflectance confocal microscopy has been used for the evaluation of several inflammatory skin conditions, such as acute contact dermatitis,46 discoid lupus erythematosus,7 and psoriasis,8 and has been correlated with conventional histologic analysis in several instances.3,6

Alopecia areata is a common form of a noncicatricial alopecia, characterized by patchy hair loss in the absence of inflammatory signs. In the last few years, dermoscopy has been increasingly used in the evaluation of patients with hair loss. This new diagnostic method has provided new clinical signs for recognizing hair diseases and enhanced features previously seen with the naked eye.9 The presence of yellow dots is a characteristic even though not a specific finding in alopecia areata. This pattern is characterized by a distinctive array of yellow to yellow-red, round and polycyclic dots that vary in size and possibly correspond to keratin and sebaceous debris contained within the dilated ostium of anagen and miniaturized hair-containing follicles.10 The aim of this study was to examine the yellow dot pattern with RCM and correlate RCM findings with dermoscopic and pathological features.


The ethics committee of the IFO Institute, Rome, Italy, approved this study. Six white patients (4 men and 2 women), aged 18 to 49 years (mean, 32.6 years) signed an informed consent form and entered the study. All patients were affected by alopecia totalis; mean disease duration was 8 years. Patients first underwent scalp dermoscopy, which was followed by RCM examination of the same area. After RCM, a 5-mm punch biopsy specimen for histological examination was obtained.

Dermoscopic images were obtained through computerized polarized light videomicros copy (FotoFinderdermoscope; Teachscreen Software, Bad Birnbach, Germany), with lenses with magnification factors of ×20 to ×70 at ×10 increments. Epiluminescent mode was used with thermal water as the immersion fluid.

We used a commercially available Vivascope 1500 RCM device (Lucid Technologies, Henrietta, New York) for clinical in vivo imaging. This system includes a diode class 3A Laser (European version) with a wavelength excitation maximum at 830 nm and power lower than 35 mW at tissue level. A 30 × 0.9-NA (numerical aperture) water immersion objective lens was used. The RCM was attached to the skin using an adhesive ring to reduce motion artifacts during examination. Immersion media included water between the adhesive window and the skin and ultrasound gel between the adhesive window and the objective lens. Details of this system have been reported previously.11 Single images (0.5 × 0.5 mm) were obtained from different skin levels for descriptive analysis. In addition, Vivablock software (Lucid Technologies) was used to obtain mosaics of 16 to 64 images (2 × 2 to 5 × 5 mm) at the level of the spinous layer. These mosaics were used for correlation with dermoscopy to define adnexal structure distribution, dimension, and density and for yellow dot location. Vertical Vivastack software imaging (Lucid Technologies) was used to evaluate the adnexal structures from the ostium to the reachable dermis. Stacked images were captured starting from the squamous layer and progressing deeper in 5-μm steps until reaching the last visible dermis.


Dermoscopy at low magnification revealed the yellow dot pattern in all patients. Yellow dots appear as round or polycyclic, yellow to yellow-pink dots, which may be devoid of hair or contain miniaturized short regrowing hairs, cadaverized hairs, or dystrophic hairs (Figure 1).

Figure 1.
Image not available

A, Dermoscopic findings showing the yellow dot pattern (original magnification ×20); B, yellow dots correspond to follicular openings containing broken and vellus hair shafts (original magnification ×40).


Vivablock mosaic images taken at the level of the spinous layer showed a striking reduction of follicular adnexal structures and the presence of empty adnexal lumina fulfilled by highly refractile material corresponding to yellow dots seen on dermoscopy (Figure 2 and Figure 3). Some lumina occasionally contained remnant of hair structures (Figure 4). The VivaStack software study of the yellow dots revealed highly bright luminal structures extending from the stratum corneum to the upper dermis. No or few inflammatory cells were seen.

Figure 2.
Image not available

Vivablock mosaic image (3 × 3 mm) at the level of the spinous layer showing presence of highly bright luminal structures corresponding to yellow dots (yellow arrows) seen on dermoscopy. In the reflectance confocal microscopy field, 2 remaining hairs can be seen as refractile linear structures delimitated by dark spaces (white arrows).

Figure 3.
Image not available

Luminal structures surrounded by follicular epithelium and filled by highly bright material corresponding to keratin (red arrow). Black lumina with epithelial structures corresponding to duct glands (green arrow). Inflammatory cells are present around adnexal structures (white arrows).

Figure 4.
Image not available

Highly bright material inside a luminal structure seen at the level of the spinous layer and corresponding to the yellow dot.


Specimens from 5-mm punch biopsies obtained from the scalp region exhibiting the yellow dot pattern showed active alopecia areata lesions. Horizontal sections at the upper level revealed widened infundibula containing keratinous debris and occasionally hair shaft fragments, bacteria, and yeasts (Figure 5). Sections at the isthmus level showed an increased number of velluslike anagen and telogen follicles, catagen follicles, and telogen germinal units surrounded by a mild lymphocytic infiltrate. Sections at the bulbar level showed a perifollicular and lymphocytic infiltrate with the typical “swarm of bee” pattern diagnostic for alopecia areata.

Figure 5.
Image not available

Pathological analysis. A, Horizontal section at infundibulum level showing dilated infundibula containing keratin material and bacteria. Note the presence of mild lymphocytic infiltrate in the dermis (hematoxylin-eosin, original magnification ×4). B, Higher magnification showing a dilated infundibulum filled with keratin and hair shaft debris (hematoxylin-eosin, original magnification ×40).


At RCM examination of alopecia areata, yellow dots are clearly visible during the evaluation of the spinous layer as highly refractile, round structures brighter than duct glands. Deeper into the skin (using RCM and Vivastack software evaluation) at the upper dermis level, the yellow dots clearly disclose their correspondence to small follicles, in which the epithelial component, surrounding a homogeneously bright central, round area, is clearly visible. The epithelial component is smaller than in a normal hair follicle, and a homogeneous material presenting a reflectance index similar to keratin composes the central bright area. Furthermore, in some yellow dots, remnant hair structures can also be seen, confirming the correspondence between yellow dots and inefficient and damaged follicular structures. Findings from the pathological study showed that the yellow dots correspond to the dilated infundibula of the velluslike anagen (also referred to as “nanogen”) and telogen follicles that characterize the chronic phase of alopecia areata.12 RCM technology can be used to evaluate the presence of inflammatory cells with adnexotropism and sclerosis of the upper dermis6 features that are generally absent in alopecia areata.

Our study shows that RCM technology permits noninvasive evaluation of the upper follicle with very good correlation with pathological analysis. General limitations of the technique include the high cost of the device, the time required to evaluate large skin or scalp areas, and the necessity of specific training with the technology before its routine application. An important limitation of RCM in the study of hair disorders is the loss of image resolution at the level of the upper dermis, which makes the technique not useful in the study of the lower follicle.

Further studies are needed to define if RCM can also provide information on yellow dots seen in other conditions such as alopecia areata incognita or advanced androgenetic alopecia10 or prognostic data in patients with alopecia areata.

Back to top
Article Information

Correspondence: Antonella Tosti, MD, Department of Dermatology, University of Bologna, Via Massarenti, 1-40138 Bologna, Italy (antonella.tosti@unibo.it).

Accepted for Publication: December 22, 2009.

Author Contributions: Drs Ardigò and Tosti had full access to all of the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis. Study concept and design: Ardigò, Tosti, Cameli, and Vincenzi. Acquisition of data: Ardigò, Tosti, Cameli, Vincenzi, and Misciali. Analysis and interpretation of data: Ardigò, Tosti, Cameli, Vincenzi, and Berardesca. Drafting of the manuscript: Ardigò, Tosti, Cameli, Vincenzi, Misciali, and Berardesca. Critical revision of the manuscript for important intellectual content: Ardigò and Tosti. Administrative, technical, and material support: Ardigò, Tosti, Cameli, Vincenzi, Misciali, and Berardesca. Study supervision: Ardigò and Tosti.

Financial Disclosure: None reported.

Rajadhyaksha  M Confocal reflectance microscopy: diagnosis of skin cancer without biopsy? In Frontiers of Engineering.  Washington, DC National Academies Press1999;24- 33
Rajadhyaksha  MGrossman  MEsterowitz  DWebb  RHAnderson  RR In vivo confocal scanning laser microscopy of human skin: melanin provides strong contrast. J Invest Dermatol 1995;104 (6) 946- 952
González  SGonzález  EWhite  WMRajadhyaksha  MAnderson  RR Allergic contact dermatitis: correlation of in vivo confocal imaging to routine histology. J Am Acad Dermatol 1999;40 (5, pt 1) 708- 713
Swindells  KBurnett  NRius-Diaz  FGonzález  EMihm  MCGonzález  S Reflectance confocal microscopy may differentiate acute allergic and irritant contact dermatitis in vivo. J Am Acad Dermatol 2004;50 (2) 220- 228
Astner  SGonzalez  ECheung  ARius-Diaz  FGonzález  S Pilot study on the sensitivity and specificity of in vivo reflectance confocal microscopy in the diagnosis of allergic contact dermatitis. J Am Acad Dermatol 2005;53 (6) 986- 992
Ardigò  MMaliszewski  ICota  C  et al.  Preliminary evaluation of in vivo reflectance confocal microscopy features of discoid lupus erythematosus. Br J Dermatol 2007;156 (6) 1196- 1203
González  SRajadhyaksha  MGonzález-Serva  AWhite  WMAnderson  RR Confocal reflectance imaging of folliculitis in vivo: correlation with routine histology. J Cutan Pathol 1999;26 (4) 201- 205
González  SRajadhyaksha  MRubinstein  GAnderson  RR Characterization of psoriasis in vivo by reflectance confocal microscopy. J Med 1999;30 (5-6) 337- 356
Tosti  AWhiting  DIorizzo  M  et al.  The role of scalp dermoscopy in the diagnosis of alopecia areata incognita. J Am Acad Dermatol 2008;59 (1) 64- 67
Ross  EKVincenzi  CTosti  A Videodermoscopy in the evaluation of hair and scalp disorders. J Am Acad Dermatol 2006;55 (5) 799- 806
Ardigo  MCota  CBerardesca  EGonzález  S Concordance between in vivo reflectance confocal microscopy and histology in the evaluation of plaque psoriasis. J Eur Acad Dermatol Venereol 2009;23 (6) 660- 667
Whiting  DA Histopathologic features of alopecia areata: a new look. Arch Dermatol 2003;139 (12) 1555- 1559