European Journal of Dermatology

, Volume 26, Issue 4, pp 361–369 | Cite as

Diagnostic value of horizontal versus vertical sections for scarring and non-scarring alopecia: a systematic review and meta-analysis

  • Xufeng Du
  • Zhongming Li
  • Wenrong Xu
  • Xiaohui Zhou
  • Shaowen Tang
  • Chuang Song
  • Weixin Fan
Investigative report

Abstract

Background

Histopathological diagnosis of scalp biopsies remains a challenging area in dermatopathology. Published studies have described the benefits of different sectioning techniques although the application of these techniques is still under clinical investigation.

Objectives

To review published literature and evaluate the value of horizontal sections compared to vertical sections in the diagnosis of alopecia.

Materials & methods

Databases, such as PubMed andEMBASE, among others, were searched for published articles; to identify additional relevant studies, the literature search was performed manually. The total number of cases and diagnosed cases, and diagnostic rates, were extracted from each included study. Pooled diagnostic rates with 95% confidence intervals (CI) were used to evaluate the value of different sectioning techniques, and we tested for publication bias and heterogeneity.

Results

Most studies had a suboptimal design. With regards to non-scarring alopecia, there were eight horizontal and eight vertical section studies. The pooled diagnostic rates were 0.81 (95% CI: 0.70-0.92) and 0.76 (95% CI: 0.60-0.93), respectively, and extensive heterogeneity existed among these studies. For the diagnosis of scarring alopecia, there were three horizontal and five vertical sectioning studies. The pooled diagnostic rates were 0.86 (95% CI: 0.66-1) and 0.90 (95% CI: 0.82-0.98), respectively, and heterogeneity was also observed.

Conclusion

Based on published studies, no significant difference exists between horizontal and vertical sectioning techniques in the diagnosis of alopecia. Whereas most studies had a suboptimal design, future studies in this area would benefit from a scientific approach and standardised measurements to explore the value of horizontal and vertical sectioning.

Key words

alopecia scarring non-scarring scalp biopsy histopathology vertical section horizontal section 

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References

  1. 1.
    Bathish N, Ben IO, Shemer A, Bergman R. A study of serial vertical sectioning of scalp biopsies to increase the histological diagnostic yield in alopecias. J Eur Acad Dermatol Venereol 2010; 24: 709–15.CrossRefPubMedGoogle Scholar
  2. 2.
    Wilk M, Zelger BG, Zelger B. Lichen Planopilaris-histologic criteria & clues in vertical sections. Hair: Therapy & Transplantation 2013; 3: 111.Google Scholar
  3. 3.
    Headington JT. Transverse microscopic anatomy of the human scalp. A basis for a morphometric approach to disorders of the hair follicle. Arch Dermatol 1984; 120: 449–56.CrossRefPubMedGoogle Scholar
  4. 4.
    Sperling LC, Winton GB. The transverse anatomy of androgenic alopecia. J Dermatol Surg Oncol 1990; 16: 1127–33.CrossRefPubMedGoogle Scholar
  5. 5.
    Whiting DA. Diagnostic and predictive value of horizontal sections of scalp biopsy specimens in male pattern androgenetic alopecia. J Am Acad Dermatol 1993; 28: 755–63.CrossRefPubMedGoogle Scholar
  6. 6.
    Whiting DA. Histopathology of alopecia areata in horizontal sections of scalp biopsies. J Invest Dermatol 1995; 104: 26S–7S.CrossRefPubMedGoogle Scholar
  7. 7.
    Templeton SF, Santa CDJ, Solomon AR. Alopecia: histologic diagnosis by transverse sections. Semin Diagn Pathol 1996; 13: 2–18.PubMedGoogle Scholar
  8. 8.
    Frishberg DP, Sperling LC, Guthrie VM. Transverse scalp sections: a proposed method for laboratory processing. J Am Acad Dermatol 1996; 35: 220–2.CrossRefPubMedGoogle Scholar
  9. 9.
    Olsen EA, Bergfeld WF, Cotsarelis G, et al. Summary of North American Hair Research Society (NAHRS)-sponsored Workshop on Cicatricial Alopecia, Duke University Medical Center, February 10 and 11, 2001. J Am Acad Dermatol 2003; 48: 103–10.CrossRefPubMedGoogle Scholar
  10. 10.
    Eudy G, Solomon AR. The histopathology of noncicatricial alopecia. Semin Cutan Med Surg 2006; 25: 35–40.CrossRefPubMedGoogle Scholar
  11. 11.
    Flotte TJ. Transverse sectioning of the scalp (Headington technique) in the 19th century. J Cutan Pathol 2008; 35: 82–5.PubMedGoogle Scholar
  12. 12.
    Kim G, DeClerck B, Sorenson E. Processing dermatological biopsies. Methods Mol Biol 2014; 1180: 221–36.CrossRefPubMedGoogle Scholar
  13. 13.
    Tailor A, Asher RG, Craig PJ, Groves RW, Fenton DA, Stefanato CM. The current state of play in the histopathologic assessment of alopecia: two for one or one for two. J Cutan Pathol 2013; 40: 298–304.CrossRefPubMedGoogle Scholar
  14. 14.
    Elston D. The’ Tyler technique’ for alopecia biopsies. J Cutan Pathol 2012; 39: 306.CrossRefPubMedGoogle Scholar
  15. 15.
    Nguyen JV, Hudacek K, Whitten JA, Rubin AI, Seykora JT. The HoVert technique: a novel method for the sectioning of alopecia biopsies. J Cutan Pathol 2011; 38: 401–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available from: URL: http://www.ohri.ca/programs/clinical_epidemiology/oxford.htm (accessed 2015 Jun 19).Google Scholar
  17. 17.
    Rostom A, Dubé C, Cranney A, et al. (Agency for Healthcare Research and Quality (US). 2004 Sep. (Evidence Reports/Technology Assessments, No. 104.) Appendix D. Quality Assessment Forms. Available from: URL: http://www.ncbi.nlm.nih.gov/books/NBK35156 (accessed 2015 Jun 19).Google Scholar
  18. 18.
    Ioannidis JP, Trikalinos TA. The appropriateness of asymmetry tests for publication bias in meta-analyses: a large survey. CMAJ 2007; 176: 1091–6.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Bergfeld W, Mulinari-Brenner F, McCarron K, Embi C. The combined utilization of clinical and histological findings in the diagnosis of trichotillomania. J Cutan Pathol 2002; 29: 207–14.CrossRefPubMedGoogle Scholar
  20. 20.
    Sinclair R, Jolley D, Mallari R, Magee J. The reliability of horizontally sectioned scalp biopsies in the diagnosis of chronic diffuse telogen hair loss in women. J Am Acad Dermatol 2004; 51: 189–99.CrossRefPubMedGoogle Scholar
  21. 21.
    Elston DM, Ferringer T, Dalton S, Fillman E, Tyler W. A comparison of vertical versus transverse sections in the evaluation of alopecia biopsy specimens. J Am Acad Dermatol 2005; 53: 267–72.CrossRefPubMedGoogle Scholar
  22. 22.
    Garcia C, Poletti E. Scalp biopsy specimens: transverse vs vertical sections. Arch Dermatol 2007; 143: 268.PubMedGoogle Scholar
  23. 23.
    Jameel K, Ejaz A, Sohail M, Rahman SB. Value of transverse section scalp biopsy in alopecia areata- a clinicopathological correlation. J Coll Physicians Surg Pak 2008; 18: 338–41.PubMedGoogle Scholar
  24. 24.
    Chaitra V, Rajalakshmi T, Kavdia R. Histopathologic profile of alopecia areata in Indian patients. Int J Trichology 2010; 2: 14–7.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Ekmekci TR, Sakiz D, Koslu A. Occipital involvement in female pattern hair loss: histopathological evidences. J Eur Acad Dermatol Venereol 2010; 24: 299–301.CrossRefPubMedGoogle Scholar
  26. 26.
    Peckham SJ, Sloan SB, Elston DM. Histologic features of alopecia areata other than peribulbar lymphocytic infiltrates. J Am Acad Dermatol 2011; 65: 615–20.CrossRefPubMedGoogle Scholar
  27. 27.
    Inchara YK, Tirumalae R, Kavdia R, Antony M. Histopathology of scarring alopecia in Indian patients. Am J Dermatopathol 2011; 33: 461–7.CrossRefPubMedGoogle Scholar
  28. 28.
    Ozcan D, Ozen O, Seckin D. Vertical vs. transverse sections of scalp biopsy specimens: a pilot study on the comparison of the diagnostic value of two techniques in alopecia. Clin Exp Dermatol 2011; 36: 855–63.CrossRefPubMedGoogle Scholar
  29. 29.
    Childs JM, Sperling LC. Histopathology of scarring and nonscarring hair loss. Dermatol Clin 2013; 31: 43–56.CrossRefPubMedGoogle Scholar
  30. 30.
    Sperling LC. Hair density in African Americans. Arch Dermatol 1999; 135: 656–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Lee HJ, Ha SJ, Lee JH, Kim JW, Kim HO, Whiting DA. Hair counts from scalp biopsy specimens in Asians. J Am Acad Dermatol 2002; 46: 218–21.CrossRefPubMedGoogle Scholar
  32. 32.
    Tandon YK, Somani N, Cevasco NC, Bergfeld WF. A histologic review of 27 patients with lichen planopilaris. J Am Acad Dermatol 2008; 59: 91–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Boer A, Hoene K. Transverse sections for diagnosis of alopecia. Am J Dermatopathol 2005; 27: 348–52.CrossRefPubMedGoogle Scholar
  34. 34.
    Elston DM, McCollough ML, Angeloni VL. Vertical and transverse sections of alopecia biopsy specimens: combining the two to maximize diagnostic yield. J Am Acad Dermatol 1995; 32: 454–7.CrossRefPubMedGoogle Scholar
  35. 35.
    McCalmont TH. Dealing with loss. J Cutan Pathol 2011; 38: 391–3.CrossRefPubMedGoogle Scholar
  36. 36.
    Elston DM. What’s new in the histologic evaluation of alopecia and hair-related disorders. Dermatol Clin 2012; 30, 685–94, vii.CrossRefPubMedGoogle Scholar
  37. 37.
    Rubin AI, Seykora JT. Is more hair always better? A single biopsy specimen is preferred for the evaluation of alopecia. J Cutan Pathol 2014; 41: 66–7.CrossRefPubMedGoogle Scholar
  38. 38.
    Sperling LC, Solomon AR, Whiting DA. A new look at scarring alopecia. Arch Dermatol 2000; 136: 235–42.PubMedGoogle Scholar
  39. 39.
    Aslani FS, Dastgheib L, Banihashemi BM. Hair counts in scalp biopsy of males and females with androgenetic alopecia compared with normal subjects. J Cutan Pathol 2009; 36: 734–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Whiting DA. Chronic telogen effluvium: increased scalp hair shedding in middle-aged women. J Am Acad Dermatol 1996; 35: 899–906.CrossRefPubMedGoogle Scholar
  41. 41.
    Marwah M, Nadkarni N, Patil S. ’Ho-ver’ing over alopecia areata: histopathological study of 50 cases. Int J Trichology 2014; 6: 13–8.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Miteva M, Misciali C, Fanti PA, Tosti A. Histopathologic features of alopecia areata incognito: a review of 46 cases. J Cutan Pathol 2012; 39: 596–602.CrossRefPubMedGoogle Scholar
  43. 43.
    Miteva M. A comprehensive approach to hair pathology of horizontal sections. Am J Dermatopathol 2013; 35: 529–40.CrossRefPubMedGoogle Scholar
  44. 44.
    Miteva M, Tosti A. Dermatoscopic features of central centrifugal cicatricial alopecia. J Am Acad Dermatol 2014; 71: 443–9.CrossRefPubMedGoogle Scholar

Copyright information

© John Libbey Eurotext 2016

Authors and Affiliations

  • Xufeng Du
    • 1
  • Zhongming Li
    • 1
  • Wenrong Xu
    • 1
  • Xiaohui Zhou
    • 2
  • Shaowen Tang
    • 3
  • Chuang Song
    • 4
  • Weixin Fan
    • 4
  1. 1.Department of DermatologyAffiliated Wuxi People’s Hospital of Nanjing Medical UniversityWuxiChina
  2. 2.Department of GynecologyHua-Dong SanatoriumWuxiChina
  3. 3.Department of Epidemiology & Biostatistics, School of Public HealthNanjing Medical UniversityNanjingChina
  4. 4.Department of DermatologyFirst Affiliated Hospital of Nanjing Medical UniversityNanjingChina

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