dermoscopy has become an integral part of diagnosing scalp disorders and differentiating cicatricial from noncicatricial alopecia .
discoid lupus erythematosus ( dle ) is seen in 50 to 85% of patients with cutaneous lupus erythematosus , and scalp involvement is most often the presenting symptom .
accurate and rapid diagnosis is critical and if left untreated , scarring and atrophy commonly occur .
dermoscopic findings described in scalp dle include follicular red dots , reduced follicular ostia , arborizing vessels , white patches , honeycomb pigmented network , blue - grey dots , and variable scaling.[24 ] follicular keratotic plugging is a typical feature of dle that can be easily appreciated on clinically and dermoscopically .
clinically , the keratotic plugs have been referred to as the carpet tack sign since they project up similar to carpet tacks .
we present here a case series of three females affected by scalp dle with prominent follicular plugging on dermoscopy and corresponding keratotic plugs on pathology .
all dermoscopic images were obtained with the handyscope ( handyscope for iphone 4 , fotofinder , bad birnbach , bavaria , germany ) .
a 40-year - old african american female with long - standing scarring alopecia presented to our clinic [ figure 1 ] . clinical examination revealed scarring alopecia of the vertex of the scalp with complete loss of pigmentation in the involved scalp except for sparing of a few pigmented patches .
some areas of alopecia had an atrophic appearance but other areas showed prominent follicular plugging .
dermoscopy showed reduced follicular density and numerous yellow keratotic follicular plugs [ figure 2 ] .
a dermoscopy - guided 4 mm punch biopsy from the scalp area exhibiting the prominent follicular plugging was obtained .
horizontal sections were bisected at the level of the lower follicle and multiple sections were examined on hematoxylin and eosin ( h and e ) . at the level of the fat and dermis
in the dermis , there were dense nodular collections of lymphoid cells surrounding vessels and adnexal structures . at the level of the infundibulum ,
many infundibular ostia were filled with keratotic material ( follicular plugs ) [ figure 3 ] .
there was an interface lymphocytic infiltrate of the infundibular ostia and around the sweat ducts .
in vertical sections , the epidermis showed orthokeratosis with hyperkeratosis and vacuolar changes of the basal layer .
case 1  scarring alopecia of the scalp associated with diffuse hypopigmentation , sparse follicular plugs , and diffuse scaling at the borders of the alopecic areas case 1  dermoscopy guided biopsy , the area shows numerous yellow keratotic plugs case 1  horizontal section at the level of the infundibulum demonstrates infundibular ostia filled with keratotic material ( follicular plugs ) ( h and e , 4 ) a 58-year - old female presented with a five - month history of worsening alopecia on her scalp .
physical examination revealed hypopigmented , atrophic plaques on her upper arms , and well - defined , scaly , patches of alopecia on her scalp .
vertical sections of her scalp demonstrated loss of hair follicles replaced by follicular scars and few follicles with dilated infundibulums filled with keratin ( keratotic plugs ) .
there was an interface infiltrate of lymphocytes and some plasma cells in a perifollicular and perivascular distribution , with some of the aggregations forming germinal - like centers . at the dermoepidermal junction ,
a 39-year - old female presented with rapidly progressing alopecic patch of the scalp for the past four months [ figure 4 ] .
dermoscopic examination of her scalp showed polymorphous vasculature , white patches , follicular keratotic plugs , and follicular hyperkeratosis [ figure 5 ] .
the follicles had a patulous orifice and there was marked vaculolar alteration of the basal layer and a superficial and deep lymphocytic and histiocytic infiltrate , deeper around adnexal structures .
case 3  alopecic patch showing erythema and pigmentation case 3  dermoscopic images showing follicular keratin plugs follicular keratotic plugs are a marker of dle and were originally described as a sign of early and active lesions and not in areas of scarring or healed skin .
we would like to note that follicular keratotic plugs may still be present in areas of chronic alopecia .
their presence can aid in correctly diagnosing scalp dle alone or in conjunction with other described dermoscopic features such as follicular red dots , blue - grey dots , white patches , reduced follicular ostia , and absence of pinpoint white dots [ table 1 ] . in conclusion , trichoscopy is critical for diagnosing hair disorders and recognition of follicular keratotic plugging in dle can lead to timely diagnosis and initiation of treatment .
a 40-year - old african american female with long - standing scarring alopecia presented to our clinic [ figure 1 ] . clinical examination revealed scarring alopecia of the vertex of the scalp with complete loss of pigmentation in the involved scalp except for sparing of a few pigmented patches .
some areas of alopecia had an atrophic appearance but other areas showed prominent follicular plugging .
dermoscopy showed reduced follicular density and numerous yellow keratotic follicular plugs [ figure 2 ] .
a dermoscopy - guided 4 mm punch biopsy from the scalp area exhibiting the prominent follicular plugging was obtained .
horizontal sections were bisected at the level of the lower follicle and multiple sections were examined on hematoxylin and eosin ( h and e ) . at the level of the fat and dermis
in the dermis , there were dense nodular collections of lymphoid cells surrounding vessels and adnexal structures . at the level of the infundibulum ,
many infundibular ostia were filled with keratotic material ( follicular plugs ) [ figure 3 ] .
there was an interface lymphocytic infiltrate of the infundibular ostia and around the sweat ducts .
in vertical sections , the epidermis showed orthokeratosis with hyperkeratosis and vacuolar changes of the basal layer .
case 1  scarring alopecia of the scalp associated with diffuse hypopigmentation , sparse follicular plugs , and diffuse scaling at the borders of the alopecic areas case 1  dermoscopy guided biopsy , the area shows numerous yellow keratotic plugs case 1  horizontal section at the level of the infundibulum demonstrates infundibular ostia filled with keratotic material ( follicular plugs ) ( h and e , 4 )
a 58-year - old female presented with a five - month history of worsening alopecia on her scalp . physical examination revealed hypopigmented , atrophic plaques on her upper arms , and well - defined , scaly , patches of alopecia on her scalp
vertical sections of her scalp demonstrated loss of hair follicles replaced by follicular scars and few follicles with dilated infundibulums filled with keratin ( keratotic plugs ) .
there was an interface infiltrate of lymphocytes and some plasma cells in a perifollicular and perivascular distribution , with some of the aggregations forming germinal - like centers . at the dermoepidermal junction ,
a 39-year - old female presented with rapidly progressing alopecic patch of the scalp for the past four months [ figure 4 ]
. dermoscopic examination of her scalp showed polymorphous vasculature , white patches , follicular keratotic plugs , and follicular hyperkeratosis [ figure 5 ] .
the follicles had a patulous orifice and there was marked vaculolar alteration of the basal layer and a superficial and deep lymphocytic and histiocytic infiltrate , deeper around adnexal structures .
case 3  alopecic patch showing erythema and pigmentation case 3  dermoscopic images showing follicular keratin plugs follicular keratotic plugs are a marker of dle and were originally described as a sign of early and active lesions and not in areas of scarring or healed skin .
we would like to note that follicular keratotic plugs may still be present in areas of chronic alopecia .
their presence can aid in correctly diagnosing scalp dle alone or in conjunction with other described dermoscopic features such as follicular red dots , blue - grey dots , white patches , reduced follicular ostia , and absence of pinpoint white dots [ table 1 ] . in conclusion , trichoscopy is critical for diagnosing hair disorders and recognition of follicular keratotic plugging in dle can lead to timely diagnosis and initiation of treatment .
 dermoscopy has become an integral part of diagnosing scalp disorders including discoid lupus erythematosus ( dle ) . 
 follicular keratotic plugs are a marker of dle and correlate with the hyperkeratosis and plugging of the follicular ostia with keratotic material . 
 they may be present in acute or chronic lesions and their presence alone or in conjunction with other described dermoscopic features can lead to timely diagnosis and initiation of treatment . 
 we present three cases of scalp dle and discuss the clinical , dermoscopic and histopathologic features . 
INTRODUCTION
CASE REPORTS
Case 1
Case 2
Case 3