Skin Research and Technology 2013; 19: e60e64

Printed in Singapore
All rights reserved

doi: 10.1111/j.1600-0846.2011.00608.x

2012 John Wiley & Sons A/S

Skin Research and Technology

A comparative study of hair shafts in scalp psoriasis and

seborrheic dermatitis using atomic force microscopy
Kyung Sook Kim1,2,*, M. K. Shin3,*, J. J. Ahn3, C. R. Haw3 and Hun-Kuk Park1,2,4
1

Department of Biomedical Engineering, School of Medicine, Kyung Hee University, Seoul, Korea,
2
Healthcare Industry Research Institute, Kyung Hee University, Seoul, Korea,
3
Department of Dermatology, School of Medicine, Kyung Hee University, Seoul, Korea and 4Program of Medical Engineering, Kyung Hee
University, Seoul, Korea, * These authors contributed equally to this work.

Background: As the inflammatory scalp conditions share similar clinical manifestations of scaling, inflammation, and pruritus,
the differential diagnosis of these lesions; especially between
scalp psoriasis (SP) and seborrheic dermatitis (SD) is sometimes difficult.
Objectives: The aim of this study was to investigate the differences on the hair surface in SP and SD for a clinical diagnosis, using atomic force microscopy (AFM).
Methods: The hair shafts of 14 patients and 28 patients with
SP and SD respectively, were taken from the lesional region.
Hairs from healthy adults not having any hair diseases were
also examined in the same way for the controls. Surface characteristics of SP and SD-affected hair shafts such as, pitting, scale
thickness, and roughness, were observed on the AFM images.
Results: One hundred percentage and four percentage of the
patients with SP and SD respectively had macropits on their

hair shafts. In both the SP and SD-affected hairs, the scale

thickness was more than 4-fold than that in the control hairs.
The surface of SP-affected hairs was rougher than that of SDaffected and control hairs.
Conclusion: The differences in hair shafts between SP and
SD were investigated noninvasively using AFM. The presence
of macropits could be helpful in the differentiation between SP
and SD.

a chronic, relapsing inflammatory

disease that occurs in approximately 2% of
the population; 50% of those affected will have
scalp involvement (1, 2). Seborrheic dermatitis
(SD) has a predilection for the scalp, eyebrows,
nasolabial angle, ears, and sterna region. Some
cases of SD bear a close clinical resemblance to
psoriasis, especially of the scalp. Because the
inflammatory scalp disorders share similar clinical manifestations of scaling, erythema, and
pruritus, the clinical differential diagnosis is
sometimes very difficult.
Zaias stated that the most common nail lesion
of psoriasis is pitting (3). Although pits can be
seen in normal individuals, they can also
appear in other diseases, such as chronic
eczema, alopecia areata, and lichen planus, but
they are typically deeper in the individuals having nail psoriasis. Kumar et al. reported that
macropits in the hair shaft demarcated depressions on the surface and were seen more fre-

quently in hair from psoriasis patients in the

scanning electron microscopy (4).
Atomic force microscopy (AFM) is a promising tool for observing the surface topography of
hair shafts because it is a very high-resolution
type of scanning probe microscopy. The resolution of AFM is more than 1000 times better than
the optical diffraction limit, and it can provide
three-dimensional information about the surface
morphology (5, 6). In this work, we investigated
the surface of hair shafts in scalp psoriasis (SP)
and seborrheic dermatitis (SD), using AFM. A
special focus was on the presence of macropitting on the surface of hair shafts as the differentiating point between SP and SD.

e60

SORIASIS IS

Key words: scalp psoriasis seborrheic dermatitis atomic

force microscopy pitting hair

2012 John Wiley & Sons A/S

Accepted for publication 27 November 2011

Materials and Methods

Hair sample preparation
Hairs from 14 patients with SP and 28 patients
with SD were investigated. The severity scores

Comparison of hairs in SP and SD

of scalp psoriasis were moderate (7). All patients

had psoriatic lesions elsewhere on their bodies.
The clinical form of psoriasis was psoriasis vulgaris in all the patients. The age of the patients
ranged from 24 to 75 years (mean age,
46.9 13.8 years); there were 10 male patients
and 4 female patients in this group. Patients
with other systemic diseases were excluded. SDaffected group included both erythema and scaling were more 2 point, respectively using a 4point scale (03): 0, absent; 1, mild; 2, moderate;
and 3, severe. The age of the patients ranged
from 19 to 78 years (mean age, 44.6 17.9
years); there were 14 male patients and 14
female patients in this group. None of the
patients ever had any previous systemic treatment and all had discontinued topical drug
application at least 6 months prior to this study.
Hairs from 50 healthy adult controls (27 male
patients and 23 female patients), between 21 and
60 years of age (mean age, 39.5 13.95 years)
were examined in a similar way. All hair samples were obtained by cutting with fine scissors
as close to the skin surface as possible to minimize the production of artifacts. The hair samples were washed using a 1% sodium
dodecylsulfate solution, and then rinsed using
distilled water. The hairs were then dried at
room temperature for > 4 h.
AFM
The SP and SD-affected hairs were examined for
the morphological and mechanical properties
using AFM (NANOStation II; Surface Imaging
Systems, Herzogenrath, Germany). The microscopy consisted of an AFM scanner (92.5 9
92.5 9 6 lm3 in x, y, and z directions) and a Zeiss
optical microscope (Epiplan 5009; Zeiss, EpiplanJena, Germany). To avoid any unwanted noise
signal originating from vibrations, the AFM system was placed on a vibration isolation table (TS150, Table Stable, Zwillikon, Switzerland). All
images were obtained in the non-contact mode
for an area of 20 9 20 lm2. The scan resolution
and scan speed were 512 9 512 pixels and
0.8 line/s, respectively. The specifications of the
cantilever used in this work were; frequency of
146 ~ 236 kHz, spring constant of 21 ~ 98 N/m,
length
of
225 nm,
and
resistance
of
0.01 ~ 0.02 O cm. For each sample, five or more
AFM images were taken at the same position,
which is 1 cm from the proximal root. Pit is a

sharply demarcated depression on the hair surface. The pit can be classified into two types;
micro and macropit depending on the size. The
micropit has a small diameter (< 0.5 lm) or a
smaller area (< 0.25 lm2) and the macropit has a
large diameter (> 0.5 lm) or a larger area
(> 0.25 lm2). The scale thickness was measured
at several different sites for each AFM image and
all the values were averaged. The surface roughness was measured in a randomly selected area of
3 9 3 lm2. In all samples, four parameters of the
surface roughness, Sa, Sq, Sz, and Sku were calculated. Here, Sa is the average value of the roughness, Sq is the root mean square, Sz is the peak-topeak value, and Sku is the surface kurtosis.

Statistical analysis
The analysis was performed by one-way ANOVA using the SPSS 11.0 statistical software program (SPSS, Inc., Chicago, IL, USA). A P-value
of less than 0.05 was considered as statistically
significant. The result is expressed as the
mean standard deviation.

Results
Pit
The pits observed in the SP and SD-affected
hairs are listed in Table 1. One hundred percentage and four percentage of the patients
with SP and SD respectively had macropits on
their hair shafts, and 5% of the control hair had
macropits. In the case of SP-affected hair, the
average number of pits was 2.84 0.41. In
patients with SP, most of the the pits of the
lesions (92%) were macropits. The long and
short axis of the pit observed in the lesion was
1.81 0.21 lm and 1.11 0.02 lm, respectively.
The pit was rarely observed in the SD-affected
hair collected. The total number of the pit
observed in the SD-affected hair collected from
the lesional region was 0.61 0.19. Most of the
pits in SD-affected hair were micropits: macropit was only 13% of the total pit. The number
of pits in the control hair was also small,
0.42 0.07. Most of the pits observed in the SDaffected hair and control hair were micropits.

Scale
The scales were observed in all samples of the
SP-affected, SD-affected, and control hairs.

e61

Kim et al.
TABLE 1. Results of pits, scale, diameter and surface roughness of hair shafts in scalp psoriasis and seborrheic dermatitis
Scalp psoriasis
Pit

Number (N)

Dimension (lm)
Scale
Roughness

Macropit
Micropit
Total pit
Long axis
Short axis
Thickness (lm)
Sa (nm)
Sq (nm)
Sku
Sz (nm)

2.61
0.23
2.84
1.81
1.11
160.11
44.31
57.51
5.91
420.41

0.11
0.04
0.41
0.21
0.02
9.21
1.91
2.61
0.51
13.41

Seborrheic
dermatitis
0.08
0.53
0.61
0.26
0.18
169.12
14.1
18.1
3.9
133.5

0.01
0.05
0.19
0.04
0.03
6.41
0.51
0.72
0.21
5.51

Control
0.03
0.39
0.42
0.37
0.24
37.96
12.31
16.41
5.41
125.11

0.001
0.07
0.07
0.11
0.11
6.81
0.31
3.41
1.81
36.89

P-value*

P-value*

P-value*

0.003
0.02
0.005
2.91 3 10 7
1.01 3 10 5
0.046
2.21 3 10 9
2.2 3 10 9
0.008
3.89 3 10 12

0.025
0.13
0.025
0.256
0.238
0.001
2.18 3 10
6.31 3 10
0.36
4.36 3 10

3.45
1.25
0.32
0.09
0.24
0.001
0. 91
0.22
0.45
0.45

10
11

11

*Statistical results between SP and SD, SP and control, and SD and control hairs, respectively. Statistically significant results were written in bold letter.

Fig. 1. Representative AFM images of scalp psoriasis (a), seborrheic dermatitis (b) and control hairs (c). The colors indicate height of the surface
topography: the light and dark colors correspond to the higher and the lower topography, respectively. (d)(f) are enlarged images of dotted circles
and (g)(i) enlarged images of dotted rectangles in (a)(c), respectively.

However, the scales were observed more frequently in the SP and SD-affected hairs than in
control hairs. There was a significant difference
in the scale thickness between the SP or SDaffected hairs, and the control hairs. The scale
thickness of the SP and SD-affected hairs was 4fold more than that of the control hairs as
shown in Table 1. The SP-affected hairs
(160.11 9.21 nm) showed a scale thickness
similar to that of the SD-affected hairs
(169.12 6.41).

e62

Roughness
The SP-affected hairs showed the largest values
of all the roughness parameters indicating a
rougher surface. The SD-affected hairs showed
roughness parameter values very similar to
those of the control hairs.

Discussion
The scale of SD has often shown a yellow,
greasy appearance. Psoriasis is characterized by

Comparison of hairs in SP and SD

more well-defined erythematous plaques, with

heavier silvery scales that peel in layers. Psoriatic lesions in the scalp areas are moist and erythematous, with yellow, greasy, soft scales,
rather than dry and micaceous scales (8). Therefore, the differential diagnosis between seborrheic dermatitis and scalp psoriasis may be
difficult. Indeed, the clinical overlap between
SP and SD has led some clinicians to describe
the cases in which psoriatic lesions appear
along with those of SD as seborrhiasis. An
accurate diagnosis of SP is important to predict
the prognosis of patients; however, it is more
difficult than that in the case of SD.
Microscopic examination of the scalp hair is
commonly used to confirm the diagnosis of SP.
However, the histopathologic features of SD are
a combination of those observed in psoriasis and
spongiotic dermatitis. In SD, the stratum corneum contains focal parakeratosis, with a predilection for the follicular ostia, a finding known as
shoulder parakeratosis. Werner et al. reported that
42% cases of SP may exhibit contains focal parakeratosis, with a predilection for the follicular
ostia (9). A definitive diagnosis of SP may be difficult after studying the pathologic examination
(6). Also, the invasive nature of the technique
renders it impractical as a routine method for
monitoring the disease progression or the pharmacogenomic effects of various treatments.
Noninvasively, the presence or absence of
twisted loops as a dermoscopic sign is thought
to correspond to tortuous capillaries in the dermal papilla, and it can be particularly helpful in
clinically difficult cases (10). Ross et al. reported
that all cases of psoriasis, regardless of the
stage, exhibited twisted loops, in comparison
with 20% cases of seborrheic dermatitis. In the
present study, 100% of the patients with SP
showed macropitting, whereas only 4% of the
patients with SD showed macro pits in the hair
shaft. This result implies that the presence of
macropitting may be one of the important differentiating points between SP and SD.
Using the AFM, the observed scale thickness
was not significantly different between the SP

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Acknowledgements
This work was supported by a grant from the
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