Report

The study of hair follicle counts from scalp histopathology in

the Thai population
Yingluck Visessiri1, MD, Kallapan Pakornphadungsit2, MD, Kanchana Leerunyakul2, MD,
MSc, Suthinee Rutnin2, MD, Smith Srisont3, MD and Poonkiat Suchonwanit2, MD

1
Department of Pathology, Faculty of Abstract
Medicine, Ramathibodi Hospital,Mahidol Background The horizontal section of a scalp specimen offers an advantage over a
University, Bangkok, Thailand, 2Division of
vertical section by providing quantitative information. The reference data for hair counts in
Dermatology, Department of Medicine,
Faculty of Medicine, Ramathibodi Hospital,
Asians, including Thais, are inconclusive. We aimed to determine the normal values of hair
Mahidol University, Bangkok, Thailand, and counts in scalp biopsy specimens in the Thai population.
3
Forensic Unit, Department of Pathology, Methods A 4-mm punch biopsy was performed at the occipital area of the scalp from
Faculty of Medicine, Ramathibodi Hospital, subjects presenting with clinically normal hair and scalp appearance. All specimens were
Mahidol University, Bangkok, Thailand
horizontally sectioned and observed to assess the number of follicular units and hair
follicles, type of hairs, and phase of the hair cycle. The results were further compared
Correspondence
Poonkiat Suchonwanit, MD between sexes and with the pre-existing data from previous studies.
Division of Dermatology Results Ninety specimens were collected from 90 subjects. The average number of total
Faculty of Medicine hairs, terminal hairs, vellus hairs, and follicular units per 4-mm punch scalp skin were
Ramathibodi Hospital
20.5  5.2, 18.2  4.1, 2 (range 0–7), and 9.1  1.6, respectively. The mean ratio of
Mahidol University
270 Rama VI Road, Ratchathewi
terminal to vellus hair was 8.9:1 and of anagen to telogen hair was 91.9:7.9. There were
Bangkok 10400 no gender differences in any of the parameters and no correlations with changing age.
Thailand Compared to other Asian populations, Thais and Taiwanese showed intermediate values
E-mail: poonkiat@hotmail.com between Iranians and Koreans; when compared to other ethnic groups, hair density in
Asians showed lower than Caucasians and Hispanics but was comparable to Africans.
Conflict of interest: None.
Conclusion This study established reference values of scalp horizontal sections in the
Thai population; this will be helpful for clinicians and researchers to evaluate hair disorders.
Funding source: Funding provided by the
Division of Dermatology, Department of
Medicine, Faculty of Medicine, Ramathibodi
Hospital, Mahidol University, Thailand.

doi: 10.1111/ijd.14989

required as a reference point in the interpretation of scalp speci-

Introduction
Alopecia is a common problem in dermatological practice. The
diagnosis of alopecia generally requires a combination of patient
history, physical examination and, occasionally, additional labora-
tory investigation. Although there are several methods of hair loss
evaluation, histopathological examination of a scalp biopsy is con-
sidered the standard approach for definitive diagnosis, as well as
for quantitative and qualitative evaluations.1,2 Scalp biopsy speci-
mens can be obtained via a horizontal or vertical approach. The
horizontal section provides an advantage over the vertical section
in assessing the magnitude of the hair follicle and its structures at
various anatomical levels, as well as the different stages of the hair
cycle, thereby establishing a more precise clinicopathological
1-4
diagnosis of hair disorder, especially nonscarring alopecia. The
quantitative data of normal values of scalp horizontal sections are
mens for a more accurate diagnosis of alopecia.
The pre-existing quantitative information of scalp biopsy has
been researched in Caucasians,4 Africans,5 Hispanics,6 Irani-
ans,7 Koreans,8 Taiwanese,9 and Thais.10 All studies reported
that the variation in follicular counts among different ethnicities
can be applied as a reference value for histopathological evalua-
tion of alopecia for each corresponding ethnicity. However, the
reference data in Asians are still inconclusive because of a variety
of Asian phenotypes, inconsistent results, and various locations
of scalp biopsies. Moreover, a previous study in Thais obtained
specimens from the vertex,10 which may be influenced by early
androgenetic alopecia (AGA) as it is the miniaturized-prone
area.11 The aim of this study was to determine normal hair counts
in the Thai population, establish a reference value, and compare
the results with hair count values of other ethnicities. 1

ª 2020 the International Society of Dermatology International Journal of Dermatology 2020

2 Report Hair follicle counts in the Thai population Visessiri et al.

including anagen, catagen, and telogen, were recorded. A half

Methods
The study protocol was approved by the Mahidol University
Institutional Review Board for Ethics in Human Research (ID
09-59-16). Deceased subjects who required legal autopsies
were included in the study. Written informed consent was
received from subjects’ relatives. Inclusion criteria included
subjects aged 18 years or older with clinically normal hair and
scalp appearance. The duration between the time of death and
the time of specimen collection was less than 8 hours in order
to avoid an autolytic change in scalp specimens, as cited in a
10
previous study. Subject’s demographic data and medical
history were collected from the medical records at the time of
biopsy. Hair disorder and treatment histories were additionally
obtained from relatives of the deceased. Exclusion criteria
included unknown demographic data, incomplete medical
records, undetermined time of death, history of hair loss or
other hair and scalp disease, history of systemic diseases,
history of medications affecting hair growth cycle within
6 months, history of scalp laser or light treatment within
3 months, and a positive hair pulling test at the time of biopsy.
A 4-mm punch biopsy specimen was obtained 1 cm below
the greater occipital protuberance of the occipital scalp. The
biopsy specimens were processed according to Whiting’s
method.4 The histopathological evaluation was performed by a
blinded dermatopathologist. All follicular structures were
identified at various anatomical levels from the epidermis to the
subcutaneous tissue (Fig. 1). The numbers of follicular units
and hair follicles; types of hair follicles including terminal,
intermediate, and vellus hairs; and phases of hair follicles
of all indeterminate hairs were assigned to the terminal hair
group, and the other half were assigned to the vellus hair
group. We did not discriminate between catagen and telogen
phases. The results were further analyzed and compared with
the data from previous studies of other ethnicities.
Statistical analysis was performed using SPSS, version 18.0
(SPSS Inc., Chicago, IL, USA). The sample size was estimated
based on data from a previous study of hair counts from scalp
biopsy specimens in Asians.8 To achieve a power of 80% and a
significance level of 5%, the calculated minimum number of
subjects was 50. The statistical differences between genders
were calculated using t-test or Mann–Whitney test as
appropriate. P value less than 0.05 was considered statistically
significant. The effect of age was determined using a correlation
coefficient.
Results
Ninety scalp biopsy specimens were taken from 90 normal sub-
jects comprising 51 males and 39 females. The mean age was
36.5  15.1 years, ranging from 19 to 83 years. The average
number of follicular units was 9.1  1.6 per 4-mm punch scalp
skin. The mean number of total hairs was 20.5  5.2;
18.2  4.1 was the mean number of terminal hairs, and 2
(range 0–7) was the median number of vellus hairs. The aver-
age terminal to vellus hair (T:V) ratio was 8.9:1; the average
anagen to telogen (A:T) ratio was 91.9:7.9. The hair count
parameters obtained in our study are summarized in Table 1.
The differences in the hair count parameters between male
and female subjects were compared statistically (Table 1).
Although the average number of total hairs, terminal hairs, and

Table 1 Hair counts from 4-mm punch biopsy specimens in

normal Thai patients and comparison of hair count
parameters between males and females

Total Male Female P

(n = 90) (n = 51) (n = 39) value

Age, mean  SD 36.5  15.1 35.9  16.5 38.2  14.6 0.51

Total hairs, 20.5  5.2 20.9  5.1 19.5  5.4 0.69
mean  SD
Terminal hairs, 18.2  4.1 18.4  4.1 17.3  4.3 0.52
mean  SD
Vellus hairs, median 2 (0–7) 2 (0–7) 2 (0–5) 0.95
(range)
Follicular units, 9.1  1.6 9.3  1.9 8.4  1.7 0.62
mean  SD
Figure 1 A horizontal section of normal scalp at the level of the Terminal/vellus ratio 8.9:1 92.:1 8.5:1 0.43
isthmus reveals 10 follicular units with 31 total hairs (26 terminal, 3 Anagen/telogen 91.9:7.9 92.1:7.8 91.7:7.9 0.61
indeterminate, and 2 vellus hairs). The terminal to vellus hair ratio is ratio
7.9:1, and the percentage of telogen hairs is 9.7%. (hematoxylin
and eosin; original magnification 94) P value of statistical comparison between genders.

International Journal of Dermatology 2020 ª 2020 the International Society of Dermatology

Visessiri et al. Hair follicle counts in the Thai population Report 3

vellus hairs was greater in male subjects, there were no statisti-
cally significant differences between the two genders. The aver-
age number of follicular units, average T:V ratio, and average
A:T ratio were also comparable. The analysis did not reveal
any correlations between hair count parameters and changing
age.
The comparison of hair count parameters among different
ethnicities is demonstrated in Table 2. The number of total and
vellus hairs in our study was less than that reported in Thais;10
however, the number of terminal hairs was greater. The T:V
ratio was also much higher in this study. Many of the Asian hair
parameters presented with the lowest values when compared to
the other ethnicities.4-6 The average A:T ratio was similar to that
previously reported in studies in both Thais and other popula-
tions.4-10
Discussion
Horizontal sectioning of scalp biopsy specimens is a utility pro-
cess to evaluate quantitative and qualitative information of hair
follicles. To accurately diagnose alopecia in Asians, the normal
values of hair follicles should be determined, as the characteris-
tics of hair in this population are distinct. Our study reports hair
count parameters including the average number of total hairs,
terminal hairs, vellus hairs, follicular units, T:V ratio, and A:T
ratio per 4-mm punch scalp skin from the occipital scalp in the
normal Thai autopsied subjects.
Follicular units and hair follicles are the fundamental struc-
tures of the scalp. In our study, the number of total hairs and
number of follicular units were lower than those of Caucasians
and Hispanics but relatively similar to those of Africans.4-6
Among Asian populations, Iranians exhibited the greatest hair
counts, followed by Taiwanese, Thais (present study), and
Koreans (Table 2).7-9 These results corresponded to Lous-
souarn et al.’s study conducted on 24 different ethnic groups,
using the phototrichogram method, that determined higher hair
densities in Thai, Indian, and North-African populations than in
groups from East Asia.12 We theorize that genetic predisposi-
tion and racial factors play a role in hair counts and follicular
production. It is important to note that the methodology and
conditions of subjects in pre-existing studies of Asians varied
and could be the cause of the different outcomes. In a Korean
study, more than one third of the subjects presenting with AGA
were included; this may explain the lower number of hair counts
compared to our study.8 The scalp location of biopsy was
another determinant in the conflicting results. Prior studies of
scalp biopsies reported variations of hair counts at different
areas of the scalp.3,9 Studies employing automated phototri-
chograms also demonstrated that hair density differed according
to scalp location.13-15 Thus, the parameters obtained from stud-
ies with various scalp locations did not correlate with the results
we collected exclusively from the occipital area.
Evaluation of terminal and vellus hairs is important for the
diagnosis of nonscarring alopecia, especially in AGA. The num-
ber of terminal and vellus hairs in Asians as well as total hair
counts was relatively similar to that in Africans but lower than in
Caucasians and Hispanics.4-6 When compared to previous stud-
ies of Asians, the number of vellus hairs in the present study
was higher than that reported in East Asians (Table 2).8,9 One
reason was the racial differences. Another may be explained by
the different techniques used for slide preparation and
histopathological evaluation. The changes in terminal hairs or
vellus hairs affect the T:V ratio and represent alterations of hair
follicles, such as miniaturization. A reduced T:V ratio indicates
the miniaturization of hair follicles; a T:V ratio less than 4:1 is
suggestive of AGA.16 Our study displayed a remarkably higher
T:V ratio than the previous research in Thais.10 The apparent
ratio reduction in Yaprohm et al.’s study may be because of
procuring specimens from the vertex, a common site for initial
presentation of AGA.10,11 The occipital scalp is known to be the

Table 2 Comparison of hair count parameters among ethnic groups

Asian African Caucasian

Ethnic group American Hispanic
Present
Country study Thai10 Taiwan9 Korea8 Iran7 USA5 USA5 USA4 Mexico6

Number of cases 90 20 31 35 30 22 12 22 50
Site of specimens Occipital Vertex Vary Occipital Vary Vary Vary Vertex Occipital
Age (years) 36.5  15.1 55.1  15.8 37  15.3 33.1  10.0 35.5  14.7 31.7  8.5 34.7  12.2 43  3.5 34.14  10.6
Total hairs 20.5  5.2 28.3  9.2 21.3  4.8 16.1  3.6 36.4  7.2 21.5  5.0 35.5  5.5 40  2.2 23.2  4.3
Terminal hairs 18.2  4.1 16.5  8.4 20.5  4.6 14.9  3.2 34  6.4 18.4  5.0 30.4  6.4 35  2.1 21.08  4.1
Vellus hairs 2 (0–7) 6.9  7.0 0.8  1.0 1.1  1.3 2.4  1.2 3.0  2.1 5.1  3.5 5  0.6 2.12  1.0
Follicular units 9.1  1.6 10.7  2.6 9.4  1.9 7.8  1.7 NA NA NA 14  0.5 10.7  2.6
Terminal/vellus 89:1 2:1 25.3:1 13.5:1 17.4:1 6.1:1 6.0:1 7.0:1 11.37:1
ratio
Anagen/telogen 91.9:7.9 NA 91.6:8.4 93.6:6.4 93.7:6.3 93.9:6.1 94.5:5.5 93.5:6.5 90.7:7.8
ratio

ª 2020 the International Society of Dermatology International Journal of Dermatology 2020

4 Report Hair follicle counts in the Thai population
donor area least affected by miniaturization. We believe that
data obtained from this location provide a more accurate refer-
ence index.
Hair growth cycles display continuous follicular modification
and are composed of: anagen, a growing phase; catagen, a
transitional phase; and telogen, a resting phase. An assessment
of the A:T ratio would aid in estimating an abnormality in the
hair growth cycle. Values between this study and previously
published studies are similar (Table 2).4-10 There is no effect of
racial or ethnic differences observed in the A:T ratio, suggesting
that the ratio of active hair follicles in normal scalp is persistent
and could universally be used as a normal parameter despite
racial differences.
Since previous studies of hair parameters reported differ-
ences in hair count values among varying scalp sites,3,9,13-15
this study specifically obtained biopsies from the occipital area.
Therefore, our results may not be representative of other scalp
areas, and this could be a limitation of the study. Further stud-
ies evaluating the hair count parameters in each scalp area are
encouraged to establish the most reliable data for each scalp
location.
Conclusion
In conclusion, the present study established hair count parameters
in the normal Thai population. This study also confirmed the varia-
tion of hair values among different ethnicities. The established
data would be useful as reference parameters for histopathological
evaluation of hair disorders in the Thai population.
Data Availability Statement
The data used to support the findings of this study are available
from the corresponding author upon request.
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ª 2020 the International Society of Dermatology