Skin Research and Technology 2013; 19: e60–e64
Printed in Singapore
All rights reserved
doi: 10.1111/j.1600-0846.2011.00608.x
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 simi-
lar clinical manifestations of scaling, inflammation, and pruritus,
the differential diagnosis of these lesions; especially between
scalp psoriasis (SP) and seborrheic dermatitis (SD) is some-
times difficult.
Objectives: The aim of this study was to investigate the differ-
ences on the hair surface in SP and SD for a clinical diagno-
sis, 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 charac-
teristics 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
a chronic, relapsing inflammatory
P SORIASIS IS
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 clin-
ical 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 hav-
ing nail psoriasis. Kumar et al. reported that
macropits in the hair shaft demarcated depres-
sions on the surface and were seen more fre-
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© 2012 John Wiley & Sons A/S
Skin Research and Technology
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 SD-
affected 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.
Key words: scalp psoriasis – seborrheic dermatitis – atomic
force microscopy – pitting – hair
Ó 2012 John Wiley & Sons A/S
Accepted for publication 27 November 2011
quently in hair from psoriasis patients in the
scanning electron microscopy (4).
Atomic force microscopy (AFM) is a promis-
ing tool for observing the surface topography of
hair shafts because it is a very high-resolution
type of scanning probe microscopy. The resolu-
tion 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 macropit-
ting on the surface of hair shafts as the differen-
tiating point between SP and SD.
Materials and Methods
Hair sample preparation
Hairs from 14 patients with SP and 28 patients
with SD were investigated. The severity scores

of scalp psoriasis were moderate (7). All patients
had psoriatic lesions elsewhere on their bodies.
The clinical form of psoriasis was psoriasis vul-
garis 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. SD-
affected group included both erythema and scal-
ing were more 2 point, respectively using a 4-
point scale (0–3): 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 treat-
ment 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 sam-
ples were obtained by cutting with fine scissors
as close to the skin surface as possible to mini-
mize the production of artifacts. The hair sam-
ples 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 micros-
copy 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, Epiplan-
Jena, Germany). To avoid any unwanted noise
signal originating from vibrations, the AFM sys-
tem was placed on a vibration isolation table (TS-
150, 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
Comparison of hairs in SP and SD
sharply demarcated depression on the hair sur-
face. 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 rough-
ness 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 calcu-
lated. Here, Sa is the average value of the rough-
ness, Sq is the root mean square, Sz is the peak-to-
peak value, and Sku is the surface kurtosis.
Statistical analysis
The analysis was performed by one-way ANO-
VA using the SPSS 11.0 statistical software pro-
gram (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 per-
centage 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: macro-
pit 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 SD-
affected hair and control hair were micropits.
Scale
The scales were observed in all samples of the
SP-affected, SD-affected, and control hairs.
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Kim et al.

TABLE 1. Results of pits, scale, diameter and surface roughness of hair shafts in scalp psoriasis and seborrheic dermatitis

Seborrheic
Scalp psoriasis dermatitis Control P-value* P-value* P-value*

Pit Number (N) Macropit 2.61 ± 0.11 0.08 ± 0.01 0.03 ± 0.001 0.003 0.025 3.45
Micropit 0.23 ± 0.04 0.53 ± 0.05 0.39 ± 0.07 0.02 0.13 1.25
Total pit 2.84 ± 0.41 0.61 ± 0.19 0.42 ± 0.07 0.005 0.025 0.32
Dimension (lm) Long axis 1.81 ± 0.21 0.26 ± 0.04 0.37 ± 0.11 2.91 3 10 7 0.256 0.09
Short axis 1.11 ± 0.02 0.18 ± 0.03 0.24 ± 0.11 1.01 3 10 5 0.238 0.24
Scale Thickness (lm) 160.11 ± 9.21 169.12 ± 6.41 37.96 ± 6.81 0.046 0.001 0.001
Roughness Sa (nm) 44.31 ± 1.91 14.1 ± 0.51 12.31 ± 0.31 2.21 3 10 9 2.18 3 10 10
0. 91
Sq (nm) 57.51 ± 2.61 18.1 ± 0.72 16.41 ± 3.41 2.2 3 10 9 6.31 3 10 11
0.22
Sku 5.91 ± 0.51 3.9 ± 0.21 5.41 ± 1.81 0.008 0.36 0.45
Sz (nm) 420.41 ± 13.41 133.5 ± 5.51 125.11 ± 36.89 3.89 3 10 12 4.36 3 10 11
0.45

*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 fre- Roughness

quently in the SP and SD-affected hairs than in
control hairs. There was a significant difference
in the scale thickness between the SP or SD-
affected hairs, and the control hairs. The scale
thickness of the SP and SD-affected hairs was 4-
fold 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).
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

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more well-defined erythematous plaques, with
heavier silvery scales that peel in layers. Psori-
atic lesions in the scalp areas are moist and ery-
thematous, with yellow, greasy, soft scales,
rather than dry and micaceous scales (8). There-
fore, the differential diagnosis between seborr-
heic 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 corne-
um contains focal parakeratosis, with a predilec-
tion for the follicular ostia, a finding known as
shoulder parakeratosis. Werner et al. reported that
42% cases of SP may exhibit contains focal para-
keratosis, with a predilection for the follicular
ostia (9). A definitive diagnosis of SP may be dif-
ficult 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 phar-
macogenomic 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 der-
mal 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 dif-
ferentiating points between SP and SD.
Using the AFM, the observed scale thickness
was not significantly different between the SP
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Comparison of hairs in SP and SD
and SD-affected groups. However, the surface
roughness showed a significant difference in
the roughness parameter values of Sa, Sq, and
Sz. This might be caused by the thinner and
wider scale of SD than that of SP.
Zaias et al. described the mechanism of
development of pitting in the psoriatic nail as
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cells in the stratum corneum that disrupt the
process of normal keratinization (3). As the nail
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better understand the mechanism of develop-
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will be needed in the future.
In conclusion, we suggest that macropitting
can be used as the differentiating point between
SP and SD of the scalp. In this view, although
SD and SP have similar clinical features, differ-
ent pathogenesis could affect the microscopic
changes in the hair shaft.
Acknowledgements
This work was supported by a grant from the
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