Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Study Letter
ARTICLE IN PRESS
doi:
10.25259/IJDVL_1145_2021

Vertical versus transverse sectioning in histopathological diagnosis of alopecia: A comparative study

Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
Corresponding author: Dr. Shipra Agarwal, Department of Pathology, All India Institute of Medical Sciences, New Delhi, India. drshipra0902@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Yadav D, Mahajan S, Agarwal S, Khandpur S, Pandey A, Singh MK. Vertical versus transverse sectioning in histopathological diagnosis of alopecia: A comparative study. Indian J Dermatol Venereol Leprol doi: 10.25259/IJDVL_1145_2021

Sir,

The most appropriate method to section a scalp biopsy is a matter of contention. Different sectioning techniques, all with respective advantages and disadvantages, have been suggested. In the current study, we prospectively compared the accuracy of serial vertical sections with that of transverse sections in the characterisation of primary alopecia after obtaining institutional ethics committee approval (IEC-668/01.12.2017). Consecutive consenting patients with alopecia were recruited after a thorough history and clinical examination. Dermoscopy was used as an additional tool to supplement the clinical diagnosis. Routine workup included relevant blood investigations like haemogram and thyroid function tests. Two 4 mm punch scalp biopsies were taken using standard methods from the most representative area. To determine the normal counts of vellus and non-anagen hair follicles in vertical sections, the uninvolved occipital scalp of six consenting patients of cicatricial alopecia was also biopsied. For transverse and vertical sections, each biopsy was exhausted in eight slides (8–10 sections per slide) while trimming the block in between. These haematoxylin-eosin stained slides were then assessed by two dermatopathologists (SA, DY) independently, blinded to the clinical details. Any possible bias was avoided by separately examining the transverse and vertical sections of each case. Various quantitative and qualitative histological parameters were assessed. For transverse sections, a ratio of ≤4: 1 at the isthmus level was considered abnormal for anagen to non-anagen and terminal to vellus hair ratios.1 For vertical sections, >2 catagen hair per section and >1 vellus hair per section were used as cut-offs for increased non-anagen hair and miniaturisation, respectively. These were in agreement with previous suggestions from literature and our findings on vertical sections from the normal scalp (catagen hair = 0–2/section; vellus hair = 0–1/section).1,2 As the same hair follicle may be visualised on serial vertical sections, follicular ratios could not be calculated on vertical sections due to the lack of a denominator. The disagreement between the two dermatopathologists was resolved with the help of a third dermatopathologist (SK). Statistical analysis was performed using clinicopathological diagnosis as the gold standard and Stata version 16.0 (StataCorp, College Station, TX, U.S.A.). A P-value <0.05 was considered significant. Percentage agreement was calculated between the gold standard and the diagnosis made by combining the results of transverse and vertical sectioning. Percentage agreement was also calculated between the gold standard and the results obtained on transverse and vertical sections individually. Results were analysed using Cohen’s kappa value (value greater than 0.90 indicating almost perfect agreement) between the gold standard (clinico-pathological correlation) and individual sectioning technique (vertical or transverse sectioning).

Seventy-eight alopecia patients (after excluding 8 due to poor sectioning) were recruited. The mean age was 27.7 years; the male: female ratio was 1.4:1, and the mean duration of illness was 4.4 years. There were 43 cases of non-cicatricial alopecia (alopecia areata: 25; androgenetic alopecia: 16; chronic telogen effluvium and trichotillomania: 1 each) and 35 cases of cicatricial alopecia (lichen planopilaris: 15; pseudopelade of Brocq: 12; discoid lupus erythematosus: 4; folliculitis decalvans: 3; linear morphea: 1). Diagnostic agreement was ‘almost perfect’ (k = 0.92, P < 0.001) for transverse sections and ‘moderate’ (k = 0.74, P < 0.001) for vertical sections. On sub-group analysis, the agreements achieved with transverse and vertical sections were ‘almost perfect’ (k = 0.91, P < 0.001) and ‘weak’ (k = 0.50, P < 0.001), respectively in non-cicatricial alopecia; and ‘strong’ (k = 0.87, P < 0.001) with either technique in cicatricial alopecia. Considering individual alopecia types, the diagnostic accuracy of transverse sections was significantly more than vertical sections for alopecia areata (97.7% and 86%, P = 0.05) and androgenetic alopecia (97.7% and 81.4%, P = 0.01). The results were similar with both techniques for lichen planopilaris (vertical section = 100%; transverse section = 97.1%, P = 0.30) and pseudopelade of Brocq (vertical section = 100%; transverse section=97.1%, P = 0.30). Amongst individual parameters, increased non-anagen hair count (39/43, 90.7% vs 23/43, 53.5%, P < 0.001), miniaturisation (40/43, 93% vs 27/43, 62.8%, P = 0.001) and vascular stelae (36/43, 83.7% vs 24/43, 55.8%, P = 0.009) were found significantly more frequently in transverse than vertical sections.

Sectioning technique for a scalp biopsy done for alopecia often depends upon the dermatopathologist’s preference. Cutting transverse sections needs specialised training and may not be preferred in resource-limited settings. While transverse sections allow better assessment of various follicular ratios essential for evaluating non-cicatricial alopecia; vertical sections allow quick examination of all levels of the hair follicle and dermo-epidermal junction helpful in cicatricial alopecia. Data comparing the diagnostic accuracy of transverse and vertical sections is limited and conflicting [Table 1].3-10 In a recent meta-analysis, Du did not find any statistically significant difference between the diagnostic accuracy of transverse and vertical sections for cicatricial and non-cicatricial alopecia.11 Bathish found that serial vertical sections improved the diagnostic yield in 48 (48%) cases. This was higher for non-cicatricial (52.5%) than cicatricial alopecia (48.5%).12 In the current study, we compared the diagnostic accuracy of serial vertical sections with transverse sections. To overcome the shortcoming of a limited number of follicles seen on vertical sections, we exhausted the entire biopsy on eight slides, each having 8–10 sections. Amongst the individual alopecia types, transverse sections did significantly well in alopecia areata and androgenetic alopecia. In our study, five out of 25 (20%) of alopecia areata could not be diagnosed on vertical sections. Transverse sections could establish the diagnosis in all these cases based on features like increased non-anagen hair, miniaturisation, and pigment casts in the absence of characteristic peri-bulbar inflammation [Figure 1].8 In androgenetic alopecia, miniaturisation was missed in seven (43.7%) on vertical sections and in one (6.2%) on transverse sections. Nevertheless, the two techniques did equally well in cicatricial alopecia. Interestingly, epidermal and dermo-epidermal changes could be appreciated equally well on transverse and vertical sections.

Table 1:: Results of various studies comparing the utility of transverse vs vertical sections in alopecia
Study Type of study Sectioning technique Number of sections No. of cases Percentage cases accurately diagnosed on TS Percentage cases accurately diagnosed on VS Conclusion
Whiting3, 1993 Prospective VS: bisected into half
TS: sectioned at the level of entry of sebaceous ducts into the follicle (approximately 1-1.5 mm below the dermoepidermal junction, depending on dermal thickness)
VS: 6
TS: 24
A:106*
CA: 0
NCA: 106
100% 93% TS provided more diagnostic information than VS^
Whiting4, 1995 Prospective VS: NS
TS: NS
NS A: 287#
CA: 0
NCA: 287
67% 49% TS provided more diagnostic information than VS^
Elston5, 2005 Retrospective VS: NS
TS: step cuts from deeper fat to papillary dermis
NS A: 102
CA: 73
NCA: 29
78.4% 94.1% Combination of TS and VS is better, VS alone had higher concordance than TS alone^
Garcia and Poletti6, 2007 Retrospective VS: NS
TS: NS
NS A: 276
CA: 64
NCA: 202
Normal: 10
100% 100% TS and VS performed equally well^
Özcan7, 2011 Prospective VS: bisected into half
TS: sectioned at 1 mm below the dermoepidermal junction
V: 6$
T: 3-4$
A: 47
CA:17
NCA: 30
A: 91.5%
CA: 76.5%
NCA: 100%
A: 82%
CA: 82.4%
NCA: 83.3%
TS better than VS for NCA; TS and VS are equally diagnostic for CA
Peckham8, 2011 Retrospective VS: NS
TS: NS
NS A: 15#
CA: 0
NCA: 15
93.3% 100% TS and VS gave comparable results^
Singh9, 2016 Prospective VS: NS
TS: sectioned around 1–2 mm below the epidermal surface
NS A: 30#
CA: 0
NCA: 30
100% 93.3% TS performed better than VS^
Palo10
-, 2017
Retrospective VS: NS
TS: sectioned around 1-1.5 mm below the epidermal surface
NS A: 228
CA: 44
NCA: 162
Inconclusive: 22
90.4% 90.4% TS and VS performed equally well^
Present study Prospective VS: whole processed, without prior bisection into two halves
TS: whole processed without prior bisection into two halves
VS: 60-80
TS: 60-80
A: 78
CA: 35
NCA: 43
A: 96.1%
CA: 97.1%
NCA: 95.3%
A: 78.2%
CA: 94.2%
NCA: 65.1%
TS better than VS for NCA, TS and VS are equally diagnostic in CA

A: all alopecia cases, CA: cicatricial alopecia, NCA: non-cicatricial alopecia, NS: not specified, VS: vertical, TS: transverse, *: only androgenetic alopecia cases, #: only alopecia areata cases, $: 4 additional sections were examined if required, ^: P -value not mentioned in the study

Figure 1a:: Alopecia areata: Smooth non scarring alopecia patch over fronto-temporal scalp
Figure 1b:: Alopecia areata: Increased vellus hair (marked with arrows) indicating miniaturisation on vertical sections (H&E, ×40)
Figure 1c:: Alopecia areata: Vascular stelae without pigment casts on vertical section (H&E, ×100)
Figure 1d:: Alopecia areata: Miniaturisation with increased non-anagen hair count on transverse sections at the level of isthmus (H&E, ×40)
Figure 1e:: Alopecia areata: Miniaturised telogen hair with coarse pigment casts on transverse section (H&E, ×100)
Figure 1f:: Alopecia areata: Vascular stelae with coarse pigment casts on transverse section at the level of subcutis (H&E, ×100)

Our study used serial vertical sections (reducing the sampling error) and performed appropriate statistical measures for comparing the two techniques. Although there are a few limitations, including a relatively small sample size, especially telogen effluvium cases, and a lack of ancillary studies like immunofluorescence and special stains, we got significant results. Transverse sections performed better than serial vertical sections in non-cicatricial alopecia but equally well in cicatricial cases. Hence, transverse sections should be the preferred technique in the histopathological evaluation of non-cicatricial alopecia. For cicatricial alopecia, either of the two sectioning methods may be used, depending upon the preferences of the laboratory personnel.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.

References

  1. , , . An Atlas of Hair Pathology with Clinical Correlations (ed 2). London: Informa Healthcare; .
    [Google Scholar]
  2. , . Histopathologic approach to alopecia. Indian J Dermatopathol Diagn Dermatol. 2018;5:79-88.
    [CrossRef] [Google Scholar]
  3. . Diagnostic and predictive value of horizontal sections of scalp biopsy specimens in male pattern androgenetic alopecia. J Am Acad Dermatol. 1993;28:755-63.
    [CrossRef] [PubMed] [Google Scholar]
  4. . Histopathology of alopecia areata in horizontal sections of scalp biopsies. J Invest Dermatol. 1995;104:26S-27S.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , , , . A comparison of vertical versus transverse sections in the evaluation of alopecia biopsy specimens. J Am Acad Dermatol. 2005;53:267-72.
    [CrossRef] [PubMed] [Google Scholar]
  6. , . Scalp biopsy specimens: Transverse vs vertical sections. Arch Dermatol. 2007;143:268.
    [CrossRef] [PubMed] [Google Scholar]
  7. , , . 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.
    [CrossRef] [PubMed] [Google Scholar]
  8. , , . Histologic features of alopecia areata other than peribulbar lymphocytic infiltrates. J Am Acad Dermatol. 2011;65:615-20.
    [CrossRef] [PubMed] [Google Scholar]
  9. , , , . A comparison of vertical and transverse sections in the histological diagnosis of alopecia areata scalp biopsy specimens. Int J Trichology. 2016;8:111-5.
    [CrossRef] [PubMed] [Google Scholar]
  10. , . Utility of horizontal and vertical sections of scalp biopsies in various forms of primary alopecias. J Lab Physicians. 2018;10:95-100.
    [CrossRef] [PubMed] [Google Scholar]
  11. , , , , , , et al. Diagnostic value of horizontal versus vertical sections for scarring and non-scarring alopecia: A systematic review and meta-analysis. Eur J Dermatol. 2016;26:361-9.
    [CrossRef] [PubMed] [Google Scholar]
  12. , , , . 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.
    [CrossRef] [PubMed] [Google Scholar]

Fulltext Views
2,816

PDF downloads
66
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections