Hertoghe's sign
back to main page
Hertoghe’s sign, also called Queen Anne’s sign (Queen Anne’s sign), is a characteristic thinning or complete loss of the outer, lateral part of the eyebrows. It is not an independent disease, but a clinical sign that may indicate endocrine, dermatological, autoimmune, or systemic disorders. It is most commonly associated with hypothyroidism and atopic dermatitis, but it also occurs in the course of many other conditions. Due to its relatively high diagnostic value, the appearance of Hertoghe’s sign requires a thorough clinical assessment and determining the cause of hair loss. Diagnosis is based on a medical examination, skin assessment, and, if necessary, laboratory and dermoscopic tests.
Hertoghe's sign - what it looks like
Hertoghe's sign consists of progressive thinning or loss of hair in the lateral third of the eyebrow. Hair loss can be unilateral or bilateral, although it most commonly affects both eyebrows to a similar degree. The process usually develops gradually and remains unnoticed by the patient for a long time.
Typical features of the sign include:
- gradual decrease in hair density on the terminal section of the eyebrow,
- shortening of the eyebrow length from the temporal side,
- preservation of normal hair in the medial part,
- absence of clearly demarcated areas of alopecia,
- symmetrical nature of the changes.
The appearance of the skin at the site of hair loss depends on the underlying disease. In hypothyroidism, the skin often becomes dry, cool, and rough. In atopic dermatitis, erythema, itching, skin thickening, and traces of chronic scratching may coexist. In other inflammatory diseases, scaling, discoloration, or features of chronic inflammation may occur.
The Hertoghe sign itself does not cause pain or itching. Symptoms, if present, result from the disease responsible for the hair loss.
Hertoghe's sign - where to look for the loss
The characteristic location of Hertoghe's sign is the lateral third of the eyebrow arch, which is the part located closest to the temple. This is the area of the greatest diagnostic value, as hair loss in this region is much more frequently associated with systemic diseases than with physiological aging.
During the examination, the doctor assesses:
- the extent of hair loss,
- the symmetry of the changes,
- the presence of hair breakage or thinning,
- the condition of the skin under the eyebrow,
- the presence of signs of inflammation or scarring.
Eyebrow trichoscopy, which is a dermoscopic examination of the hair and skin, is helpful in diagnostics. It allows for the assessment of hair follicles, hair diameter, and the presence of inflammatory changes or characteristic features of various types of alopecia.
Hertoghe's sign may affect only the tip of the eyebrow or gradually involve a larger part of the arch. In advanced cases, there is an almost complete disappearance of the lateral parts of both eyebrows.
It should be remembered that slight thinning of the outer parts of the eyebrows can occur physiologically in elderly people. Hertoghe's sign is referred to when the hair loss is pronounced, progressive, and associated with an underlying disease.
Hertoghe's sign - which diseases cause it
The Hertoghe sign is not a diagnosis, but a signal indicating the possible presence of various conditions. It is most commonly associated with disorders affecting the hair growth cycle or chronic skin inflammation.
The most important causes include:
Disease | Mechanism of development of the Hertoghe sign |
|---|---|
slowing of the hair growth cycle, increased transition of follicles into the resting phase | |
Atopic dermatitis | chronic inflammation and mechanical damage to hair due to itching and scratching |
Iron deficiencies | impairment of hair growth and increased hair loss |
Zinc deficiencies | impaired proliferation of hair follicle cells |
Biotin or protein deficiencies | weakening of hair growth |
Secondary syphilis | diffuse non-scarring hair loss also involving the eyebrows |
Leprosy | damage to hair follicles during the course of chronic infection |
Chronic inflammatory dermatoses | damage to hair follicles by the inflammatory process |
Less frequently, the Hertoghe sign is observed in the course of:
- chronic lupus erythematosus,
- sarcoidosis,
- severe systemic diseases,
- long-term malnutrition,
- chronic metabolic stress.
Diagnostics should include assessment of thyroid function (TSH, fT4), complete blood count, iron metabolism (ferritin), zinc levels, and other parameters depending on the clinical presentation. In selected cases, immunological or serological tests, or a skin biopsy are also performed.
Hertoghe's sign - how to distinguish from alopecia areata of the eyebrows
The most important element of diagnosis is distinguishing Hertoghe's sign from alopecia areata of the eyebrows (alopecia areata). Although both conditions lead to hair loss, they differ in their mechanism of development, clinical picture, and dermoscopic examination results.
The most important differences are presented in the table below.
Feature | Hertoghe's sign | Eyebrow alopecia areata |
|---|---|---|
Location | lateral 1/3 of the eyebrow | any part of the eyebrow |
Nature of hair loss | gradual thinning | sudden focal alopecia |
Symmetry | usually bilateral | often asymmetrical |
Cause | systemic or dermatological disease | autoimmune disease |
Dermoscopy | absence of characteristic dystrophic hairs | exclamation mark hairs, black dots, yellow dots |
Prognosis | depends on the treatment of the underlying disease | recurrent, unpredictable course |
In alopecia areata, hair loss usually occurs rapidly, and the patches are well-demarcated. Dermoscopic examination reveals characteristic features of an active autoimmune process, such as exclamation mark hairs or black dots.
In contrast, in Hertoghe's sign, hair loss develops slowly and is chronic in nature. Treatment primarily consists of the diagnosis and effective therapy of the underlying disease. In many cases, especially after managing hypothyroidism or controlling skin inflammation, gradual regrowth of eyebrow hair occurs. In situations where hair follicles have retained their regenerative capacity, improvement can be supported by treatments stimulating their activity, such as needle mesotherapy, platelet-rich plasma (PRP), or therapies utilizing growth factors. If permanent damage to the hair follicles has occurred, the possibilities of hair restoration are limited and require individual qualification for treatment.
