Am J Dermatopathol 2017 Aug 9. Epub 2017 Aug 9.

Departments of *Pathology, and †Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL; and ‡Robert H. Lurie Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.

Background: Accurate identification of follicular streamers versus follicular scars on horizontal scalp biopsy sections is important to differentiate between cicatricial and noncicatricial alopecias. However, distinguishing between them can be difficult especially in nonoptimal specimens. The utility of elastic Verhoeff-Van Gieson (EVG) stain in cicatricial alopecias has been described on vertical sections, but its evaluation on horizontal sections has not been performed. Read More

Int J Trichology 2017 Jan-Mar;9(1):25-29

Department of Dermatology, Saint Louis University, St. Louis, MO, USA.

Background: Telogen effluvium (TE) is a type of acquired, diffuse alopecia that occurs due to an abnormal shift of scalp hair follicles from anagen to telogen, leading to premature shedding of hair. Previous studies have suggested the existence of a neuroimmunologic "brain-hair follicle" axis, in which mast cells have been implicated as an important link between the nervous system and immunologic system.

Objective: The current study sought to investigate the role of mast cell presence and mast cell degranulation in the pathogenesis of TE. Read More

Cas Lek Cesk 2017 ;156(3):145-146

Mesotherapy (from Greek meso = in between, therapeia = treat) is a non-surgical, mostly cosmetic therapy, where active substances are injected intradermally into a depth of about 4 mm. It is an effective and easy-to-use method in the treatment of alopecia. It is effective both in the therapy of androgenetic alopecia and telogen effluvium. Read More

G Ital Dermatol Venereol 2017 Jul 11. Epub 2017 Jul 11.

Department of Dermatology, University of Genoa, Genoa, Italy.

Skin Appendage Disord 2017 Mar 28;3(1):36-38. Epub 2017 Jan 28.

University of Genoa, Genoa, Italy.

Chronic telogen effluvium is most often intermittent, alternating periods of spontaneous remissions with episodes of unexplained relapses. This article reports the case of a male who was able to graphically depict the sequence of emotional events and the corresponding severity of his telogen effluvium during 31 months. The case is interesting as it documents for the first time the intermittency of chronic telogen effluvium and the pathogenetic role of emotional strains, and it stresses the importance of the modified wash test in evaluating the severity of hair shedding. Read More

Skin Appendage Disord 2017 Mar 17;3(1):7-14. Epub 2016 Dec 17.

Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA.

Background: Contact dermatitis of the scalp is common and might be caused by many chemicals including metals, ingredients of shampoos and conditioners, dyes, or other hair treatments. Eliciting a careful history and patch tests are necessary to identify the responsible allergen and prevent relapses.

Objectives: To identify allergens that may cause contact dermatitis of the scalp by reviewing patch test results. Read More

Yonsei Med J 2017 May;58(3):682-683

Department of Dermatology, Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea.

An Bras Dermatol 2017 Jan-Feb;92(1):35-40

Department of Dermatology - Sisli Hamidiye Etfal Training and Research Hospital - Istanbul, Turkey.

Background:: Androgenetic alopecia (AGA) is a patterned hair loss occurring due to systemic androgen and genetic factors. It is the most common cause of hair loss in both genders. In recent years, many studies investigating the relation between systemic diseases and androgenetic alopecia presented controversial results. Read More

Dermatol Ther (Heidelb) 2017 Mar 20;7(1):155-165. Epub 2017 Feb 20.

Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1475 NW 12th Avenue Suite 2175, Miami, FL, USA.

Introduction: Hair shedding is a common consequence of the normal hair cycle that changes with internal and external factors. Female pattern hair loss (FPHL) is difficult to assess in terms of shedding severity as the conscious perception of hair shedding varies according to each individual, and most utilized methods are semi-invasive or very time consuming. In this study, we establish and validate a hair-shedding scale for women with thick hair of different lengths. Read More

J Am Acad Dermatol 2017 Mar 20;76(3):472-477. Epub 2016 Dec 20.

Division of Dermatology, Ottawa Hospital, Ottawa, Ontario, Canada. Electronic address:

Background: The hair pull test lacks validation and has unclear pretest guidelines.

Objective: We sought to quantify normal hair pull test values and elucidate the effect of pretest hair washing and brushing. The impact of hair texture and lifestyle was also examined. Read More

Skin Appendage Disord 2016 Sep 21;2(1-2):39-44. Epub 2016 May 21.

Center for Dermatology and Hair Diseases Professor Trüeb, Wallisellen, Switzerland.

Skin Appendage Disord 2016 Sep 18;2(1-2):35-38. Epub 2016 May 18.

Department of Dermatology, University of Genoa, Genoa, Italy.

Telogen effluvium (TE) is a pathogenically heterogeneous condition which so far has been classified into acute and chronic forms - or, according to Headington, into 5 different pathogenetic forms. Regrettably, Headington's classification is difficult to apply in the office, and most papers dealing with TE ignore it. The present review intends to propose a novel classification of TE and to introduce, tentatively, a new variety of TE. Read More

Drugs Real World Outcomes 2016 Mar;3(1):1-6

King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London, UK.

Hair loss is associated with the anticoagulants heparin and warfarin. With the recent availability of direct oral anticoagulants (DOACs) it is of clinical interest to know if they are implicated with hair loss and/or whether they could be successfully prescribed for patients who suffer from coumarin- or heparin-related alopecia. Initially reports of heparin- and coumarin-associated alopecia available through PubMed and Medline were explored in order to establish the cause of this side effect. Read More

J Drugs Dermatol 2016 Oct;15(10):1235-1237

Telogen effluvium is one of the most common forms of non-scarring alopecia for which patients present to a dermatologist. It is a challenging disorder to treat and study, primarily owing to its multifactorial etiology which includes both physiologic and non-physiologic factors. Nutritional deficiency has been purported to contribute to hair shedding, and a patient's clinical history usually aids in directing laboratory evaluation. Read More

Am J Dermatopathol 2017 Sep;39(9):668-671

Departments of *Pathology, and †Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL; and ‡Robert H. Lurie Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.

Background: Eccrine duct dilation (EDD) and syringoma-like sweat duct proliferation have been described as reactive changes occurring in a variety of skin conditions. However, extensive evaluation of EDD in scalp biopsies performed for alopecia has not been performed.

Methods: We retrospectively examined 129 cases of cicatricial alopecia (lichen planopilaris, central centrifugal cicatricial alopecia, and discoid lupus erythematosus) and 130 cases of noncicatricial alopecias (androgenetic alopecia, telogen effluvium, and alopecia areata) for the presence of EDD. Read More

Acta Derm Venereol 2017 Feb;97(2):173-181

Department of Dermatology, Environmental Medicine and Health Theory, University of Osnabrück, DE-49076 Osnabrück, Germany.

Isotretinoin (13-cis retinoic acid) is the most effective sebum-suppressive drug for the treatment of severe acne. Its effect depends on sebocyte apoptosis, which results from isotretinoin-induced expression of the apoptotic protein tumour necrosis factor-related apoptosis-inducing ligand, insulin-like growth factor-binding protein-3 and neutrophil gelatinase-associated lipocalin. This review proposes that the pharmacological mode of action of isotretinoin in the treatment of severe acne, acute promyelocytic leukaemia, and neuroblastoma results from apoptosis. Read More

Dermatol Online J 2016 May 15;22(5). Epub 2016 May 15.

Departments of Dermatology: The Permanente Medical Group (Vallejo, CA), University of California, San Francisco, Case Western Reserve University.

Chronic telogen effluvium describes the clinical condition noted mostly in middle-aged women of increased, diffuse scalp hair shedding that is prolonged and often presents with a fluctuating course that may continue for years but does not lead to visible hair thinning. Despite its description almost 20 years ago, the underlying pathologic cause of CTE is yet to be identified. However the culmination of research in the field of hair biology and the burgeoning field of chronobiology may lead to exciting breakthroughs in our understanding of CTE. Read More

Dermatol Ther (Heidelb) 2016 Dec 9;6(4):471-507. Epub 2016 Sep 9.

Department of Experimental and Clinical Medicine, Institute of Dermatology, University of Udine, Udine, Italy.

Over the last few years, dermoscopy has been shown to be a useful tool in assisting the noninvasive diagnosis of various general dermatological disorders. In this article, we sought to provide an up-to-date practical overview on the use of dermoscopy in general dermatology by analysing the dermoscopic differential diagnosis of relatively common dermatological disorders grouped according to their clinical presentation, i.e. Read More

Int J Trichology 2016 Apr-Jun;8(2):73-7

Center for Dermatology and Hair Diseases Professor Trüeb, Zurich-Wallisellen, Switzerland.

Biotin is a coenzyme for carboxylase enzymes that assist various metabolic reactions involved in fatty acid synthesis, branched-chain amino acid catabolism, and gluconeogenesis important for maintenance of healthy skin and hair. Due to its availability, affordability, and effective marketing for this purpose, biotin is a popular nutritional supplement for treatment of hair loss. However, there are little data on the frequency of biotin deficiency in patients complaining of hair loss and on the value of oral biotin for treatment of hair loss that is not due to an inborn error of biotin metabolism or deficiency. Read More

Int J Trichology 2016 Apr-Jun;8(2):57-61

Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC V5Z 4E8, Canada; Department of Dermatology, New York University Langone Medical Center, New York City, New York, USA.

Background: Female pattern hair loss (FPHL) is a very common problem in women. The underlying pathophysiology remains unclear, and there are no universally agreed treatment guidelines.

Objective: We explored the clinical features, relevant medical and family history, laboratory evaluation, and treatment and compliance of 210 patients with FPHL. Read More

Ann Dermatol Venereol 2017 Feb 5;144(2):125-129. Epub 2016 Aug 5.

Service de médecine interne générale, hôpitaux universitaires de Genève, 1206 Genève, Suisse; Service de médecine interne, hôpital de la Tour, 1217 Meyrin-Genève, Suisse.

Introduction: Scurvy, or "Barlow's disease", is a widely described disease involving cutaneous and mucosal lesions resulting from vitamin C deficiency. Herein, we report a case of scurvy in a 48-year-old woman that was unusual in its atypical cutaneous-mucosal presentation as well as its association with anorexia nervosa.

Patients And Methods: A 48-year-old woman treated for depression for several years was admitted to hospital for her impaired general state of health. Read More

Acta Dermatovenerol Croat 2016 Jun;24(2):150-3

Jana Zímová, MD. Department of Dermatology. University Hospital Ostrava. 17. listopadu 1790. 708 52 Ostrava - Poruba. Czech Republic;

Trichotillomania (TTM) is defined by the Diagnostics and Statistic Manual of Mental Disorders, 4th edition (DMS-IV) as hair loss from a patient`s repetitive self-pulling of hair. The disorder is included under anxiety disorders because it shares some obsessive-compulsive features. Patients have the tendency towards feelings of unattractiveness, body dissatisfaction, and low self-esteem (1,2). Read More

Skin Appendage Disord 2016 May 20;1(4):198-201. Epub 2016 Apr 20.

Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain.

Introduction: Postpartum telogen effluvium (PPTE) is a commonly described entity, but few studies deal with the real incidence and pathogenesis of this claimed common disease.

Objective: To analyze the objective data published and to define the real incidence of the so-called PPTE.

Method: A retrospective review of the published data was conducted. Read More

Skin Appendage Disord 2016 Feb 19;1(3):141-3. Epub 2015 Nov 19.

Dermatology Division, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.

Topical minoxidil, the only approved treatment for female pattern hair loss (FPHL), has been associated with scalp allergic contact dermatitis (ACD). We report the case of 2 female patients who developed ACD from minoxidil solution with severe telogen effluvium and psoriasiform scalp dermatitis. Scalp dermoscopy was useful to identify the psoriasiform vascular pattern, whereas patch testing made it possible to differentiate the cause of sensitization. Read More

Arch Dermatol Res 2016 Aug 3;308(6):415-21. Epub 2016 May 3.

Dermatology and Venereology Department, Faculty of Medicine for Girls, Al Azhar University, 3 El-Sherkah El-Porsaeedeya, Ard Elgolf, Heliopolis, Cairo, 11361, Egypt.

Alopecia areata incognita (AAI) is a type of diffuse hair fall with no confirmatory diagnostic test. The UL16 binding protein-3 (ULBP3) is ligands for natural-killer group 2, member D (NKG2D) receptor. It is a key regulator of both innate and adaptive immune responses. Read More

Drugs Real World Outcomes 2016;3:1-6. Epub 2016 Jan 7.

King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London, UK.

Hair loss is associated with the anticoagulants heparin and warfarin. With the recent availability of direct oral anticoagulants (DOACs) it is of clinical interest to know if they are implicated with hair loss and/or whether they could be successfully prescribed for patients who suffer from coumarin- or heparin-related alopecia. Initially reports of heparin- and coumarin-associated alopecia available through PubMed and Medline were explored in order to establish the cause of this side effect. Read More

Dermatol Res Pract 2016 20;2016:6279108. Epub 2016 Jan 20.

Department of Dermatology, Dr. D. Y. Patil Medical College and Hospital and Research Centre, Pimpri, Pune, Maharashtra 411018, India.

Alopecia can either be inherited or acquired; the latter, more common, can be diffuse, patterned, and focal, each having cicatricial and noncicatricial forms. This observational study of 135 cases in a semiurban Indian population aimed to detect the prevalence of various forms of acquired alopecia in females and correlate the same with levels of hemoglobin, serum ferritin, triiodothyronine, thyroxin, and thyroid stimulating hormone. The majority (84, 62. Read More

Int J Dermatol 2016 Jul 29;55(7):e373-9. Epub 2015 Dec 29.

Department of Pathology, Medical School, State University of Campinas, Campinas, Brazil.

Background: The distinction between chronic telogen effluvium (CTE) and female pattern hair loss (FPHL) is important because of their different prognosis and treatment. Non-invasive methods have been described to be useful in differentiating FPHL from CTE. This prospective study investigated the use of the washing method to differentiate CTE from mild FPHL. Read More

Int J Dermatol 2016 Apr 23;55(4):382-4. Epub 2015 Dec 23.

University of Genoa, Genova, Italy.

Trichodynia designates a painful sensation on the scalp sometimes reported by patients with hair loss. Its best description dates back to 1960, when Sulzberger et al. (Arch Dermatol 1960; 81: 556-560) reported it in a proportion of women complaining of an unexplained diffuse alopecia. Read More

Int J Trichology 2015 Jul-Sep;7(3):100-6

Department of Dermatology, Andrology and Sexually Transmitted Diseases, Faculty of Medicine, Mansoura University, El-Gomhoria St., Mansoura, Egypt.

Introduction: Hair loss is a common and distressing problem that can affect both males and females of all ages. Chronic telogen effluvium (CTE) is idiopathic diffuse scalp hair shedding of at least 6 months duration. Hair loss can be one of the symptoms of metal toxicity. Read More

Ann Dermatol 2015 Oct 2;27(5):539-50. Epub 2015 Oct 2.

Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea.

Background: Trichoscopic findings of hair loss have been well described for the differential diagnosis of alopecia; however, critical findings were not thoroughly investigated or compared among all ethnic groups, including Asians.

Objective: We aimed to find any characteristic trichoscopic findings in Korean alopecia patients and to verify whether those findings are closely related to previously reported observations.

Methods: Three hundred and twenty-seven patients with hair loss of various causes and 160 normal scalps were analyzed. Read More

J Clin Diagn Res 2015 Sep 1;9(9):WE01-3. Epub 2015 Sep 1.

Senior Resident, Department of Dermatology, Venereology and Leprosy, ESIC Medical College , Kalaburagi, Karnataka, India .

Telogen effluvium was first described by Kligman in 1961. It is a most common cause of diffuse hair loss. Women with telogen effluvium more frequently present to dermatologist. Read More

Med Clin North Am 2015 Nov 4;99(6):1195-211. Epub 2015 Sep 4.

Division of Dermatology, Department of Medicine, University of Washington, Box 354697, 4225 Roosevelt Way Northeast, 4th Floor, Seattle, WA 98105-6920, USA. Electronic address:

This article reviewed some of the more common diseases of the skin appendages that are encountered in medicine: hyperhidrosis, acne, AA, FPHL, AGA, and TE. The pathophysiology behind the conditions and their treatments were discussed so that the clinician can make logical therapeutic choices for their affected patients. Read More

J Clin Diagn Res 2015 Aug 1;9(8):WC01-4. Epub 2015 Aug 1.

Senior Resident, Department of Dermatology, Venereology and Leprosy, ESIC Medical College Kalaburagi, Karnataka, India .

Background: Diffuse hair loss is a common complaint encountered by dermatologists in their daily clinical practice. Hair loss in women is a distressing condition. Various underlying factors individually or in combination contribute to the pathogenesis. Read More

Int J Dermatol 2015 Oct;54(10):1169-74

San Camillo Forlanini Hospital, Rome, Italy.

Background: In Ethiopia, skin diseases are among the leading causes of outpatient attendance to primary health service. Correlation of skin diseases and HIV has long been recognized and used to guide medical management in resource-limited settings. Therefore, this study aims to assess the correlation of skin diseases and HIV infection, to estimate epidemiological distribution in the study area, and to provide health workers of skin indicators for HIV early detection. Read More

Curr Probl Dermatol 2015 20;47:97-106. Epub 2015 Feb 20.

In this chapter, we will discuss the most common alopecias due to drugs and other skin and systemic disorders. The following hair disorders will be analyzed: telogen effluvium (acute and chronic); anagen effluvium; folliculotropic mycosis fungoides; and folliculitis due to bacteria, fungi, parasites, human immunodeficiency virus disease, lupus erythematosus, and sarcoidosis. We will cover topics including the epidemiology, etiology, clinical picture, and diagnosis of and current treatments for each disease. Read More

Curr Probl Dermatol 2015 20;47:21-32. Epub 2015 Feb 20.

Scalp dermoscopy or `trichoscopy' represents a valuable, noninvasive technique for the evaluation of patients with hair loss that allows for magnified visualization of the hair and scalp skin. It may be performed with a manual dermoscope (×10 magnification) or a videodermoscope (up to ×1,000 magnification). In particular, trichoscopy enhances the diagnosis of androgenetic alopecia, alopecia areata, telogen effluvium, trichotillomania, congenital triangular alopecia, scarring alopecia, tinea capitis and hair shaft disorders. Read More

J Clin Aesthet Dermatol 2015 Aug;8(8):52-4

Rady Children's Hospital, San Diego, California and University of California, San Diego;

"Errors of transcription" are rarely reported, but may cause significant adverse effects in patients. Here, the authors report the case of a 15-year-old Burmese girl presenting with telogen effluvium after being dispensed the wrong medication due to a pharmacy auto-complete error. Read More

Biosci Biotechnol Biochem 2015 4;80(1):74-9. Epub 2015 Aug 4.

a Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine , The University of Tokyo , Tokyo , Japan.

Alopecia impairs the physical and mental health of patients. We have previously shown that 8-week-old ob/ob mice have no reactivity to depilation, which is a stimulus that induces anagen transition in normal mice, while no hair cycle abnormalities have been reported in other studies until mice reach 7 weeks of age. Therefore, we hypothesized that ob/ob mice have abnormalities in hair cycle progression beyond 7 weeks of age. Read More

Clin Exp Dermatol 2015 Oct 23;40(7):717-21. Epub 2015 Jul 23.

Department of Dermatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.

Alopecia and other hair abnormalities occurring in patients with psoriasis were first recognized over four decades ago, yet psoriatic alopecia is not a well-known concept among clinicians. Alopecia may be directly related to the psoriasis itself, and can affect both the scalp and other parts of the body. On the scalp, psoriatic alopecia most commonly affects lesional skin, but may present as a generalized telogen effluvium. Read More

Semin Cutan Med Surg 2015 Jun;34(2):81-8

Department of Dermatology; Wake Forest Baptist Health Medical Center; Winston-Salem, North Carolina, USA.

Hair loss in skin of color patients can vary from the very simplest of diagnoses to a unique diagnostic challenge requiring extensive knowledge of historical symptoms, haircare practices, and previous treatments. There are several disorders in the literature that are noted to be more common in patients of African descent as compared to Caucasian populations. These disorders include central centrifugal cicatricial alopecia, dissecting cellulitis, discoid lesions of lupus erythematosus, traction alopecia, seborrheic dermatitis, and hair breakage. Read More

Semin Cutan Med Surg 2015 Jun;34(2):67-71

Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.

Diffuse hair loss in women causes a significant impact on quality of life, reduces self-esteem, and increases stress. One of the major challenges when evaluating patients with diffuse hair loss is to determine whether you are dealing with either female pattern alopecia, telogen effluvium, or both, as they can coexist. Establishing the correct diagnosis is mandatory for optimal patient care. Read More

Int J Dermatol 2015 Sep 3;54(9):e332-8. Epub 2015 Jul 3.

Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland.

Background: Skin problems in the elderly population have rarely been the subject of scientific research.

Objectives: The present study aimed to determine the prevalences of the most common dermatological conditions in elderly subjects and to investigate their associations with systemic diseases.

Methods: The study involved a group of 198 consecutive patients aged ≥ 65 years who were admitted to the Departments of Dermatology and Geriatrics at the study institution. Read More

Skinmed 2015 Mar-Apr;13(2):98-101

Effluvium capillorum is a form of nonscarring alopecia characterized by diffuse hair shedding. This condition occurs when the normal balance of hairs in growth and rest phases is disrupted. Trichoscan is a computerized program used for digital measurement of hair growth and hair loss. Read More

J Dermatol Case Rep 2015 Mar 31;9(1):1-5. Epub 2015 Mar 31.

Department of Dermatology, Medical University of Warsaw, Poland;

Background: Loose anagen hair syndrome (LAHS) is typically diagnosed in girls older than 2 years who present with hair that "will not grow". Hair microscopic examination shows absent inner and outer root sheaths, ruffling of the cuticle on the proximal hair shaft and deformed pigmented anagen bulbs.

Objective: The aim of the study was to assess whether there are characteristic trichoscopic features favoring the diagnosis of LAHS. Read More

Hepat Mon 2015 Mar 20;15(3):e24804. Epub 2015 Mar 20.

Department of Pathology, Ministry of Health Bagcilar State Hospital, Istanbul, Turkey.

Introduction: Various types of dermatological manifestations have been reported due to hepatitis C virus (HCV) infection and anti-HCV therapy. Some of them have been described during IFN-based therapies. PEG-IFN-α-2a/RBV combination is used as the international standard of treatment for HCV infection for a long time. Read More

G Ital Dermatol Venereol 2017 Apr 24;152(2):184-185. Epub 2015 Mar 24.

Department of Pathophysiology and Transplantation, Università degli Studi di Milano, I.R.C.C.S. Foundation, Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.

Rev Med Liege 2014 Dec;69(12):686-91

The diagnosis of most alopecia problems is based on the clinical history and a well conducted clinical examination. The additional contributions of dermoscopy, trichoscopy and trichogram are helpful. However, a scalp biopsy is occasionally necessary to establish the correct diagnosis. Read More

Case Rep Urol 2015 11;2015:642547. Epub 2015 Feb 11.

Department of Urology, Faculty of Medicine, Bozok Universitesi Uygulama ve Arastirma Hastanesi, Uroloji AD, 66100 Yozgat, Turkey.

Penile tourniquet syndrome (PTS), a rare urologic emergency, may lead to undesirable results including necrosis and amputation of penis, if not diagnosed and treated appropriately. Sometimes these injuries may be accepted as a forensic case. Miscellaneous objects used for strangulation can be metallic or nonmetallic. Read More