Case Number : Case 808 - 23rd July Posted By: Admin_Dermpath

Syphilitic alopecia
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[color="#000000"][font="Palatino Linotype, serif"][size="4"]Acne keloidalis nuchae. Classic microscopic features are present and include lymphoplasmacytic infiltrate surrounding dilated hair follicles that show thinning of the infundibular epithelium and polytrichia, loss of sebaceous glands, and interfollicular dermal scarring with a fuzzy lamellar appearance. Site, age and gender are also typical.[/size][/font][/color]

I agree that there are many things in which make me think about Folliculitis Keloidalis Nuchae, but the histological findings are not specific and this disease is more commom in African-american people. In my opinion, the case is probably a late stage of Folliculitis decalvans in which neutrophils could not be find, however plasma cells are quite common.

Two pack compond follicles other then 6 pack suggest a lymhocyte-mediated cicatricial alopecia such as keloidalis nuchae

([url="http://www.ncbi.nlm.nih.gov/pubmed/21083676"]The amount counts: distinguishing neutrophil-mediated and lymphocyte-mediated cicatricial [b]alopecia[/b] by compound follicles.[/url] Pincus LB, Price VH, McCalmont TH.

[b]J Cutan Pathol[/b]. 2011 Jan;38(1)

Though the presence of plasma cells should make one exclude syphilis, these are not very specific in the context of a lymphocytic scarring alopecia.

discoid lupus would be my favoured diagnosis, of the clinical differentials listed. However, would like to see vertical sections too!

The clinical impression of Seborrheic dermatitis doesn´t fit, so I would expect the lesion has crusting and erythema. The paper Engin Sezer showed is really helpful and is a required reading for all dermpath-lovers, but at the same time it favors LMCA, the interfollicular dermal fibrosis and the plasma cells in this case favors a NMCA (neutrophilic-mediated cicatricial alopecia) at a late stage. Amazing case.

[i][before spirochete stains were posted ....][/i]

Late-stage lichen planopilaris might be a consideration, in addition to lupus and the above entities.
- LPP clinically presents with erythema and scaling at the follicles, so makes sense with the clinical differential diagnosis that includes seb derm and lupus.
- This is a scarring non-suppurative alopecia with interface component and follicular plugging. Although vacuolar change is not prominent, this is a high-level horizontal section with targeted perifollicular and epidermal interface inflammation, and spiky follicular epithelial cross sections with hypergranulosis. The presence of melanophages and slight basement membrane thickening is congruent with an interface component.

I was going to suggest syphilitc alopecia on the H&E (I thought M21 might be a clue). This has no features of scarring to me and is not nuchal!

If it is syphilis - thanks Mark I have never seen a case of syphilitic alopecia.

Look at all those spirochetes highlighted by immunostain!!! Dra. Maria George is right, it's syphilitic alopecia.

Syphilitic alopecia.

Lovely, wounderful...

Difficult case. I did not think of Sypihils for two reasons: first, I never saw a case beatiful like this; second, clinically, Syphilitic alopecia has a moth-eaten patern of hair loss and resembles more non-cicatricial alopecia, mostly alopecia areata. Great case.

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Syphilitic alopecia
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Well done Dr. Maria George!!