Case Number : Case 784 - 19th June Posted By: Guest

No significant inflamation. Trichomalacia and fractured hair shafts. Damaged inner root sheath. Not sure I can see pigment casts. Maybe there is some haemorrhage around the hair bulb. Dx: Trichotillomania

Agree with clinical suspicion of trichotillomania. It's a non-inflammatory and non-scarring alopecia showing signs of follicular damage: irregularly shaped hair follicles, loss of hair shafts, and trichomalacia.
A catagen hair follicle with thickened corrugated basement membrane can also be seen, probably indicating that there is increased number of follicles in this phase of hair growth.

Agree with trichotillomania, although I would be more confident if melanin casts were present.

Trichotillomania

There are twisted hair shaft or multiple hair shafts in one follicle,Follicular drop out,Follicular plugging by keratin,Perifollicular fibrosis, and premature keratinization and damage of inner root sheath .
If in the skin , I might thought of some exotic conditions like scurvy or Keratosis follicularis spinulosa decalvans, ..etc.
But in scalp , I will say this is central centrfugal alopecia or hot comb alopecia.

Agree that it is not quite enough for trichotillomania but can't make it into anything else, given the clinical.

Alopecia diagnosis on these images with limited clinical may be a challenge.
There are numerous hairs present so will presume this is a perilesional biopsy.

[i]Clinical questions: [/i]
1. Do we know the pattern of hair loss (asymmetric patchy or geographic would be expected in trichotillomania). Is it diffuse or dense?
2. Is patient on steroids that may decrease inflammation?

We can't assess CAT follicle ratios or vellus hair ratios.
But if the images are taken for what they are, at least narrowing down the differential may be possible.
I agree with Maria that this leans more towards the central centrifugal scarring alopecia (CCSA) direction:

[b]A. Trichotillomania (disfavored):[/b]
[i]Supportive findings[/i]: Minimal inflammation. Moderate distortion of architecture in the catagen bulb (mid left photo), and mild distortion of the anagen bulb outline in the mid-right photo). Clinical suspicion of trichotillomania.
[i]Dismissive findings[/i]: No pigment casts. No collapsed outer root sheaths (bottom left photo shows artifactual loss of hair shaft, but no collapse). Lack of significant trichomalacia/distortion of the terminal hairs present (ignoring the expected sectioning artefact).

[b]B. CCSA / scarring alopecia (favored): [/b]
[i]Supportive findings[/i]: polytrichia/tufting with possible follicle fusion (top two photos). Hint of premature desquamation of inner root sheath, and especially notable: asymmetric thinning or atrophy of the follicular epithelium (top left photo on left edge center). Follicular plugging. Location on vertex (most common).
[i]Dismissive findings:[/i] No significant perifollicular lamellar fibrosis. No significant perifollicular chronic inflammation. Sebaceous glands appear intact (not obliterated/scarred out).

The diagnosis for this was [color=#1C2837][font=arial, verdana, tahoma, sans-serif][size=4]trichotillomania.[/size][/font][/color]

Agree, trichotillomania.