Case Number : Case 947 - 7th February Posted By: Guest

Clinical corrected to F68.

Scarring alopecia without significant inflammatory cell infiltration or interface change. Favor pseudopelade of Brocq. Would like to see the elastic tissue stain if available.

There is a clear attenuation of dermis.What about En Coup de Sabre? Patology iis not typical for clinclall ..So scarriing alpecia for intestigations.

I think this is a tough one without CPC. LPP is usually a clear cut clinical diagnosis in most cases. If it is a frontal pattern alopecia, there is really no other clinical differential in a post-menopausal female, unless she is pulling her hair back tight or something. A.Areata wouldn't usually enter my clinical differential in FFA.

Histo shows a scarring alopecia, but no significant inflammatory infiltrate to support LPP. However, it doesn't exclude resolved LPP!

End stage scarring alopecia of any etiology (no clues pointing to a specific etiology) or Pseudopelade (idiopathic).

I favor late stage of alopecia areata. I can’t see terminal follicles in anagen, but only catagen follicles and fibrous tracts. There are also “widowed” bundles of arrector pili muscle, whose corresponding follicles are lost. Collagen whorls with sparse swarm of bees-like lymphocytic infiltrate follicular have replaced papillae in the deep reticular dermis and in the subcutaneous fat.

I don´t think Pseudopelade actually exists and I would base my diagnosis over the clinical impression together with the histopathologic features. If the clinical aspects support a FFA it would be a better diagnosis than a Pseudopelade.

I think Robledo is right, despite I don´t see AA clinically simulating FFA.

I want to note the loss of sebaceous glands, which is a sign of end-stage primary scarring alopecia. When non-scarring alopecia such as alopecia areata and traction alopecia become end-stage and irreversible, sebaceous glands are typically preserved. Therefore this is most likely not end-stage alopecia areata.

Reference: Sperling et al. An atlas of Hair Pathology with Clinical Correlations, Second edition.

Thanks Nooshin. I think Sherlock Holmes would be proud of you as it it a classic case of the dog not barking in the night. Often it is the absence of something that is a major clue (in this case the lack of sebaceous glands) and in the case of the Sherlock Holmes story the fact the dog did not bark in the night (I think the story was about a stolen race horse). The pathological lack of something in a section always seems to be harder to appreciate than the addition of aberrant pathology. But in this case we also have nice follicular scars in the upper horizontal sections but only non-scarred stellae in the lower horizontal sections. Taking these histological features together with the clinical I reported this as strongly favouring a late stage of FFFA/LPP. Yes we are are looking at the grave stones but I think we can be fairly confident of the nature of the previous assault by reading the information written on them!