Case Number : Case 1704 - 8 December - Dr Arti Bakshi Posted By: Guest

Another great case to go with shiny new portrait of today's Case Poster Dr Arti Bakshi

Cheers, Geoff Cross - DermpathPRO Projects

Trichotilomaina ,trichomalacia?

Alopecia is a tricky pathology chapter for me. Being to what I studied, this case looks like an alopecia aerata with overlapped trichotillomania...but sincerely I'm not sure... 

For me is quite a tricky chapter of dermpath Vincenzo, and to be honest Im not a fan of it either haha. I see catagen and telogen predominance, infundibular dilation, pigment casts  and distorted follicles. Absence of follicle miniaturization and apparently no hemorrhage or prominent inflammatory infiltrate (although I have my doubts in picture 8 lower right corner). This is a tricky differential, due to the absence of follicular miniaturization and inflammatory infiltrate and the presence distorted follicles I would tend to favour trichotillomania for CPC. 

Trichotillomania is my favored diagnosis

Catagen/telegen increase with Pigment casts. There is some peribulbar inflammation. Naturally, two differentials come to mind, chronic phase of alopecia areata ( will have marked catagen/telogen excess and miniatiaturised follicles) and trichotillomania. The latter can have some minimal inflammation. Would favour trichotilomania. CPC to r/o chronic AA.

Alopecia areata favoured. You can get pigment casts in AA.

Favor AA

Well done to all who favoured alopecia areata!

Ofcourse the main differential is a traumatic alopecia in view of prominent pigment casts and trichomalacia. But the clue to the correct diagnosis is in the (rather focal) peribulbar inflammation. I purposely did not zoom into in, but as Raul rightly observed it is present in image 8 (and also image 4). I have asked Geoff to put some high power images of these areas. Also, note that these bulbs are high up in the dermis, hence represent bulbs of miniaturised follicles. Remember, peribulbar inflammation can be focal and even absent in chronic forms of AA.  Clinically, the pattern was felt to be more in keeping with AA too. See link for a good article on changes other than peribulbar inflammation in AA.https://www.ncbi.nlm.nih.gov/pubmed/21684037

So, the main take home message is that traumatic alopecia can overlap histologically with AA. Whilst pigment casts, trichomalacia and increased telogen counts are common to both, peribulbar inflammation and miniaturisation are features not seen in traumatic alopecias.

@Vincenzo....you did pretty well, so maybe the alopecia chapter isn't so difficult after all!!

Arti et al, I have just added the two extra images as requested.

Cheers, Geoff Cross - DermpathPRO Projects

Thank you and nice case Arti very instructive as always. Well done to the colleagues too

I just saw this beautiful case.

Thanks Arti!