Case Number : Case 1460- 28 January Posted By: Guest

Central centrifugal cicatricial alopecia? is she a black woman?

No, she is caucasian.

Lichen planopilaris.

Increase in telogen hair, irregularity of IRS, surface showing scale crust (fig 7), around the hair there is no significant inflammation but in the upper to mid-demis there is mild to moderate mononulclear infiltrate.

thinking of Trichotillomania with overlying LSC

Maam, Is there any history of hair pulling?

No history of hair pulling or traction. Some of Biswanath's observations are correct, but there is something in the history that I am withholding. (wasnt available to me too at time of bx).

Any other thoughts?

Ok I was reviewing a bit and I have another differential. Most hairs are in telogen, absence of sebaceous glands, desquamation of IRS. There is also a superficial dermal inflammatory infiltrate that appears mainly lymphocytic. On the epidermis we can see parakeratosis, marked hypogranulosis and spongiosis. I was wondering if a differential could be psoriatic alopecia. Patients are usually treated before biopsy with steroids and epidermal changes can be attenuated.

Brilliant Raul!

Yes, this a psoriatic alopecia. It is easily mistaken for a scarring alopecia due to the loss of sebaceous glands. The horizontal sections clearly show relatively preserved follicular units with hardly any inflammation, which would argue against LPP. Sebaceous gland atrophy is a typical feature of psoriatic alopecia. Figures 3 and 5 show the basophilic remnants of sebaceous glands surrounding follicles, a rather consistent feature and a good clue to the diagnosis.   Marked telogen shift and surface epidermal changes complete the picture. Remember, one may not get typical psoriatic changes on the surface and this is not a pre-requisite for the diagnosis. Sometimes, epidermal changes may resemble seborrhoeic dermatitis more than psoriasis and of course treatment may alter the picture too.  

This patient had history of scaly plaques on her body which had been treated as eczema. But on review by dermatologist, felt to be more consistent with psoriasis. There was regrowth of scalp hair with anti-psoriatic treatment, underscoring the fact that sebaceous gland loss in this setting does not connote a scarring outcome.

http://www.ncbi.nlm.nih.gov/pubmed/18360109

Great case - I am claiming CPD!  Well done Raul - again.

Thanks for sharing this great case Arti

I'm an old general pathologist and i've studied a lot in my professional life, but for the first time i'm learning a lot so vastly thanks to your all. Thanks very much. This is a wonderful web site.

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