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In this section we have spot diagnoses posted on a daily basis since June 2010, now over 1700! You can review the archived cases and read the suggested diagnoses by users and the final comment by Dr Uma Sundram, the Editor-in-Chief and main spot diagnosis host. Case are uploaded each week day by 10 a.m. UK time with the correct diagnosis will generally be posted at 8 p.m. UK time. Why not view the most recent spot diagnosis and proffer a diagnosis?

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

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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Case History: 53/F, patch of hair loss on central scalp with scaling and erythema, ?scarring alopecia (lupus/LPP), ?alopecia areata

Images 1-5: Horizontal section, images 6-7: Vertical section

Case posted by Dr Arti Bakshi


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Raul Perret

Posted

Central centrifugal cicatricial alopecia? is she a black woman?

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biswanath behera

Posted

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?

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Arti Bakshi

Posted

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?

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Dr. Mona Abdel-Halim

Posted

The surface scale crust is strange in the context of LPP or CCCA... Any history of pustules? Could it be old folliculitis decalvans?

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Raul Perret

Posted

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.

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Dr. Mona Abdel-Halim

Posted

Very good possibility Raul :-)

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Arti Bakshi

Posted

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.

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Dr. Richard Carr

Posted

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

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Raul Perret

Posted

Thanks for sharing this great case Arti

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vincenzo polizzi

Posted

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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