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Case Number : Case 2387 - 6 September 2019 Posted By: Dr. Richard Carr

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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M65. Alopecia. ?Eczema ?Scarring
Case c/o Dr Domenico Mesiano

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IgorSC

Posted

There is a great reduction on follicular counts. The follicles are miniaturized and at first glance, it looks like scarring alopecia. But as we can see in pictures 1 and 4, the pilloerector muscle are intact and we can also observe sebaceous glands, but they are atrophic. Finally, the epidermis shows hypogranulosis, acanthosis and hyperparakeratosis with neutrophils. My diagnosis is Psoriatic alopecia.

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vincenzo

Posted

Yes! I remember an other Arti Baksi's intriguing case in this web-site. Agree with Psoriatic Alopecia.

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John Zhang

Posted

To me this case is difficult. I did consider psoriatic alopecia, but the presence of perifollicular fibrosis and lymphocytic infiltrate also includes the differential diagnosis of lichen planopilaris. The intracorneal neutrophils might be incidental. Overall if the patient has a history of psoriasis I will go with psoriatic alopecia. 

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Dr. Richard Carr

Posted

I have had an additional immunostain posted on last weeks case -  it may come as a surprise!.

 

Yes this is psoriatic alopecia,well done. Patient has psoriasis. I did not mention as I did not want to make it too easy. The striking atrophy of the sebaceous glands is the helpful clue. I too learned from Arti's case (1460). 

 

Am J Dermatopathol. 2008 Apr;30(2):93-100. doi: 10.1097/DAD.0b013e31816421fd.

Histopathologic study of scalp psoriasis: peculiar features including sebaceous gland atrophy.

Author information

1
Department of Pathology, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brazil. betina.werner@gmail.com

Abstract

In a study on scalp psoriasis of 19 patients (11 males and 8 females, 15-64 years of age, psoriasis area severity index partial score of the head ranging from 0.5 to 2.8), we came to notice that, apart from the classical criteria for the diagnosis of psoriasis which were present in all cases, in a majority of patients, sebaceous glands were extremely reduced in size. We compared findings of follicular counts and sebaceous glands with a nonpsoriatic group of individuals (n = 26). Ten cases from the psoriatic population presented with completely atrophic glands, most of the time intermingled with larger glands (P = 0.03); not a single case showed sebaceous gland atrophy in the control group. There were no statistical differences regarding total number of hair follicles (P = 0.08), terminal follicles (P = 0.15), vellus follicles (P = 0.39), and telogen follicles (P = 0.58) between the groups. Other unusual features observed in the scalp psoriasis group were dilation of infundibula in 11 cases, a papillomatous epidermal surface in 8 specimens, parakeratosis at the lips of infundibular ostia in 8 specimens, mitotic figures in 7 cases, and necrotic keratinocytes in 14 cases. We conclude that psoriasis of the scalp may present itself with unexpected microscopic findings, among them being atrophy of sebaceous glands. Further studies are necessary to clarify why this atrophy develops and if it is specific to psoriasis.

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