Tips on Evaluation and Diagnosis of Scarring Alopecias. Melissa Peck Piliang, MD Dermatology and Anatomic Pathology Cleveland Clinic

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1 Tips on Evaluation and Diagnosis of Scarring Alopecias Melissa Peck Piliang, MD Dermatology and Anatomic Pathology Cleveland Clinic

2 Disclosures I do not have any relevant relationships with industry Investigator: Samumed, Kythera, Incyte, Concert, Allergan Advisory Board/Consultant: Samumed, Castle Biosciences, Proctor and Gamble

3 Scarring Alopecias Evaluation Labs Biopsy Additional tests Present diagnostic challenge: May start subtly Well described clinical patterns variations often missed Age/gender/ethnic variations Biopsy location key for accurate diagnosis Mimicker other diagnoses Mask other diagnoses

4 Cicatricial Alopecia - Overlap FAPD + Pseudopelade of Brocq LPP FFA CCSA Pseudopelade FDS AK CCLE/ DLE + Folliculitis Decalvans Dissecting Cellulitis + Predominantly African Americans FFA = Frontal Fibrosing Alopecia Significant Neutrophilic Inflammation CCSA = Central Centrifugal Scarring Alopecia Significant Inflammatory Interface Alteration and Scarring Alopecic Disorders FDS = Follicular Degeneration Syndrome AK = Acne Keloidalis Sperling,Arch Dermatol, CCLE/DLE = Chronic Cutaneous Lupus Erythematosus/ Discoid Lupus Erythematosus Modified Sperling, Arch Dermatol 2000

5 Evaluation

6 History Thorough Symptoms Pain, pruritus, itch Scale Pustules, oozing Course Rapid onset Slow and steady Prior treatments

7 Bacterial and Fungal Culture Pustules Scale Pain Drainage Folliculitis Decalvans with staph colonization Tinea Capitis

8 Laboratory Evaluation General Health CBC CMP Nutritional FERRITIN ZINC VITAMIN D Hormonal TSH Others (as indicated) Autoimmune - lupus ANA AA/LPP/FFA MICROSOMAL AB Androgen Excess DHEAS TESTOSTERONE (FREE & TOTAL) SHBG HgA1C

9 Dermoscopy White patches and lack of follicular orifices Telangectasias perifollicular Lichen Planopilaris JAAD Dec 2015

10 Wood s Light Wood s light Courtesy Dr. Wilma Bergfeld White ban frontal hair line

11 Scalp Biopsy Two punch specimen Vertical Horizontal One punch specimen for DIF P. Foliaceous

12 Scalp Biopsy Lichen Planopilaris Frontal Fibrosing Alopecia

13 Scalp Biopsy

14 CCCA

15 Folliculitis decalvans (and other inflammatory alopecias)

16 Frontal Fibrosing Alopecia: Clues

17 Frontal Fibrosing Alopecia Middle-aged, post-menopausal women Rarely men, but does happen Rarely young women Preferential involvement of vellus and intermediate hair follicles Eyebrows are affected in 50% to 75% Less frequently, eyelashes and hairs in the axilla Body vellus involvement -> Arms, axilla, pubic, legs Manifested almost always as non-inflammatory diffuse hair loss

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20 Difficult Clinical Diagnosis Confused with AGA, Alopecia Areata Subtle scarring Inflammation may be sparse Symptoms mild or absent Loss of eyebrows and/eyelashes = alopecia areata Often younger women or men

21 Clues for FFA?

22 Atrophy

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24 Hypopigmentation

25 Subtle Hypopigmentation Wood s Light

26 Decrease melanocytes in FFA

27 Prominent Veins

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29 Kossard S. Arch Derm 1994

30 Always Lift the Bangs

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32 Young Women

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36 Hypopigmentation

37 Unusual Distribution

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40 Always Look Behind the Ears

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47 Facial Papules

48 From: Facial Papules in Frontal Fibrosing Alopecia: Evidence of Vellus Follicle Involvement Arch Dermatol. 2011;147(12): doi: /archdermatol

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50 JAAD Dec 2015

51 JAAD Dec 2015 Lichen planus pigmentosis

52 FFA and LPP Happen in African Americans.

53 J Clin Aesthet Derm 2016; 9(4):45-51

54 J Clin Aesthet Derm 2016; 9(4):45-51

55 Rapid onset loss of eyebrows and scalp hair Hypopigmentation

56 Perifolicular Erythema

57 Fringe sign

58 Clues in African Americans It is not insidious Symptoms Rapid loss Perifollicular erythema Subtle atrophy

59 Scarring Alopecia Happens in Men.

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63 Images courtesy of Dr. Wilma Bergfeld

64 Images courtesy of Dr. Wilma Bergfeld Facial Papules Dyspigmentation

65 Mimics A Reminder to Biopsy

66 Beware of Lichenoid Keratoses Lupus Erythematosus

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69 Superficial and deep infiltrate Perivascular and periadnexal Follicular plugging

70 Interface dermatitis -Follicular -Interfollicular

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72 Discoid Lupus Erythematosus Mimics AK or SCC clinical and histology Beware or superficial biopsy, recurrent AK/SCC Biopsy technique critical Punch!

73 Middle aged man Scalp dermatitis and hair loss VERY itchy

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75 Treatment Methotrexate Azathioprine Prednisone Topical steroids Antihistamines

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82 Crusted (Norwegian) Scabies All immunosuppressant medications stopped Treatment: Permethrin -> x2, 1 week apart Ivermectin -> x2, 2 weeks apart

83 Outcome Pruritus rapidly improve LP Pigmentosa faded Body and facial itch resolved Scalp scale and itch persisted, but mild Alopecia and perifollicular erythema persisted Repeat scalp biopsy -> LPP without scabies

84 Clinical Infectious Diseases. 54(6):882;2012

85 When symptoms are out of proportion to findings Gets worse with treatment -> Repeat biopsy!

86 48 yo with pre diabetes - Hair loss - Scalp pustules - Folliculitis - No pruritus Frontal Hairline Vertex

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90 Tinea Capitis Biopsy and cultures Treatment: griseofulvin Resolved

91 Summary Clinical Clues Hypopigmentation Prominent veins Loss of eyebrows/eyelashes Density gradient Unusual presentations - Beware Men Young women Parietal scalp/ophiasis -> may spare frontal hair line Mimics Lupus erythematosus Infections

92 Thank You!

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99 Always Think About Contact Dermatitis

100 Biopsy showed: - Spongiotic dermatitis with eosinophils - Impetiginization - Telogen effluvium Culture grew MSSA, negative fungus

101 Clues: - Cyclical recurrence coincided with hair coloring - Weeping - Extreme pruritus

102 Central Scalp Hair Loss CCCA or AGA?

103 CCCA

104 CCCA Biopsy location important

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