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Joe R. Monroe, PA-C, MPAS, DEPARTMENT EDITOR

A case of scarring alopecia

Sven M. Hochheimer, MD, MPAS; Kimberly L. Maino, MD

Sven Hochheimer is a resident in general surgery at Wilford Hall Medical Center, San Antonio, Tex. Kimberly Maino is staff dermatologist at National Naval Medical Center, Bethesda, Md. They have indicated no relationships to disclose relating to the content of this article. Joe Monroe practices in the dermatology department of the Springer Clinic, Tulsa, Okla, and is the founder and President of the Society of Dermatology Physician Assistants.

A 53-year-old white woman presents to the dermatology clinic for a refill on her ketoconazole 2% shampoo. About 1 year ago, her primary care provider had prescribed this antifungal shampoo for treatment of a pruritic, balding, tender area on her posterior scalp. The area has not improved since she started using the shampoo, but it also has not worsened.

The physical examination reveals foci of scarring alopecia with perifollicular erythema and scaling at the vertex (see Figure 1). Polytrichia, or tufting of the hair, is also noted. Scrapings for a potassium hydroxide (KOH) test and fungal culture are obtained, and the results of these tests are negative. Two 4-mm punch biopsy specimens are obtained and submitted to a dermatopathologist for vertical and horizontal sections to establish a definitive diagnosis.

The correct diagnosis is

Tinea capitis
Lichen planopilaris
Discoid lupus erythematosus
Alopecia areata
Graham Little syndrome

Discussion

The correct diagnosis is lichen planopilaris (LPP). This idiopathic papulosquamous eruption may occur in isolation or in combination with more typical lichen planus. The usual complaint is itching of the involved areas of the scalp. Two punch biopsies for horizontal and vertical sections of the scalp should be submitted to a dermatopathologist with expertise in hair diseases for definitive diagnosis. Because of the clinical and histologic overlap of LPP and discoid lupus, screening with an antinuclear antibody (ANA) panel may be considered as well.

In most patients resolution of the inflammatory process can be achieved with topical corticosteroids. Therapy can be escalated to include the use of intralesional corticosteroids if needed. Several immune modulators and suppressants have proven useful in more recalcitrant cases.

The Graham Little syndrome is considered by some to be a variant of LPP. This syndrome includes the loss of pubic and axillary hair and rapid development of keratosis pilaris in the setting of LPP. On physical examination, this patient did not exhibit any of these findings. Discoid lupus erythematosus clinically and histopathologically closely resembles LPP. Hair biopsy and a screening ANA panel are useful in distinguishing these two clinical entities. Tinea capitis can also produce a scarring alopecia. This diagnosis is far more common in children, particularly African-American children, and was excluded in this patient by the negative results on the KOH test and fungal culture. Alopecia areata is a common cause of nonscarring alopecia and typically manifests as one or multiple discrete, smooth, annular areas of hair loss. Based on the scarring, scaling, and erythema seen in this patient, the clinician can safely exclude alopecia areata from diagnostic consideration.