Histopathologic Evaluation of Alopecias

The Association between Number of Follicular Stelae and Severity and Treatment Response of Alopecia Areata Cases: A Retrospective Study

Background

Alopecia areata (AA) is an autoimmune disease characterized by peribulbar lymphocytic infiltration, follicular miniaturization, catagen/telogen follicles, and increased follicular stelae (streamers) in skin biopsies.

Objectives

Our aim was to assess the number of follicular stelae of patients with AA and to evaluate their association with clinical type and severity and treatment response of AA.

Materials and Methods

Histopathologic features including the number of follicular stelae were recorded in skin biopsies taken from lesions of AA in 142 patients who attended our dermatology clinic from 2011 to 2017.

Results

There was a statistically significant correlation between patient age and the number of follicular stelae (P = 0.001). There was a statistically significant correlation between the severity of disease and number of follicular stelae (P = 0.005). AA subtypes (0%-25% scalp hair loss) had a significantly lower number of follicular stelae than 75%-100% of scalp hair loss and alopecia universalis (7.92 ± 4.21 vs. 13.23 ± 7.28). There was no statistically significant correlation between treatment response and the number of follicular stelae (P = 0.75).

Conclusion

Our results showed that the number of follicular stelae varied among AA clinical types and correlated with severity. This study was the first to evaluate the correlation between the number of follicular stelae and severity of AA.

Alopecias: Practical Tips for the Management of Biopsies and Main Diagnostic Clues for General Pathologists and Dermatopathologists

Accurately diagnosing specific variants of alopecia remains challenging for pathologists, potentially delaying appropriate therapeutic decisions by dermatologists. Issues such as limited knowledge on optimal biopsy types and processing methods add complexity. Understanding the normal histology of hair follicles and their changes throughout the follicular cycle further complicates microscopic evaluation. This paper aims to summarize these characteristics and highlight essential diagnostic clues for pathologists to confidently suggest a diagnosis, therefore playing a key role in alopecia diagnosis. Ongoing education, collaboration with dermatologists, and staying up to date on advancements is crucial for the accurate diagnosis and effective management of different types of alopecia.

Alopecia Areata: Case report and review of pathophysiology and treatment with Jak inhibitors

Alopecia Areata (AA) is a T-cell mediated autoimmune attack on hair follicles resulting in rapidly developing areas of hair loss involving the scalp and beard that can progress to total scalp hair loss (alopecia totalis) and loss of eyebrows, eyelashes, and total body hair (alopecia universalis). Affected patients have high rates of psychological disorders and decreased quality of life. There are no FDA approved treatments, and the available treatments have a high failure rate. JAK inhibitors are remarkably effective in many autoimmune diseases including Alopecia Areata. Presented is a case report of successful treatment with tofacitinib, and a literature review of the pathophysiology of alopecia areata, the mechanism of action of JAK inhibitors, and the JAK inhibitors in phase 2 and 3 trials.

The Association between the Number of Follicular Stelae and Severity and Treatment Response of Alopecia Areata Cases: A Retrospective Study

Background

Alopecia areata (AA) is an autoimmune disease characterized by peribulbar lymphocytic infiltration, follicular miniaturization, catagen/telogen follicles, and increased follicular stelae (streamers) in skin biopsies.

Objectives

Our aim was to assess the number of follicular stelae of patients with AA and to evaluate their association with clinical type and severity and treatment response of AA.

Materials and Methods

Histopathologic features including number of follicular stelae were recorded in skin biopsies taken from lesions of AA in 142 patients who attended our dermatology clinic from 2011 to 2017.

Results

There was a statistically significant correlation between the patient age and the number of follicular stelae (P = 0.001). There was a statistically significant correlation between the severity of disease and the number of follicular stelae (P = 0.005). AA subtypes (0%-25% scalp hair loss) had a significantly lower number of follicular stelae than 75%-100% scalp hair loss and alopecia universalis (7.92 ± 4.21 vs. 13.23 ± 7.28). There was no statistically significant correlation between the treatment response and the number of follicular stelae (P = 0.75).

Conclusion

Our results showed that number of follicular stelae varied among AA clinical types and correlated with severity. This study was the first to evaluate the correlation between the number of follicular stelae and severity of AA.

Beware of the Impostors-Scalp Pathology Primer for the Hair Transplant Surgeon

Histopathological features are important for the practicing hair transplant surgeon to ensure proper case selection, diagnosis, choice of proper treatment, and successful outcome. While the primary focus of the hair transplant surgeon is androgenetic alopecia (AGA), it is important to be aware of other conditions that can mimic AGA, whose treatment may be different. This article outlines some of these conditions such as scarring alopecias, alopecia areata, etc., and how to distinguish them. Proper identification will ensure proper treatment and avoid potential missteps in management.

Role of Hair Transplantation in Scarring Alopecia-To Do or Not to Do

Alopecia in the scalp region leads to psychosocial embarrassment for an individual. Alopecia could be due to several reasons, including genetic, hormonal, traumatic and infections. Cicatricial alopecias (CAs) are considered as trichological emergency, since their progression is rapid and always results in permanent hair loss. The pathogenesis, disease progression and prognosis of CA are poorly understood, and the treatment process is still evolving. An early diagnosis must be established, and aggressive treatment protocol should be followed in the management of scarring alopecia. This article presents various aspects of CA and determines whether hair transplant (HT) should be done in this condition.

Lesson to Learn From Cellular infiltrate in Scalp Biopsy of Alopecia Areata

BACKGROUND

Alopecia areata (AA) is a common cause of hair loss. It is mediated by T lymphocytes. Scalp biopsy findings in AA differ according to the disease phase and activity.

OBJECTIVES

To study the cellular infiltrate in the transverse section of scalp biopsy of AA at different disease stages and in relation to disease activity.

METHODS

The study was performed on 40 subjects with AA. A 4-mm punch biopsy was obtained from an AA scalp lesion. Biopsies were sectioned horizontally; 2 anatomical levels were studied (mid dermal and deep dermal levels).

RESULTS

Ninety-five percent of AA showed noncicatrical alopecia. A significant relation was found between the course of AA and the terminal:vellus ratio. Peribulbar lymphocytic infiltration was seen in 70% of cases. Mast cells were observed in 87.5% of cases, including fibrous tract and around the arrector pili muscles. Eosinophils were detected in the scalp biopsy of 22.5% of cases. Course and activity of AA were significantly related to the peribulbar lymphocytic cell infiltration but not to mast cells and eosinophils.

CONCLUSION

Although a peribulbar lymphocytic infiltrate is the classical finding of AA, it is absent in the chronic phase. Mast cells are commonly found in the scalp biopsy of AA and could explain the potential therapeutic effect of antihistamines.

Scarring Alopecias: Pathology and an Update on Digital Developments

Primary cicatricial alopecias (PCA) represent a challenging group of disorders that result in irreversible hair loss from the destruction and fibrosis of hair follicles. Scalp skin biopsies are considered essential in investigating these conditions. Unfortunately, the recognised complexity of histopathologic interpretation is compounded by inadequate sampling and inappropriate laboratory processing. By sharing our successes in developing the communication pathway between the clinician, laboratory and histopathologist, we hope to mitigate some of the difficulties that can arise in managing these conditions. We provide insight from clinical and pathology practice into how diagnoses are derived and the key histological features observed across the most common PCAs seen in practice. Additionally, we highlight the opportunities that have emerged with advances in digital pathology and how these technologies may be used to develop clinicopathological relationships, improve working practices, enhance remote learning, reduce inefficiencies, optimise diagnostic yield, and harness the potential of artificial intelligence (AI).

Deriving Keratinocyte Progenitor Cells and Keratinocytes from Human-Induced Pluripotent Stem Cells

Skin or hair loss (alopecia) may occur due to a wide variety of causes ranging from trauma to pathological processes including acquired or congenital causes. It would be ideal to replace them with immunologically compatible cells to avoid potentially exacerbating the condition. Deriving the replacement cells from human-induced pluripotent stem cells (hiPSCs) allows for sufficient scale up and using hiPSCs as the choice of human pluripotent stem cells (hPSC) will ensure immunocompatibility. Here we offer a protocol for differentiating hiPSCs into keratinocyte progenitor cells (KPC) and keratinocytes employing all-trans retinoic acid (ATRA) and L-ascorbic acid, (L-AA), bone morphogenic protein-4 (BMP4), and epidermal growth factor (EGF). We observed that the hiPSC-derived KPCs express the same panel of markers as primary hair follicle bulge stem cells (HFBSCs), including CD200, integrin α-6 (ITGA6), integrin β-1 (ITGB1), the transcription factor P63, keratin 15 (KRT15), and keratin 19 (KRT19). If permitted to differentiate further, the hiPSC-derived KPC lose CD200 expression and rather come to express keratin 14 (KRT14) indicating emergence of more mature terminally-differentiated keratinocytes. The HFBSCs are transplantable for hair follicle (HF) restoration, and the keratinocytes may be transplantable for therapy for large burns or ulcers. © 2020 Wiley Periodicals LLC. Basic Protocol 1: Reprogramming of normal human skin fibroblasts into normal hiPSCs using episomal DNA cocktail Basic Protocol 2: Differentiation of hiPSCs into KPCs and keratinocytes Alternate Protocol 2: EBS formation protocol using AggreWell™ plates (Antonchuk, 2013) Support Protocol 1: Passage hiPSC-KPC Support Protocol 2: Immunocytochemistry (ICC) Support Protocol 3: Immunofluorescence staining of cells for flow cytometry (FC).

The Role of Trichoscopy in Keratosis Follicularis Spinulosa Decalvans: Case Report and Review of the Literature

Introduction

Keratosis follicularis spinulosa decalvans (KFSD) is a rare, X-linked, hereditary disorder of keratinization, characterized by skin involvement and progressive scarring alopecia of scalp, eyebrows, and eyelashes. The diagnosis is helped by the particular clinical features, but pathology is mandatory.

Case Presentation

We described a case of a female patient referred to the outpatient's hair consultation of our department, in which we performed trichoscopy as a very useful tool for the diagnosis, followed by pathology that confirmed KFSD.

Conclusion

In our article, we underlined the importance of trichoscopy for the diagnosis of this hair disease, with also a review of the literature on diagnosis and treatment.

Histopathologic and dermoscopic features of 42 cases of folliculitis decalvans: A case series

BACKGROUND

Folliculitis decalvans (FD) is a form of inflamed primary cicatricial alopecia (PCA). FD is classified as a neutrophilic PCA; however, only a few previous studies have described its histopathology, including the assessment of systematically evaluated and quantified follicular changes in horizontally sectioned biopsy specimens with clinical and dermoscopic findings of the early and advanced stages.

OBJECTIVE

We aimed to clarify the histopathologic and dermoscopic features of early and advanced active stage FD.

METHODS

We conducted a case series study of 42 patients with FD by dermoscopy and both horizontally and vertically sectioned biopsy specimens.

RESULTS

The histopathologic findings of the early-stage lesions included loss of sebaceous glands; interfollicular acanthosis; and fibrosis with depressed, fused follicular infundibula showing thickened interfollicular keloid-like areas with tufted hairs on dermoscopy. Active lesions showed a greater number of hair clusters, clefting, and fused infundibula with dense inflammation predominantly in the upper follicles. Neutrophil-predominant infiltrates were observed in fewer than half of the patients, including those with early-stage lesions.

LIMITATIONS

This was a retrospective study.

CONCLUSION

FD has the features of mixed-cell PCA. The features of early-stage FD are thickened interfollicular keloid-like areas with tufted hairs and loss of sebaceous glands.

A Study of the Histopathological Features of Alopecias on Transverse Sections of Scalp Biopsies

Background:

Transverse sections of scalp biopsies are performed for the assessment of alopecias and are considered advantageous over vertical sections.

Aim:

The aim was to study the histopathological features of alopecias on transverse sections of scalp biopsies.

Methods:

It was a descriptive study. Clinically confirmed cases of noncicatricial and cicatricial alopecias were subjected to 4 mm scalp biopsies, which were sectioned transversely and analyzed. Biopsies obtained from occipital region of androgenetic alopecia (AGA) cases were taken as controls.

Results:

Biopsies from 41 cases were assessed, including male and female AGA, alopecia areata (AA), trichotillomania, lichen planopilaris (LPP), discoid lupus erythematosus (DLE), and folliculitis decalvans (FD). Normal scalp (control) biopsies showed the median total number of hair follicles of 35 (32–37), anagen:telogen/catagen ratio of 17.5 (16.5–31), and terminal:vellus ratio of 15 (10.7–17.5). In AGA and AA, miniaturization and shift toward telogen and catagen hair were consistently observed. Peribulbar inflammation was seen in two-third of AA. Trichotillomania showed increased catagen hair and numerous pigment casts. In DLE, besides perifollicular inflammation, prominent peri-arrector pili and peri-eccrine inflammation were observed. Type of inflammatory infiltrate was similar in DLE and LPP (lymphocytic), whereas FD showed neutrophilic and plasma cell infiltrate, both around follicles and interstitially. Basal cell damage in the follicles and pigment incontinence were seen in majority of DLE and LPP patients. DLE also showed basement membrane thickening, mucin deposition, and telangiectasia. Reduction/absence of sebaceous glands and perifollicular fibrosis were observed in almost all cicatricial alopecias.

Conclusion:

Transverse sectioning may be a useful tool in the diagnosis of alopecias.

A comparative immunohistochemical study of epidermal and dermal/perifollicular Langerhans cell concentration in discoid lupus erythematosus and lichen planopilaris: a cross-sectional study

BACKGROUND

There are times when differentiation between discoid lupus erythematosus (DLE) and lichen planopilaris (LPP) becomes quite challenging clinicopathologically.

OBJECTIVES

The aim of this study was to evaluate and compare the concentration, distribution pattern and role of Langerhans cells (LCs), identified by CD1a staining in DLE and LPP.

METHODS

Twenty-five specimens of skin biopsies from patients diagnosed with LPP and DLE were included. Immunohistochemistry (IHC) staining was performed against CD1a antigen to assess and compare the concentration and distribution pattern of LCs.

RESULTS

Compared with LPP, the mean number of epidermal CD1a⁺ cells per three high power fields was significantly lower in DLE ( p = 0.003). On the other hand, DLE cases had a significantly higher mean number of dermal/perifollicular CD1a⁺ cells in three high power fields than LPP cases ( p = 0.01).

LIMITATIONS

A small sample size and limited IHC markers.

CONCLUSIONS

There are differences in the density and distribution pattern of LCs in LPP and DLE in the epidermis and perifollicular regions. Our findings of a statistically significant decrease in LC concentration in the epidermis of DLE cases and also in the perifollicular region of LPP may serve as helpful clues in further characterization of these entities, especially in equivocal cases. However, more extensive studies are required to better understand the underlying immunopathogenesis of these diseases in providing further clues to a specific diagnosis.

Primary cicatricial alopecia: Other lymphocytic primary cicatricial alopecias and neutrophilic and mixed primary cicatricial alopecias

Primary cicatricial alopecias can be frustrating for both patients and physicians. Proper diagnosis guides more successful management of these challenging conditions. Part II will cover the remaining lymphocytic primary cicatricial alopecias, which include pseudopelade of Brocq, central centrifugal cicatricial alopecia, alopecia mucinosa, and keratosis follicularis spinulosa decalvans. It will also discuss the neutrophilic and mixed primary cicatricial alopecias, namely folliculitis decalvans, dissecting cellulitis, folliculitis keloidalis, folliculitis (acne) necrotica, and erosive pustular dermatosis.

Comparative Analysis of Immunopathological Features of Lichen Planopilaris and Female Patients with Frontal Fibrosing Alopecia

Background:

Frontal fibrosing alopecia (FFA) is a disorder characterized by progressive cicatricial alopecia (CA). Its classification as a clinical variant of lichen planopilaris (LPP) or as a unique disorder is controversial. The presence of Langerhans cells within the bulge area and the sebaceous epithelium and the presence of lymphocytic infiltrate in this area in CA have led to a series of hypotheses, although limited, about their development. To our knowledge, scarce is the literature demonstrating immunoanalytical studies comparing both disorders.

Objective:

The authors sought to describe diagnostic findings, comorbidities, and immunopathological features of female patients with FFA as compared to LPP.

Materials and Methods:

This retrospective single-center study included patients given the diagnosis of FFA or LPP. The LPP activity index was used to evaluate objective signs and subjective symptoms. Biopsy specimens were obtained from active, inflammatory areas of the scalp, and the inflammatory infiltrate intensity and quality were compared. Direct immunofluorescence for IgA, IgM, and IgG and immunohistochemistry to demonstrate the expression of CD1a, CD3, CD4, CD8, CD68, and 2,3-dioxygenase indoleamine were performed.

Results:

Twenty female patients (10 patients with FFA and 10 patients with LPP) were included in the study. Histopathological findings evidenced reduced number of hair follicles and perifollicular fibrosis in both disorders. Immunofluorescence findings resulted positive in 50% of FFA cases and 40% of LPP cases.

Conclusion:

Although clinically different, our findings suggest that there are, to date, no histological or immunological findings that allow us to accurately separate these two forms of scarring alopecia, namely FFA and LPP.

Oral isotretinoin as the most effective treatment in folliculitis decalvans: a retrospective comparison of different treatment regimens in 28 patients

BACKGROUND

Folliculitis decalvans leads to scarring alopecia through inflammatory destruction of the hair follicle. Currently, antibiotics are most commonly used to treat this disease. However, treatment regimens with antibiotics feature a high relapse rate and encourage the development of resistant bacteria.

OBJECTIVE

To evaluate the outcome of different treatment options for folliculitis decalvans.

METHODS

Retrospective study to compare the efficacy of different treatment regimens in 28 patients with folliculitis decalvans.

RESULTS

The success of treatment with clindamycin and rifampicin, clarithromycin, dapsone and isotretinoin was analysed. The evaluation of the combination of clindamycin and rifampicin showed the lowest success rate in achieving long-term remission, since 80% of the patients relapsed shortly after end of treatment. Clarithromycin and dapsone were more successful with long-term and stable remission rates of 33% and 43% respectively. Treatment with isotretinoin was the most successful oral treatment in our analysis with 90% of the patients experiencing stable remission during and up to two years after cessation of the treatment.

CONCLUSION

The common use of antibiotics as first-line therapy in folliculitis decalvans needs to be re-evaluated critically and oral isotretinoin should be considered as valid treatment alternative.

Histologic features of alopecias-part I: nonscarring alopecias

The diagnosis of disorders of the hair and scalp can generally be made on clinical grounds, but clinical signs are not always diagnostic and in some cases more invasive techniques, such as a biopsy, may be necessary. This 2-part article is a detailed review of the histologic features of the main types of alopecia based on the traditional classification of these disorders into 2 major groups: scarring and nonscarring alopecias. Scarring alopecias are disorders in which the hair follicle is replaced by fibrous scar tissue, a process that leads to permanent hair loss. In nonscarring alopecias, the follicles are preserved and hair growth can resume when the cause of the problem is eliminated. In the first part of this review, we describe the histologic features of the main forms of nonscarring alopecia. Since a close clinical-pathological correlation is essential for making a correct histologic diagnosis of alopecia, we also include a brief description of the clinical features of the principal forms of this disorder.

Primary idiopathic pseudopelade of brocq: five case reports

Pseudopelade of Brocq (PPB) is a rare, idiopathic self-limiting hair disorder resulting in progressive cicatricial alopecia primarily involving the parietal scalp and vertex. The general pathogenesis of scarring alopecias has been focused on theories of stem cell failure and sebaceous gland destruction. Acquired immunity, Borrelia infection and senescence of follicular stem cell reservoir plays suspected role. It classically presents as porcelain white hypopigmented and slightly depressed atrophic plaque. There is no standard treatment for PPB. Here, we present five cases which were labeled as primary idiopathic PPB, as on histopathology no specific changes of any cicatricial alopecia were seen.

Immunohistochemical patterns in the interfollicular Caucasian scalps: influences of age, gender, and alopecia

Skin ageing and gender influences on the scalp have been seldom studied. We revisited the changes in the interfollicular scalp. The study was performed on a population of 650 volunteers (300 women and 350 men) for over 7 years. Three age groups were selected in both genders, namely, subjects aged 20–35, 50–60, and 60–70 years. The hair status was further considered according to nonalopecic and alopecic patterns and severity (discrete, moderate, and severe). Biopsies from the parietal area were processed for immunohistochemistry. Stromal cells were distinguished according to the presence of vimentin, Factor XIIIa, CD117, and versican. Blood and lymphatic vessels were highlighted by Ulex europaeus agglutinin-1 and human podoplanin immunoreactivities, respectively. Actinic elastosis was identified by the lysozyme coating of elastic fibres. The epidermis was explored using the CD44 variant 3 and Ki67 immunolabellings. Biplot analyses were performed. Immunohistochemistry revealed a prominent gender effect in young adults. Both Factor XIIIa+ dermal dendrocytes and the microvasculature size decreased with scalp ageing. Alopecia changes mimicked stress-induced premature senescence.

Keratosis follicularis spinulosa decalvans: a rare cause of scarring alopecia in two young Indian girls

Keratosis follicularis spinulosa decalvans (KFSD) is an X-linked xenodermatosis characterized by scarring alopecia and follicular hyperkeratosis. This condition mainly affects males with females being carriers and will have milder symptoms. We present two sisters with severe form of KFSD, progressing to scarring alopecia.

Clinical and histological challenge in the differential diagnosis of diffuse alopecia: female androgenetic alopecia, telogen effluvium and alopecia areata--part II

Diffuse alopecia is mainly caused by telogen effluvium, diffuse androgenetic alopecia (female-pattern hair loss) and diffuse alopecia areata. Differential diagnosis between the three disorders may be difficult in several occasions. In this second part of our study, chronic telogen effluvium and diffuse alopecia areata are discussed in detail, including clinical, dermoscopic and histological aspects. A flowchart presents a practical and objective differential diagnostic approach to diffuse alopecia.

Prospective histologic examinations in patients who practice traumatic hairstyling

OBJECTIVES

Alopecia is the fifth most common dermatologic diagnosis in African-American patients. Central centrifugal cicatricial alopecia (CCCA) is the most common form of scarring alopecia in this group. This study sought to evaluate clinical and histologic findings in patients without clinical alopecia who use chemical and/or thermal straighteners to determine whether follicular damage is evidenced histologically.

METHODS

Eight African-American women with no clinical evidence of alopecia or scalp inflammation were included in the study. All participants had engaged in some form of traumatic hair care within the previous month. Participants submitted to clinical photography and 4-mm punch biopsy. Histologic examination was performed and the characteristics of each case recorded.

RESULTS

There were no clinical signs of alopecia or inflammation in any patient. Histopathology showed peri-infundibular lymphocytic inflammation in all patients and mild superficial perivascular lymphocytic inflammation in three. Concentric infundibular fibrosis was observed in each hair follicle in all specimens. One sample showed additional focal peri-isthmus fibrosis. There was no evidence of complete follicular dropout, follicular epithelial thinning, or premature desquamation of inner root sheaths. The mean number of hair follicles was 4.88 per 4-mm punch. Hair cycling was consistently within normal ranges.

CONCLUSIONS

Biopsy findings characteristic of CCCA suggest that a clinical prelude exists histologically. Further follow-up may provide a longitudinal timeframe for the potential progression, halting, or reversal of disease if hairstyling practices are, respectively, continued or discontinued. Central centrifugal cicatricial alopecia is likely to represent a common pathway of inflammation and scarring that can be instigated by traumatic hairstyling practices in genetically predisposed subjects.

Clinical and histological challenge in the differential diagnosis of diffuse alopecia: female androgenetic alopecia, telogen effluvium and alopecia areata - part I

Diffuse androgenetic alopecia (female pattern hair loss), telogen effluvium, and diffuse alopecia areata may have similar clinical manifestations. Subtle details on physical examination and dermoscopy of the scalp may help to identify those disorders. The authors present a practical discussion on how to approach the patient with diffuse alopecia, considering clinical history, physical examination, and dermoscopic findings. If the diagnosis remains unclear after a careful analysis of the clinical signs, a scalp biopsy may help to distinguish between the three diseases. In this first part of our study, an objective review of female androgenetic alopecia is presented and the most important histological changes are discussed.

Cicatricial (scarring) alopecias: an overview of pathogenesis, classification, diagnosis, and treatment

Cicatricial (scarring) alopecia forms a group of disorders in which the common final pathway is the destruction of the hair follicle unit that is replaced by fibrous tissue. Hair loss may occur as a primary event when the follicle is the main target of the disease process (primary cicatricial alopecias) or as a secondary event when the follicle act as an 'innocent bystander' in the course of a disease occurring outside of the follicular unit (secondary cicatricial alopecias). Permanent hair loss may also occur in the late phases of some nonscarring alopecias that are called 'biphasic alopecias.' Primary cicatricial alopecia accounts for 5% of all trichologic consultations at the Section of Dermatology, University of Genoa, Genoa, Italy. Considering that hair loss has a strong impact on patients' psychology and quality of life, and that cicatricial alopecias can be associated with underlying systemic implications, it is extremely important that every clinician is familiar with the diagnosis and treatment of the different types of cicatricial alopecia. An accurate clinical assessment integrated with (video) dermatoscopy and histopathologic studies permits a high standard performance of correct diagnoses. A brief review of our current knowledge of disease pathogenesis and the hypothetical disease mechanisms is presented. Some practical considerations for improving the 2001 North American Hair Research Society working classification of the primary cicatricial alopecias are suggested. The aim of treatment is to slow or stop the progression of the inflammatory waves and the scarring process at the earliest phase of involvement. Recommendations for therapy are based upon a literature review, personal experience, expected adverse effects, and some pragmatic considerations such as the cost and patient compliance.

Histopathologic profile of alopecia areata in Indian patients

Background:

Alopecia Areata (AA) is a “non-scarring” alopecia that has an autoimmune basis. Though clinically distinctive, problems arise in diagnosis depending on the temporal stage of the disease at presentation; some of them progress to scarring alopecia and predicting its prognosis is difficult. Histological changes depend on the disease stage and site of the biopsy.

Objectives:

To describe the spectrum of histologic features in AA.

Materials and Methods:

A prospective and retrospective study of H and E sections of all biopsies signed out as AA between 2001 and 2009 (20 cases) was undertaken.

Results:

The diagnosis was made on vertical sections in all cases. The total number of hair follicles ranged from 1 to 24 with an average of 7 and comprised mainly terminal follicles. Vellus follicles were scanty. Anagen to non-anagen ratio was 1:1.62. Miniaturization of follicles was noted in five (25%) cases. Peribulbar inflammation was seen in all the cases with a dominance of lymphocytes. Perifollicular fibrosis was noted in 12 (60%) and pigment casts in 5 (25%) cases. Scarring was seen in two cases. In these cases, a diagnosis of AA was rendered on the basis of even spacing of the fibrotic units and remnants of the catagenic basement membrane within the scars. The epidermis and interfollicular dermis were normal in all the cases.

Conclusion:

The most consistent features of AA are an increase in non-anagen terminal follicles and peribulbar lymphocytic infiltrate. The etiology can be determined even in cases that have progressed to scarring.

'Follicular Swiss cheese' pattern--another histopathologic clue to alopecia areata

Yellow dots are the most useful dermoscopic criterion in the clinical diagnosis of alopecia areata and correspond histopathologically with dilated follicular infundibula. They are found in about 95% of alopecia areata cases and help to differentiate alopecia areata from trichotillomania, telogen effluvium and from scarring alopecias. Histopathology of alopecia areata differs with disease activity and dermatopathologist, therefore, heavily depends on other diagnostic features. Objective of the study was to determine the frequency of dilated follicular infundibula, peribulbar lymphocytic infiltrate, inflammatory infiltrates of lymphocytes and eosinophils within fibrous streamers and a shift to catagen/telogen follicles in alopecia areata. Histopathologic features of 56 specimens of 33 patients were correlated with clinical findings and alopecia areata subtype.

RESULTS

57% of all biopsies showed dilated follicular infundibula, regardless of horizontal or vertical sectioning of the slides. Dilated follicular infundibula showed a maximum occurrence of 66% in the recovery stage of alopecia areata and were seen in 33% of alopecia areata incognita. In conclusion, dilated follicular infundibula, reminiscent of a Swiss cheese in horizontally sectioned slides, is an exceedingly useful criterion in the histopathologic diagnosis of alopecia areata and are of great help in the daily routine to recognize alopecia areata.

Primary cicatricial alopecias: a review of histopathologic findings in 38 patients from a clinical university hospital in Sao Paulo, Brazil

BACKGROUND

Scarring alopecias are classified into primary and secondary types according to the initial site of inflammation. In primary scarring alopecias, the hair follicle is the main target of destruction; the term secondary cicatricial alopecia implies that follicular destruction is not the primary pathologic event.

AIMS

To review the histopathologic diagnoses of cases of cicatricial alopecia in order to classify them according to the North American Hair Research Society.

PATIENTS AND METHODS

Patients with biopsy specimens diagnosed as cicatricial alopecia seen from 2000 to 2005 at the Dermatologic Department of Hospital das Clinicas, São Paulo University Medical School had hematoxylin and eosin, Periodic acid-Schiff and Weigert stained slides reevaluated and sub-typed into different primary cicatricial alopecias.

RESULTS

Thirty-eight cases of primary cicatricial alopecias were reclassified as: chronic cutaneous lupus (17), lichen planus pilaris (4), pseudopelade of Brocq (12), folliculitis decalvans (3), dissecting folliculitis (1), and non-specific scarring alopecia (1). In our cases, the methods employed allowed an accurate diagnosis in 12 of 13 cases (92.3%) previously classified as non-specific cicatricial alopecias.

CONCLUSIONS

Even in the late, pauci or non-inflammatory phases, an approach with systematic evaluation of a constellation of criteria in routine hematoxylin and eosin stain, Periodic acid-Schiff and Weigert stain allowed for a more accurate diagnosis of cicatricial alopecias.