Download Scarring Alopecia

950
Clinical Dermatology
Scarring Alopecia
BOX 24-13 Primary Scarring Alopecia
(Classification based on clinical
presentation and histology)
Initially lymphocytic
• Chronic cutaneous lupus erythematosus
• Lichen planopilaris (LPP)
• Classic lichen planopilaris
• Frontal fibrosing alopecia
• Lassueur-Graham-Little syndrome (LPP and lichen
planus and spinous lesions)
• Pseudopelade (Brocq)
• Central centrifugal cicatricial alopecia (follicular degeneration syndrome, hot comb alopecia)
Neutrophilic
• Folliculitis decalvans
• Dissecting cellulitis/folliculitis
Mixed
• Acne keloid
• Tufted folliculitis
• Acne necrotica
• Erosive pustular dermatosis
Adapted from Whiting DA: Clin Dermatol 19(2):211-225, 2001.
PMID: 11397600
BOX 24-14 Secondary Scarring Alopecia
Inherited and congenital disorders
Aplasia cutis, chondrodysplasia punctata, cutis verticis gyrata, Darier’s disease, eccrine hamartoma, epidermal nevi,
epidermolysis bullosa, hair-follicle hamartoma, hypotrichosis congenita, ichthyosis (sex-linked recessive), incontinentia
pigmenti, keratosis pilaris spinulosa decalvans, neurofibromatosis, polyostotic fibrous dysplasia, porokeratosis of Mibelli, scarring follicular keratosis
Physical/chemical agents
Chemical burns, insect bites, mechanical trauma or laceration, radiation dermatitis, thermal burns
Sclerosing disorders
Lichen sclerosus et atrophicus, morphea, scleroderma,
scleroderma en coup de sabre and facial hemiatrophy,
sclerodermoid porphyria cutanea tarda
Dermal granulomatous infiltrations
Actinic granuloma; amyloidosis; infections caused by fungi,
protozoa, syphilis, tuberculosis, viruses, etc.; Miescher’s
granuloma; necrobiosis lipoidica; sarcoidosis
Dermal neoplastic infiltrations
Adnexal tumors, basal cell carcinoma, dematofibrosarcoma
protuberans, lymphoma, melanoma, metastatic carcinoma,
squamous cell carcinoma, etc.
Adapted from Whiting DA: Clin Dermatol 19(2):211-225, 2001.
PMID: 11397600
The classification of scarring alopecia is confusing. The
cicatricial or scarring alopecias cause destruction of follicles and result in irreversible hair loss. They occur with
either destruction of the follicle or scarring of the reticular dermis. Scarring alopecias are classified as primary or
secondary. In primary scarring alopecias (Box 24-13), the
follicle is the target of inflammation. In secondary scarring alopecias (Box 24-14), the follicle is destroyed by a
nonfollicular process. In primary scarring alopecias, the
inflammation is either primarily lymphocytic or neutrophilic. All parts of the follicle can be involved, but the
bulge area of the follicle, where the arrector pili muscles
insert, is the primary target of the inflammatory process.
This bulge contains the stem cells for regeneration of the
lower follicle during normal follicular cycling. The end
stage is smooth skin with no follicular orifices. The primary cause may be related to sebaceous glands.
Central Centrifugal Scarring Alopecia (Follicular
Degeneration Syndrome). Central centrifugal cicatricial alopecia (CCCA) (previously known as hot comb alopecia, follicular degeneration syndrome) can result in the
permanent destruction of hair follicles. It is the most
common form of cicatricial hair loss among black women.
The ideology is unknown. Hair styles causing traction
and inflammation from bacterial infection may be contributing factors. The increase in diabetes mellitus type 2
among those with CCCA supports the theory that cicatricial alopecia may be a manifestation of metabolic dysregulation. CCCA presents on the vertex of the scalp and
can be divided into early (inflammatory) and late (scarring) stages (Box 24-15). Erythema and scaling indicate
the presence of inflammation around hair follicles. Pruritus and scalp tenderness are common. Early in the disease
process, there is decreased hair density in an area measuring a few centimeters. The disease progresses slowly.
Histologically there are varying levels of inflammation,
BOX 24-15 Central Centrifugal Scarring
Alopecia (Follicular Degeneration
Syndrome, Hot Comb Alopecia)
• Middle-aged black females, some black males
• Some have history of hot comb usage
• Scarring alopecia starts on the vertex, spreads forwards
and outwards and gradually assumes the central, elongated configuration of female pattern alopecia; most active disease at the periphery; eventual burnout
• Lymphocytic inflammation
• Premature disintegration of the inner root sheath
• Release of hair fragments into the dermis, causing granulomatous inflammation
• Differential diagnosis—discoid lupus erythematosus, lichen planopilaris, folliculitis decalvans, pseudopelade,
tufted folliculitis
• Treatment—minimal hair grooming; no oily scalp preparations, traction, heat, chemicals, straighteners, perming, or dyeing; treat with topical or intralesional steroids, topical minoxidil
www.PTools.ir