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Introduction

Chronic Cutaneous (Discoid) Lupus Erythematosus (CCLE): See Section 14.

LICHEN PLANOPILARIS (LPP) See "Lichen Planus" in Section 14.

Pseudopelade of Brocq
  • End stage of all noninflammatory scarring alopecias and a variety of initially inflammatory disorders.
  • Manifestations:
    • Early lesions: Discrete, smooth, skin- or pink-colored irregularly shaped areas of alopecia without follicular hyperkeratosis or perifollicular inflammation (Fig. 31-18).
    • Pattern of alopecia: Early moth-eaten pattern with eventual coalescence into larger patches of hair loss ("footprints-in-the-snow").
    • Dermatopathology: Similar to lichen planopilaris.
Central Centrifugal Scarring Alopecia (CCSA)
  • Synonyms: Follicular degeneration syndrome, hot comb alopecia, and pseudopelade.
  • Most commonly occurs in black women. Relation to chemical processing, heat, or chronic tension on the hair is uncertain, but they are best avoided.
  • Slowly progressive alopecia begins in the crown/midvertex and advances centrifugally to surrounding areas.
  • Dermatopathology: Earliest most distinctive change is premature desquamation of the inner root sheath with later changes through the outer root sheath, loss of the follicular epithelium, and replacement with fibrous tissue.
  • Alopecia Mucinosa (Follicular Mucinosis)
  • Erythematous lesions (papules, plaques, or flat patches) of alopecia, occurring mainly on the scalp and/or face.
  • Dermatopathology: Prominent follicular, epithelial/sebaceous gland mucin, and perifollicular lymphohistiocytic infiltrate without concentric lamellar fibrosis.
  • May be symptom of cutaneous T-cell lymphoma (see Section 21).
  • Folliculitis Decalvans.
  • Pustular folliculitis leading to hair loss. Surviving hairs clustered, emerging from a single follicular orifice (tufted folliculitis).
  • Bogginess or induration of scalp/beard with pustules, erosions, crusts (Fig. 31-19), and scale.
  • Staphylococcus aureus infection is common. Whether S. aureus infection is the primary process or secondary is uncertain.
  • Dermatopathology: Acute suppurative folliculitis, early.
  • Scarring alopecia is irreversible. Systemic antibiotics, rifampin, systemic and/or topical and/or intralesional glucocorticoids, and systemic retinoid have been used. S. aureus infection should be documented and treated with appropriate antimicrobial agent.
Dissecting Folliculitis
  • Synonyms: Dissecting cellulitis, perifolliculitis abscedens et suffodiens.
  • Race: Most common in black men.
  • Initial deep inflammatory nodules, primarily over the occiput, that progress to coales cing regions of boggy scalp (Fig. 31-20). Sinus tracts may form; purulent exudates can be expressed. S. aureus secondary infection is common.
  • Dermatopathology: Early follicular plugging and suppurative follicular/perifollicular abscesses with mixed inflammatory infiltrate; later, foreign-body giant cells, granulation tissue, scarring with sinus tracts.
  • Scarring alopecia is irreversible. S. aureus infection should be documented and treated with appropriate antimicrobial agent.
  • Follicultis Keloidalis Nuchae.
  • Synonym: Acne keloidalis (nuchae).
  • Occurs most commonly in black men.
  • Usually occurs on the occipital scalp and nape of the neck, starting with a chronic papular or pustular eruption (Fig. 31-21). Keloidal scar formation may occur.
  • Early mild involvement may respond to intralesional triamcinolone. If S. aureus is isolated on culture, treat with appropriate antimicrobial agent.
Pseudofolliculitis Barbae
  • Synonym: "razor bumps."
  • Occurs commonly in black men who shave.
  • Related to curved hair follicles. Cut hair retracts beneath skin surface, grows, and penetrates follicular wall (transfollicular type) or surrounding skin (extrafollicular type), causing a foreign-body reaction.
  • Distribution: Any shaved area, that is, beard (Fig. 31-22), scalp, or pubic.
  • Keloidal scarring in varying degrees occurs at involved sites.
  • S. aureus secondary infection is common.
Acne Necrotica
  • Pruritic or painful erythematous follicular-based papule with central necrosis, crusting, and healing with depressed scar.
  • Lesions occur on anterior scalp, forehead, and nose; at times, the trunk.
  • Dermatopathology: Lymphocytic necrotizing folliculitis.
  • Poor response to treatment. Systemic antimicrobial agents and isotretinoin reported to be effective.
Erosive Pustular Dermatosis of Scalp
  • A disease of the elderly, mainly women, although pediatric cases do occur.
  • Manifestations: Chronic, boggy, crusted plaque(s) on the scalp overlying exudative erosions and pustules, eventually leading to scarring alopecia.
  • May follow trauma or treatment of actinic keratoses.
  • Dermatopathology: Lymphoplasmacytic infiltrate with or without foreign-body giant cells and pilosebaceous atrophy.
  • Poor response to therapy. Treat documented S. aureus infection.

ICD codes

ICD-10: L66.0-L66.9

Laboratory Examinations

Laboratory Examination

SCALP BIOPSY 4-mm punch biopsy including subcutaneous tissue, prepared for horizontal section. A second 4-mm punch biopsy specimen for vertical sections and direct immunofluorescence, particularly if lupus is suspected.

Management

GLUCOCORTICOIDS Topical high-potency and intralesional glucocorticoids (e.g., triamcinolone) are the mainstay of treatment, improving symptoms and hair growth.

CALCINEURIN INHIBITORSTacrolimus and pimecrolimus can be helpful as topical steroid-sparing agents.

SYSTEMIC IMMUNOSUPPRESANTSMethotrexate, cyclosporine, mycophenolate, azathioprine, and others have been used in those with associated systemic conditions such as systemic lupus.

ANTIBIOTICS May be effective, especially if S. aureus infection is documented. Anti-inflammatory properties of hydroxychloroquine and doxycycline have also been used, even in the absence of documented infection, particularly for lymphocytic scarring alopecias in early clinical presentation (LPP and, CCSA).

5α-REDCUTASE INHIBITORSFinasteride and dutasteride are amongst the most efficacious treatments for frontal fibrosing alopecia.

PEROXISOME PROLIFERATOR-ACTIVATED RECEPTOR (PPAR)-γ LIGANDS Pioglitazone has been proposed as a treatment but evidence is lacking in stabilizing hair growth of lymphocytic alopecia.

RETINOIDS Case reports document efficacy in lymphocytic alopecia (FFA) with isotretinoin at lower doses (20 mg).