DENVER – To limit the progression of scarring alopecia, Dr. Jeff Donovan makes it a point to ask his patients about symptoms and shedding, and he always performs a thorough scalp examination to record the affected sites and signs of the condition.
"Everything on the history potentially may be important, but always ask about symptoms of itching, burning, pain, tenderness, and shedding," Dr. Donovan of the department of dermatology at the University of Toronto advised at the annual meeting of the American Academy of Dermatology.
Courtesy Dr. Jeff Donovan
Lichen planopilaris (LPP) in a 75-year-old woman. The patient was initially diagnosed and treated for androgenetic alopecia. However, scalp itching, burning and persistent hair shedding was an indication to investigate for scarring alopecia.
Upon examination, he continued, document sites and signs by considering the following questions: Where is the hair loss – frontal, top, or occipital? Can you still see the follicular ostia? Is there erythema of the scalp? Is there perifollicular erythema or scale, crusting, pustules, or loss of eyebrow or body hair?
"When you perform dermoscopy of the normal scalp, one can see that the hairs are similar in ‘caliber’ (no miniaturization suggestive of androgenetic alopecia), and there are no changes around the hair follicles or between the hair follicles," Dr. Donovan said. "In scarring alopecia, a variety of findings may be present which help point to the correct diagnosis."
A 4-mm punch biopsy is helpful to confirm the diagnosis and is recommended in areas of early active disease, including areas that may have primary morphologic features, areas with a positive pull test (if possible), or areas that are symptomatic (if needed). "Diagnosing a hair disease with a biopsy requires a hair to be present in the biopsy," he noted. "Biopsies of completely scarred areas are not helpful." In scarring alopecias, inflammatory infiltrates are found in the upper parts of the hair follicle, which destroys hair follicle stem cells. "It’s this destruction of stem cells which ultimately leads to permanent hair loss," Dr. Donovan said.