VANCOUVER, B.C. – Cicatricial alopecia should be considered a "trichologic emergency," Dr. Jerry Shapiro advised at the annual meeting of the Pacific Dermatologic Association. The hair loss may be permanent, "so it’s important to get on top of this, and not just sit out the condition."
Cicatricial alopecia is characterized by a loss of follicular ostia with replacement by fibrous tissue. Primary cicatricial alopecia targets the hair follicle and involves preferential destruction of the follicular epithelium with sparing of interfollicular dermis. In secondary cicatricial alopecia, "the follicle is an innocent bystander" that is destroyed in the course of infectious tinea capitis, infiltrative diseases such as metastatic disease and sarcoidosis, trauma such as radiation exposure and burns, and inflammatory conditions such as pemphigus vulgaris.
The North American Hair Research Society consensus classification of cicatricial alopecia is based on the infiltrate: lymphocytic, neutrophilic, mixed, or nonspecific.
"We determine our treatment decisions based on the infiltrate," said Dr. Shapiro, whose New York– and Vancouver–based practices are devoted exclusively to hair and scalp disorders. "A biopsy can be crucial when you’re managing these patients, so you know how actively inflamed the lesions are and what the primary infiltrate is. We always take a 4-mm punch biopsy, and we may take two. We’ll do one for transverse sectioning and another one for longitudinal sectioning."
"Sometimes there’s (histologic) overlap between lupus erythematosus or lichen planopilaris," he said. The clinical and pathologic findings can be variable, so the differential diagnosis is difficult. "There are no cures, and the cause of these conditions is unknown."
Discoid lupus erythematosus often presents with atrophy and extensive hair loss. A hallmark feature is central follicular hyperkeratosis. If less than 10% of the scalp is involved, Dr. Shapiro uses ultrapotent topical corticosteroids such as clobetasol with or without triamcinolone acetonide (TCA) injections (10 mg/cc for a maximum total of 2 ccs per sitting once a month). "We inject into the areas that are red as well as the surrounding areas so that it doesn’t spread," he said.
If a patient responds to this regimen he continues to use it on an as-needed basis. For nonresponders, Dr. Shapiro resorts to hydroxychloroquine 200 mg b.i.d. or isotretinoin 40 mg b.i.d. Other alternatives can include topical tacrolimus. Others have used tazarotene and imiquimod, he said, but "I find the latter two too irritating."
For patients with 10% or greater scalp involvement, Dr. Shapiro uses hydroxychloroquine plus ultrapotent topical steroids, plus TCA injections, plus bridging therapy with prednisone, usually with 40 mg prednisone tapered.
Patients with lichen planopilaris typically present with peripheral hyperkeratosis, or frontal fibrosing alopecia, which is marked by loss of a strip of hair at the front and/or the sides of the scalp. Frontal fibrosing alopecia is "a silent epidemic. In Vancouver, I’m seeing about seven cases per day of this, and three to four cases per day in New York. Sometimes, the eyebrows are the first sign of hair loss. Many times it can go completely around the scalp, so it’s [considered] marginally fibrosing," Dr. Shapiro said.
Frontal fibrosing alopecia primarily affects postmenopausal women. "We think there is a hormonal component that is causing this, but there is also a trigger in the environment," Dr. Shapiro said. "We don’t know what the trigger is, but certain countries have less of it. China does not see that much of it, nor does Saudi Arabia."
Dr. Shapiro and his associates recently published a retrospective study of 62 cases of frontal fibrosing alopecia seen between January 2004 and March 2012. Of the 62 patients, 61 were women (Int. J. Dermatol. 2014 [doi:10.1111/ijd.12479]). Their average age was 61 years and the age of onset ranged from 18 to 81 years. In terms of symptoms, 22 (35%) patients were asymptomatic, 42 (68%) had a history of female pattern hair loss, and 50 (81%) patients’ eyebrows were affected.
In Dr. Shapiro’s experience, intralesional TCA with or without oral tetracycline or hydroxychloroquine may help to halt or slow the progression of frontal fibrosing alopecia. He typically uses intralesional Kenalog 2.5 mL/cc. "I do 30 injections for 3 ccs total: 0.1 cc/injection site and I go from one ear to the other," Dr. Shapiro said. "We’ll also use clobetasol solution at the beginning and taper to a betamethasone solution. Other things to consider are tacrolimus, Cetaphil cleanser, and finasteride."
Dr. Shapiro disclosed that he is a consultant to Johnson & Johnson, GSK/Stiefel, Allergan, MSD, and Applied Biology.
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