Clinical Update
Scarring alopecia in women Alopecia (hair loss) is a common and distressing complaint, necessitating identifying and treating the cause, plus being aware of the potential psychological, social and cultural consequences for the patient. Clinicians play a key role in providing women with a thorough evaluation, a specific diagnosis, evidencebased treatment options, and counselling.
By Dr Kate Borchard Dermatologist Mt Hawthorn
Figure 3. Scarring alopecia algorithm based on examination findings.
Scarring Alopecia
Pustules/Boggy swelling?
Erythema/Scale?
Atrophy only?
Consider infection, folliculitis decalvans, dissecting cellulitis, acne necrotica, acne keloidalis nuchae
Consider tumour, lichen planus, discoid lupus erythematosus, alopecia mucinosa.
Consider trauma, burnt out lichen planus or discoid lupus erythematosus, scleroderma, pseudopelade of Brocq
Causes of alopecia in women The mechanisms of alopecia include decreased hair growth, increased shedding, loss of hair follicles and hair breakage. Those of dermatological aetiology present with pruritus, pustules, scale or scarring, whereas systemic causes present with increased shedding and thinning in a patterned or diffuse manner. Common causes of alopecia in women are androgenic alopecia, nutritional deficiency, autoimmune disease, hair care practices and trichotillomania. The most helpful approach is to think of alopecia as scarring or nonscarring. Scarring is permanent, so early diagnosis and prompt treatment has the best potential to limit the extent.
Dissecting cellulitis
Frontal fibrosing alopecia
Scarring alopecia Clinical approach
Trauma, infection and skin disease may injure the hair follicle, resulting in localised areas of scarring and bald patches in which there are no visible follicles. In the acute or active phase, there may be pustules, follicular erythema or scale. In burnt out lesions, the affected scalp is smooth and atrophic, and the surrounding follicles may become trapped or tufted (multiple hairs in a single follicle). Once the follicles are lost, there is no potential for regrowth, and the alopecia will be permanent. In the infective causes, especially kerion and Staphylococcus, alopecia may be preventable with early diagnosis and prompt treatment. Skin diseases include folliculitis decalvans, dissecting cellulitis, acne keloidalis nuchae, cutaneous lupus erythematosus and lichen planus. Lichen planus and its variants are more common in women than in men. Lichen planopilaris, though rare, is one of the common causes of scarring alopecia. It may
Kerion
develop in association with lichen planus affecting the skin, mucosa and/or nails. Symptoms are often absent, but may include pruritus or pain/tenderness/burning. The clinical appearance is of multifocal scarring alopecia often with an atrophic centre, and surrounding follicular erythema and scale. These areas may merge into larger irregular areas, and may uncommonly cause diffuse scarring alopecia.
TABLE. CAUSES OF SCARRING ALOPECIA Trauma
Injury, burn, surgery, pressure, radiotherapy or traction (from tying or braiding the hair too tightly)
Infection
Staphylococcal folliculitis or tinea capitis (esp kerion). Herpes zoster, tuberculosis less common.
Pseudofolliculitis
Shaving hair too close to the scalp (more common in men), when severe, can scar.
Skin disease
Folliculitis decalvans, dissecting cellulitis, lichen planus such as lichen planopilaris and frontal fibrosing alopecia, alopecia mucinosa, acne necrotica, acne keloidalis nuchae, discoid lupus erythematosus and scleroderma.
MEDICAL FORUM
In the history, ask about onset (sudden or gradual), amount of hair loss, areas of involvement, presence of local (itching, pain, discharge) and systemic symptoms. If suspicious of kerion, ask about animal contacts. Examination includes identification of the pattern and extent of hair loss, signs of active disease (erythema, scale, pustules, positive hair pull test) or burnt-out disease (atrophic or keloidal scarring, tufting). To perform a hair pull test, gently but firmly pull approximately 60 hairs and if more than 6 are obtained the test is positive. In the case of cutaneous lupus erythematosus and lichen planus, look for other areas of involvement. Investigations will depend on clinical findings, but may include swabs and biopsy. Treatment depends on the cause and is aimed at symptom control and limitation of severity and extent. Realistic expectations are important. Scarring alopecia is permanent, so treatment for extensive disease becomes cosmetic camouflage and psychological support. Local causes may be treated with topical or intralesional steroids, calcineurin inhibitors, antibiotics, antifungals, immunosuppressants, immunotherapy or retinoids.
Author competing interests - no relevant disclosures. Questions? Contact the author kate@oxforddaysurgery.com.au
DECEMBER 2015 | 53