Alopecia scarring L66.8

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

alopecia cicatricans; alopecia major; primary scarring alopecia; scarred alopecia; scarring alopecia; traumatic alopecia

Definition
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Congenital or acquired, irreversible hairlessness ( alopecia) due to nevoid, inflammatory, neoplastic or traumatic processes. These result in a defective or missing follicular system (genodermatoses) or in an irreversible destruction of the follicle with consecutive scarring (clinically: mirror-like smooth surface without evidence of follicular openings). Pseudopelad (Brocq) is still understood today, without prejudice, as a polyätiological "final state" of a process leading to scarring.

Classification
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Classification of primary scarring alopecia (PVA) according to histopathological criteria in accordance with the recommendation of the North American Hair Research Society (Olsen EA et al. 2003)

PVA group I (lymphocytic)

PVA group II (neutrophil)

PVA group III (mixed cell)

PVA Group (unspecific)

  • Idiopathic scarring alopecia with unspecific clinical and histopathological findings.
  • End stage of various inflammatory scarring alopecia

Classification of secondary scarring alopecia according to etiological criteria (varies according to Kanti V et al. 2018)

Physical or chemical trauma

  • Incineration
  • Alkali or acid burns
  • Ischemia/pressure
  • Traction Alopecia
  • Trichotillomania (advanced stage)

Ionising rays

  • Therapeutic irradiation

Infections

Tumours

  • Primary tumors
  • Metastases
  • Lymphoproliferative diseases
  • Epidermal and organoid nevi (e.g. nevus sebaceus)

Genodermatoses

Granulomatous diseases

Autoimmune diseases

Deposit dermatoses

  • Amyloidosis
  • Mucinosis

Inflammatory diseases

Drugs (rare)

  • Busulfan

Etiopathogenesis
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  • see classification below

Diagnosis
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Medical history:

  • Family anamnesis
  • Cosmetic analysis and hair care (chemical or physical smoothing or waving procedures, traction, professional or personal headgear (e.g. helmets)
  • environment analysis: pets, professional animal contact
  • Previously known significant and permanent diseases
  • Initial manifestation (age)
  • First-time or chronic or chronically recurrent course
  • Effluvium (currently active hair loss)
  • Effluvium diffuse or localised
  • Malperceptions (burning, pain, pruritus) with time documentation (never, rarely, intermittently, continuously)
  • Gynaecological history (ovulation inhibitor, menopause)
  • medication (continuous, intermittent regular, irregular)

Clinical examination:

  • Inspection of the scalp (extension and pattern of alopecia, signs of inflammation, follicular erythema, pustules, erosions, increased scaling), tufts of hair, hair shaft sheaths (follicular casts).
  • Dermatoscopy (follicles in the centre of the lesion preserved or absent, follicular hyperkeratoses). It is important to distinguish it from alopecia areata (follicular structure preserved)
  • Plucking test (hair can be extracted painlessly)
  • Inspection of the entire integument (indications for lichen planus, psoriasis, lupus erythematosus, blistering autoimmune disease), the mucous membranes (especially oral mucosa), the nails (especially fingernails).
  • Laboratory diagnostics:
    • Standard profile; special laboratory depending on clinical symptoms, if necessary microbiological diagnostics.
    • Biopsy: Sufficiently deep, follicular apparatus (follicleostium strictly in the middle of a 4 mm diameter punch biopsy). Punch biopsy from the still follicle-bearing marginal area of the lesion (the scarred area is not histologically significant).
    • With questionable. Autoimmune diseases, an immunofluorescence examination is diagnostically valuable.

Differential diagnosis
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Non-scarring alopecia, e.g. Alopecia areata.

External therapy
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  • The treatment naturally depends on the underlying disease.
    • In the acute phase of an underlying inflammatory disease ( lichen planus, lupus erythematosus) the external application of glucocorticoids as a tincture or cream can be attempted in addition to specific systemic treatment, e.g. 2 times/day prednicarbate Lsg. (e.g. Dermatop), Mometasone Lsg. (e.g. Ecural), triamcinolone (e.g. Volon A tincture), betamethasone (e.g. Betnesol-V-crinale, Celestan-V-crinale).
    • Alternatively, intralesional, intracutaneous injections of triamcinolone crystal suspension (e.g. Volon A 10 diluted 1:2 to 1:5 e.g. with mepivacaine). This is primarily intended to stop the further scarring process. Permanent alopecia at the scarred areas.

Notice! When glucocorticoid crystal suspensions are injected in the temporal and anterior parietal region, there is a risk of crystals being carried over into the retinal arteries with subsequent blindness!

Operative therapie
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If necessary, excision of the scar or hair transplantation.

Literature
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  1. Kanti V et al (2018) Scarring alopecia. JDDG 16: 435-461
  2. Olsen EA et al (2003) Summary of North American Hair Research Society (NAHRS)-sponsered Workshop on Cicatricial Alopecia, Duke University Medical Center, February 10 and 11, 2001 J Am Acad Dermatol 48: 103

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

Authors

Last updated on: 29.10.2020