Management of Primary Cicatricial Alopecias: Options for Treatment

M.J. Harries; R.D. Sinclair; S. MacDonald-Hull; D.A. Whiting; C.E.M. Griffiths; R. Paus

Disclosures

The British Journal of Dermatology. 2008;159(1):1-22. 

In This Article

Diagnostic Principles

The characteristic disappearance of follicular ostia in PCA is best visualized under a hand lens or dermatoscope, which will also highlight the often concomitant epidermal atrophy and/or presence of pustules, scaling and other signs of inflammatory skin changes.

Scalp biopsy is mandatory in all clinically suspected cases of PCA, particularly when the clinical picture does not allow a firm diagnosis. Ideally two 4-mm punch biopsies, orientated parallel to the hair shaft to avoid cutting through the follicle, should be taken from clinically active, hair-bearing skin. These should be submitted for both vertical and horizontal sectioning and staining with haematoxylin and eosin as this will increase the chances of winning diagnostically helpful clues to accurate disease classification. Elastin stains (Verhoeff–van Gieson) may be used to confirm the presence of scarring and can be particularly useful in differentiating late-stage lesions.[14]

One study suggests that, although samples with lymphocyte-predominant and neutrophil-predominant infiltrates could be readily differentiated from one another, current histopathological techniques could not differentiate clinically distinct PCAs within each of these histological subgroups.[15] Unfortunately this study excluded patients with chronic cutaneous lupus erythematosus (CCLE) which, in the majority of cases, can usually be differentiated from lichen planopilaris (LPP) on histological grounds.[16] Their conclusions must therefore be interpreted with this caveat in mind.

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