Dr. Heather Woolery-Lloyd shares tips for differentiating the various types scarring alopecia.
Heather Woolery-Lloyd, MD, is Director of the Skin of the Color Division for the University of Miami Miller School of Medicine, Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miami, Florida
“Differentiating scarring alopecia is actually quite challenging. Some scarring alopecias are very straightforward and when you look at the patient you know exactly what it is. But for many types of scarring alopecia there is a lot of overlap,” said Heather Woolery-Lloyd, MD, who presented “Differentiating Scarring Alopecia” at the Diversity in Dermatology 2022 Conference.
“The things that I see regularly in my practice are lichen planopilaris, frontal fibrosing alopecia, acne keloidalis nuchae, central centrifugal alopecia, central centrifugal cicatricial alopecia, folliculitis decalvans, and dissecting cellulitis.”
Tips for Diagnosis
Central centrifugal cicatricial alopecia typically occurs in patients of African descent, according to Dr. Woolery-Lloyd.
“It’s a progressive thinning on the crown of the scalp. Sometimes patients will complain of itching, burning, sensitivity, [and] tenderness in the area preceding the hair loss. Sometimes we’ll even see papules and pustules. But because it is very common in African American women and has a characteristic presentation on the crown of the scalp, it really is something that is relatively straightforward to diagnose, though biopsies can be helpful.”
Patients with frontal fibrosing alopecia lose their frontal hairline, said Dr. Woolery-Lloyd.
“It’s a very clear scarring alopecia. At the existing hairline, you can sometimes see hyperkeratosis or follicular prominence. There can also be some follicular prominence of the fine hairs of the face. Sometimes you’ll see little pinpoint papules on the forehead and cheeks. The other characteristic finding is that, in my practice, most of those patients also report thinning or loss of their eyebrows.”
The tricky part about diagnosing frontal fibrosing alopecia is that it can look like traction alopecia, said Dr. Woolery-Lloyd.
However, there are ways to differentiate the two. One is that traction alopecia patients generally do not have any issues with their eyebrows, while frontal fibrosing alopecia patients report thinning if not complete loss of their eyebrows, she said.
“Usually, their eyebrows are tattooed in, so it’s like a clinical clue when you see those eyebrows tattooed in that it may be frontal fibrosing alopecia.”
“The other clinical clue is those fine pinpoint papules on the forehead and cheeks. That is likely due to involvement of the vellus hairs on the face. Those are the two that are very straightforward clues that it’s frontal fibrosing alopecia,” said Dr. Woolery-Lloyd.
Another straightforward and truly clinical diagnosis is acne keloidalis nuchae, according to Dr. Woolery-Lloyd.
“… you get the scarring papules on the occipital scalp. They can be discreet papules, but they can also coalesce into large keloidal plaques. It’s another very classic presentation, not to be confused with anything else.”
Lichen planopilaris can be more difficult to diagnose. It presents with more nonspecific hair loss, said Dr. Woolery-Lloyd.
“With lichen planopilaris, a biopsy is extremely helpful. Lichen planopilaris is a very common form of alopecia. Some reviews suggest it makes up 25% of all the causes of cicatricial alopecia. It’s more common in women. Almost all of my lichen planopilaris patients are women, and they tend to be middle aged. The peak ages are between 30 and 60 years old.”
Biopsies also help to correctly diagnose dissecting cellulitis and folliculitis decalvans, according to Dr. Woolery-Lloyd.
“Patients with dissecting cellulitis present with a very boggy scalp with lots of draining sinuses and nodules. Those patients are extremely uncomfortable. They usually have a tremendous amount of purulent exudate. It’s a very challenging condition to treat and can be confused with other things.”
Folliculitis decalvans is more follicular, so sometimes patients present with a yellow crust, according to Dr. Woolery-Lloyd.
“That’s because staph may be implicated in this condition. It’s a neutrophilic scarring alopecia and could represent an abnormal response to staph. That is another one where biopsy is very helpful.”
Treating Scarring Alopecia
Dr. Woolery-Lloyd treats most scarring alopecia cases with intralesional steroids, as a first line therapy, she said.
“Intralesional steroids are usually my first-line treatment for central centrifugal alopecia and central centrifugal cicatricial alopecia. I also do intralesional steroids for my frontal fibrosing alopecia patients.”
But there are other treatments that are available and have also been used with good success, she said.
“Interestingly for central centrifugal cicatricial alopecia there are some new treatments that have been proposed in case reports. One is 10% topical metformin. I have started a few patients on that but haven’t seen those patients back yet.”
“Another treatment that I think is promising and I have seen results with is platelet-rich plasma (PRP). Almost all patients respond. I have one or two that were non-responders. With PRP, I do a series of treatments every four to six weeks. We do three to six treatments and then tend to evaluate where the patient is,” said Dr. Woolery-Lloyd.
Disclosures:
Dr. Woolery-Lloyd receives grant and research support from Allergan, Arcutis, Eirion Therapeutics, Galderma, Merz, and Pfizer. She is a consultant or advisory board member for Arcutis, CLUE, Incyte, L’Oreal, and Merz. And she is on the speakers’ bureau for EPI, L’Oreal, and Ortho Dermatologics.