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Transcript of SYM S049 - Tosti - 12963 10430 - aad.org S049... · Tosti A, Miteva M, Torres F. Lonelyhair: a...
Alopecia
Antonella TostiFredric Brandt Endowed Professor of
Dermatology&Cutaneous Surgery Miller School of Medicine, University of Miami
Antonella Tosti, MDS049 Alopecia
DISCLOSURES
Fotofinder :Consultant, Springer & Verlag , CRC Press :Author-Royalties , Karger : Editor in chief
DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY
Most important challenges
1 Clinico/pathological correlations
2 Utilize dermoscopy to select optimal biopsy site
3 Distinguish early scarring alopecias from MPHL/FPHL
4 Pitfalls
Most important challenges
1 Lack of clinico/pathological correlations
The clinician is convinced that the patient has scarring alopecia
Pathologist signs as non scarring alopecia
1 Lack of clinico/pathological correlations
Most common reasons
Site of biopsy
Clinicians often decide to take the biopsy at the periphery of the patch as this is where the disease is active and it is more likely to obtain a pathological diagnosis
1 Lack of clinico/pathological correlations
Most common reasons
Site of biopsy
This site might not be affected and pathology shows no scarring
1 Lack of clinico/pathological correlations
How to deal?
Look at the problem together!
1)Take a new biopsy in the scarring area, as patient otherwise gets confused
2) Use dermoscopy to see where the disease is active at periphery and in this case take a dermoscopy guided biopsy
1 Lack of clinico/pathological correlations
How to deal?
Look at the problem together!
2) Use dermoscopy to see where the disease is active at periphery and in this case take a dermoscopy guided biopsy
1 Lack of clinico/pathological correlations
Different situation
In this case the clinician is unsure if this is scarring or non scarring: it is very important to take the biopsy at the center of the patch!
1 Lack of clinico/pathological correlations
Transverse
Vertical
Most common reasons
Specimen processing
1 Lack of clinico/pathological correlations
Best approach
If the clinician provides two biopsies process one for horizontal and one for vertical sections
If the clinician provides one biopsy process for horizontal sections
Childs JM, Sperling LC. Histopathology of scarring and nonscarring hair loss.Dermatol Clin. 2013 Jan;31(1):43-56.
1 Lack of clinico/pathological correlationsBest approach
Nguyen JV, Hudacek K, Whitten JA, Rubin AI, Seykora JT. The HoVert technique:a novel method for the sectioning of alopecia biopsies. J Cutan Pathol. 2011May;38(5):401-6.
2 Utilize dermoscopy to select optimal biopsy site
Use the dermatoscope to select the biopsy site!
Area to select depends on disease
Miteva M, Tosti A. Dermoscopy guided scalp biopsy in cicatricial alopecia. J Eur Acad Dermatol Venereol. 2013 Oct;27(10):1299-303.
-DermLite® (3Gen LLC.)
-Handyscope® (FotoFinderSystems)
-DermScope ® (Canfield Imaging Systems)
2 Utilize dermoscopy to select optimal biopsy site
Instruments
2 Utilize dermoscopy to select optimal biopsy siteArea to select depends on clinical diagnosis and dermoscopic features
Select the area with dermoscopy
Mark and circle the area
Confirm selection with a dermoscopic picture
2 Utilize dermoscopy to select optimal biopsy siteDermoscopic features associated with disease activity in scarring alopecias.
Peripilar castsHair tuftingKeratotic plugsWhite gray halos
2 Utilize dermoscopy to select optimal biopsy site
Peripilar casts
White concentric scales surrounding the hair shaft at its emergency
2 Utilize dermoscopy to select optimal biopsy siteHair tufting
Tuft of 2 or more hairs surrounded by casts
2 Utilize dermoscopy to select optimal biopsy siteKeratotic plugs
Keratotic masses filling the follicular openings
2 Utilize dermoscopy to select optimal biopsy siteWhite gray halos
White gray dots surrounding a tuft of 2 hais
2 Utilize dermoscopy to select optimal biopsy site
Lichen planopilaris: tufted hairs with peripilar casts
Frontal fibrosing alopecia: terminal hairs with peripilar casts
Discoid lupus erythematosus: keratotic plugs, red dots
Folliculitis decalvans: tufts of six or more hairs emerging together
Central centrifugal cicatricial alopecia: white-gray halos
Site of Biopsy in Scarring Alopecias
Dermoscopy guided biopsy
•Increases pathological accuracy(diagnosis in 95% of biopsies)
•Very helpful in cases of early or focal disease
•Useful for dermoscopic-pathological correlations
2 Utilize dermoscopy to select optimal biopsy site
3 Distinguish early scarring alopecias from FPHL/MPHL
Frontal fibrosing alopecia
Fibrosing alopecia with a pattern distribution
Important mimics of MPHL/FPHL
Frontal fibrosing alopecia
Frequency is increasing world wideNot limited to postmenopausal womenCommonly associated with androgenetic alopeciaEarly cases can be difficult to detects
3 Distinguish early scarring alopecias from FPHL/MPHL
Frontal hairline recession Loss of eyebrows Prominent temporal/frontal veinsHair loss in the limbsFacial lesions
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Clinical features
Mean glabellar–frontal distance : 8,5 cm ( controls 5.9 cm)
The alopecic area shows less signs of photodamage as compared with the forehead
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Lencastre A, Tosti A. Images in clinical medicine. A receding hairline. N Engl J Med. 2013 Jul 11;369(2):e2.
Frontal hairline recession
Lonely hair : a clue to diagnose Frontal Fibrosing Alopecia
Presence of one or few isolated remaining terminal hair in the middle of the forehead, at site of the original hairline implantation is a clinical clue for diagnosis of FFA
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Frontal hairline recession
Tosti A, Miteva M, Torres F. Lonely hair: a clue to the diagnosis of frontalfibrosing alopecia. ArchDermatol. 2011 Oct;147(10):1240
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Frontal hairline recession
Perifollicular erythema and scaling
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Clinical features
Loss of eyebrows (75% of patients
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Clinical features
Prominent temporal/frontal veins
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Very common in Europe, Americas, Africa, few cases reported from China, rare in South Arabia
Role of sunscreens
Frequence is increasing world wide
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Also seen in young women and men
Not limited to postmenopausal women
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Increasingly reported in men1: Tolkachjov SN, Chaudhry HM, Camilleri MJ, Torgerson RR. Frontal fibrosing alopecia among men: A clinicopathologic study of 7 cases. J Am Acad Dermatol. 2017 Jul 14.
2: Ormaechea-Pérez N, López-Pestaña A, Zubizarreta-Salvador et al . Frontal Fibrosing Alopecia in Men: Presentations in 12 Cases and a Review of the Literature. Actas Dermosifiliogr. 2016 Dec;107(10):836-844
3: White F, Callahan S, Kim RH, et al Frontal fibrosing alopecia in a 46-year-old man. Dermatol Online J. 2016 Dec 15;22(12).
4: Salido-Vallejo R, Garnacho-Saucedo G, Moreno-Gimenez JC, Camacho-Martinez FM. Beard involvement in a man with frontal fibrosing alopecia. Indian J Dermatol Venereol Leprol. 2014 Nov-Dec;80(6):542-4.
5: Khan S, Fenton DA, Stefanato CM. Frontal fibrosing alopecia and lupus overlap in a man: guilt by association? Int J Trichology. 2013 Oct;5(4):217-9.
6: Chen W, Kigitsidou E, Prucha H, Ring J, Andres C. Male frontal fibrosing alopecia with generalised hair loss. Australas J Dermatol. 2014 May;55(2):e37-9.
7: Debroy Kidambi A, Dobson K, Holmes S et al . Frontal fibrosing alopecia in men: an association with facial moisturizers and sunscreens. Br JDermatol. 2017 Jul;177(1):260-261.
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Increasingly reported in men
Can start from sideburns
Beard and body hair commonly involved
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Commonly associated with androgenetic alopecia
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Look at the hairline of all women consulting for hair loss!
Parietal hairline often first site of involvement
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Tips to recognize early FFA
Suspect FFA in all patients showing sparse/tattooed eyebrows
Be aware of facial lesions!
Look for presence/absence of vellus hair at the hairline
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Tips to recognize early FFASuspect FFA in all patients showing sparse/tattooed eyebrows
Anzai A, Donati A, Valente NY, Romiti R, Tosti A. Isolated eyebrow loss in frontal fibrosing alopecia: relevance of early diagnosis and treatment. Br J Dermatol. 2016 May 13
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Tips to recognize early FFA
Facial papulesKeratosis pilaris like lesionsFacial erythemaFacial maculesFacial hyperpigmentation
Be aware of facial lesions!
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Facial papulesMore common in women with dark phototypes
Forehead Temples ChecksChin
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Facial papulesLichenoid inflammation involving vellus hair follicles and perifollicular fibrosis
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Facial papules
Pinkus acid orcein staining showing reduction and fragmentation of elastic fibers .
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Facial papules
We propose that an abnormal elastic framework could be responsible for the remodeling of the shape of sebaceous lobules and ducts in this anatomic microenvironment, leading to the popping out of sebaceous glands and the clinical formation of FP
Pirmez R, Barreto T, Duque-Estrada B, Quintella DC, Cuzzi T. Histopathology offacial papules in frontal fibrosing alopecia and therapeutic response to oralisotretinoin. J Am Acad Dermatol. 2018 Feb;78(2):e45.
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Facial papules
Pedrosa AF, Duarte AF, Haneke E, Correia O. Yellow facial papules associatedwith frontal fibrosing alopecia: A distinct histologic pattern and response toisotretinoin. J Am Acad Dermatol. 2017 Oct;77(4):764-766.
Frontal fibrosing alopecia
3 Distinguish early scarring alopecias from FPHL/MPHL
Other facial lesions
In dark phototypes easily confused with melasma
In fair phototypes easily confused with rosacea
Frontal fibrosing alopecia
Look at hairline for presence/absence of vellus hair
3 Distinguish early scarring alopecias from FPHL/MPHL
Tips to recognize early FFA
You need a dermatoscope!
3 Distinguish early scarring alopecias from FPHL/MPHL
FFA increasingly commonNot limited to postmenopausal womenYou might get eyebrow biopsiesYou might get biopsies of facial lesions
Take home message
3 Distinguish early scarring alopecias from FPHL/MPHL
26 year old man with patterned alopecia and scalp itching
3 Distinguish early scarring alopecias from FPHL/MPHL
Dry dermoscopy
Hair shaft variability
Peripilar casts
Hair tufting
V sign
First described by Zinkernagel &Trueb in 2011
Pathology :miniaturization (as in androgenetic alopecia) and lichenoid perifollicular inflammation
Fibrosing alopecia with a pattern distribution
Zinkernagel MS, Trüeb RM. Fibrosing alopecia in a pattern distribution: patterned lichen planopilaris or androgenetic alopecia with a lichenoid tissue reaction pattern? Arch Dermatol. 2000 Feb;136(2):205-11.
3 Distinguish early scarring alopecias from FPHL/MPHL
Fibrosing alopecia with a pattern distribution
Diagnosis :
Need to take dermoscopy guided biopsy !
3 Distinguish early scarring alopecias from FPHL/MPHL
Fibrosing alopecia with a pattern distribution
Diagnosis pathology :
Need horizontal sections!
3 Distinguish early scarring alopecias from FPHL/MPHL
Fibrosing alopecia with a pattern distribution vs lichen planopilaris
FAPD :miniaturization LPP : vellus hairs areis a specific feature lost
3 Distinguish early scarring alopecias from FPHL/MPHL
Fibrosing alopecia with a pattern distribution
3 Distinguish early scarring alopecias from FPHL/MPHL
May be no so uncommon
Might be the reason of LPP after hair transplantation
Pathologists are really important in detecting these patients
Chiang YZ, Tosti A, Chaudhry IH, Lyne L, Farjo B, Farjo N, Cadore de Farias D,Griffiths CE, Paus R, Harries MJ. Lichen planopilaris following hairtransplantation and face-lift surgery. Br J Dermatol. 2012 Mar;166(3):666-370
4 Pitfalls
14 year ol africanamerican girl
3 months history of erythema, boggy induration,serosanguinous drainage and hair loss
4 PitfallsTreatment with doxycicline 200 mg daily and clobetasol 0.01% foam produced no improvement.
Follow up after 3 months showed persistence of tender scalp nodules , scalp erythema ,severe alopecia, pus discharge and cervical adenopathy
4 PitfallsDiagnosis : tinea capitis
Terbinafine 250 mg day for 6 weeks
At end of treatment inflammation had completely resolved but areas of alopecia were still present
Diagnosis confirmed by culture that grew Trichophyton sp
black dots
Tinea Capitis Mimicking Dissecting Cellulitis
Nodulocystic form of tinea capitis with overlying alopecia, closely resembling dissecting cellulitis of thescalp.
Histopathology shows a dense mixed lympho -plasmacytic and neutrophilic infiltrate and fungal stains are usually negative
Miletta NR, Schwartz C, Sperling L. Tinea capitis mimicking dissectingcellulitis of the scalp: a histopathologic pitfall when evaluating alopecia inthe post-pubertal patient. J Cutan Pathol. 2014 Jan;41(1):2-4.
4 Pitfalls
4 PitfallsTinea Capitis Mimicking Dissecting Cellulitis
Inflammatory tinea capitis can mimic dissecting cellulitis clinically and histologically
Dermoscopy may indicate correct diagnosis
Always take a culture in inflammatory scalp diseases of children and adolescents!!!
Culture and fungal stains maybe negative
LaSenna CE, Miteva M, Tosti A. Pitfalls in the diagnosis of kerion. J Eur Acad Dermatol Venereol. 2014 Dec 10. doi: 10.1111/jdv.12912.