CASE 1
A 52-year-old African American woman presented with concerns of hair loss and scalp pruritus. The patient reported a two-year history of progressive hair loss with an associated mild itch on her scalp. She denied scalp tenderness or hair breakage at her crown. She denied a family history of hair loss. Gross examination revealed hair thinning on her crown with decreased density and discrete areas of scarring (Figure 1a). Based on the patient's demographics and initial gross examination, CCCA rose to the top of the differential. Trichoscopy of the region, however, revealed significant perifollicular scale and subtle erythema. Honeycomb pattern was also present with uneven white dots (Figure 1b). Histopathological examination of a biopsy specimen demonstrated perifollicular fibrosis, polytrichia, and a subtle lichenoid folliculitis (Figure 1c) that was most suggestive of lichen planopilaris (LPP).
CASE 2
A 75-year-old African American woman presented with a 5-year history of progressive hair loss. The patient reported scalp pruritus for the past five to six months. She mentioned dyeing her hair 3 or 4 times per year for the past 10 years. Gross examination revealed significant thinning of hair on the frontal scalp with extension to the crown (Figure 2a). Prior to trichoscopic exam, clinical findings were more consistent with
CCCA. Trichoscopy revealed miniaturized hair. Honeycombing was noted with presence of multiple pinpoint white dots with mild erythema (Figure 2b). A biopsy specimen from the mid-scalp revealed miniaturized hairs, retained sebaceous gland lobules, and no significant inflammatory infiltrate (Figure 2c) that was most consistent with androgenetic alopecia.
Superimposed features of chronic rubbing were also noted. Upon further inquiry, the patient noted a different hair dye may have been used prior to the onset of her pruritus. She was instructed to temporarily cease dyeing her hair and was started on fluocinonide 0.05% solution daily as needed and minoxidil 5% solution twice a day. After exactly 2 months of treatment, patient started to show signs of new hair growth.
CASE 3
An Afrolatino male presented with a 3-year history of progressive hair loss with associated mild itch. The patient denied any family history of hair loss. Gross examination revealed two round patches of alopecia on his right parietal scalp with decreased hair density and loss of follicular ostia with slight hyperpigmentation centrally. (Figure 3a). Based purely on the initial gross clinical exam, the clinician was concerned about possible discoid lupus erythematosus (DLE) or CCCA. Trichoscopy, however, revealed significant peripilar casts and scale; no follicular plugging was noted (Figure 3b). Histopathological examination demonstrated polytrichia, perifollicular fibrosis, and a perifollicular lichenoid folliculitis (Figure 3c) that was consistent with LPP. A deep inflammatory infiltrate or deposits of mucin that would point to DLE were not identified. The patient was not interested in intralesional triamcinalone acetonide injections and was started on TCM therapy (tacrolimus, clobetasol, and minoxidil) applied twice daily. He was later lost to follow up.
