Minimizing Bias in Alopecia Diagnosis in Skin of Color Patients

We present three cases of alopecia initially suspected to represent CCCA based on a hair loss pattern predominantly involving the vertex or crown of the scalp in skin of color patients. CCCA is the most common form of primary scarring alopecia in African American females and presents with hair loss beginning on the crown and spreading centrifugally.^5,6 In each of these cases, however, trichoscopic findings were suggestive of alternate diagnosis and led to a clinical decision of performing a biopsy. Histopathological examination from the biopsy specimens in each of these cases led to diagnoses other than CCCA.  

In Patients 1 and 3, trichoscopic findings of perifollicular scale, which can be seen in LPP, were corroborated with the histopathological features on biopsy. The distinction between CCCA and LPP is important as treatment can vary between the two conditions. While initial treatment approaches with intralesional triamcinolone and oral antibiotics may be similar, 3rd line agents such as naltrexone and/or pioglitazone for LPP or topical metformin for CCCA may necessitate a more definitive diagnosis.^9-11

In Patient 2, the biopsy specimen demonstrated androgenetic alopecia with features of chronic rubbing. External breakage of hair from trauma or rubbing is likely an under-reported contributing factor to presentations of alopecia. Therefore, treatments that also target pruritus or concomitant allergic contact dermatitis or seborrheic dermatitis should be added for optimal results.  

4-mm punch biopsies down to the subcutaneous tissue are optimal specimens for the evaluation of alopecia. The presence of premature desquamation of the inner root sheath, perifollicular fibrosis, and follicular compounding point to a scarring process. Lymphocytic-mediated scarring alopecias such as CCCA, LPP, and DLE can be further distinguished by the depth and density of the infiltrate, the presence of interface changes at the dermal-epidermal junction as well as the basal layer of follicular epithelia, and the presence or absence of mucin. In late-stage or end-stage disease, however, histopathological features can be non-specific and dermatopathology may present similarly.

All three cases presented were in patients of color and revealed pathologic changes in the scalp during trichoscopic evaluation and biopsy that differed from the initial suspected clinical diagnosis. Some scarring alopecia subtypes are more prevalent in certain racial groups. However, focusing solely on patient demographics and gross clinical findings may obscure accurate diagnoses. We challenge clinicians to reexamine their biases and fully evaluate patients of color with alopecia. An examination should include a thorough history, clinical examination, trichoscopy, and potentially a biopsy, particularly when findings do not correlate. Our cases highlight the challenges and disparities that exist in diagnosis of alopecia in Black patients. We emphasize the need for continued research regarding alopecia in skin of color and the importance of a complete workup for alopecia to improve diagnostic outcomes.