Vol 9, No 4 (2023)
Case report
Published online: 2023-12-13

open access

Page views 414
Article views/downloads 201
Get Citation

Connect on Social Media

Connect on Social Media

CASE REPORT

Forum Dermatologicum

2023, Vol. 9, No. 4, 167–171

DOI: 10.5603/fd.96951

Copyright © 2023 Via Medica

ISSN 2451–1501, e-ISSN 2451–151X

Trichoscopy-guided biopsy for the evaluation of scarring alopecia due to discoid lupus erythematosus

Kinga Kołcz12Ewa Kaznowska3Adam Reich1Magdalena Żychowska1
1Department of Dermatology, Institute of Medical Sciences, Medical College of Rzeszow University, Rzeszów, Poland
2The Doctoral School, University of Rzeszow, Rzeszów, Poland
3Department of Pathology, Institute of Medical Sciences, Medical College of Rzeszow University, Rzeszów, Poland

Address for correspondence:

Kinga Kołcz, MD, Department of Dermatology,
University of Rzeszow, Szopena 2, 35055 Rzeszow,
Poland; e-mail: kingakolcz@gmail.com

Received: 5.11.2023 Accepted: 28.11.2023 Early publication date: 13.12.2023

ABSTRACT
Discoid lupus erythematosus (DLE) is an autoimmune disease that represents one of the subtypes of chronic cutaneous lupus erythematosus (CCLE). When located on the scalp, DLE may lead to the development of scarring alopecia. The following study presents the case of a 60-year-old female patient with slowly progressing cicatricial alopecia of a four-year duration. The clinical presentation did not allow for a definite diagnosis. The selection of the most representative site for biopsy was guided by trichoscopy and ultraviolet (UV)-enhanced dermo­- scopy. The histopathological examination was consistent with the diagnosis of DLE. This paper also discusses the most common dermoscopic findings in active and end-stage DLE. It is postulated, that in all cases of alopecia, picking the spot for biopsy should be guided by trichoscopy.
Forum Derm. 2023; 9, 4: 167171
Keywords: alopecia, scarring alopecia, discoid lupus erythematosus, dermoscopy, dermoscopy-guided biopsy

INTRODUCTION

Discoid lupus erythematosus (DLE) is an autoimmune disease that represents one of the subtypes of chronic cutaneous lupus erythematosus (CCLE). Apart from DLE, CCLE comprises chilblain lupus erythematosus (CHLE), a deep variant of lupus erythematosus (LE profundus LEP), lupus erythematosus tumidus (LE tumidus LET) and Blaschko’s linear lupus erythematosus (BLLE) [1]. DLE lesions that develop on the scalp may lead to permanent hair loss. A patient is presented with scarring alopecia, in whom dermoscopic examination allowed a selection of a suitable site for surgical biopsy (trichoscopy-guided biopsy) and make a diagnosis of underlying DLE.

CASE REPORT

A 60-year-old woman, with a history of hyperthyroidism, was admitted to the Department of Dermatology in Rzeszow for evaluation of gradually progressing irregular alopecic patches in the parietal-occipital scalp. The first patch of loss of hair, accompanied by pruritus, started to develop 4 years before hospitalization. Her previous treatment included numerous topical corticosteroid preparations of varying potency, minoxidil and an irritant capsaicin mixture, with no clinical improvement.

Figure 1. Clinical presentation (A); video dermoscopy (Canfield D200EVO) performed in the parietal region large pinkish area with fibrotic white dots and discrete honeycomb pigment pattern. No hair follicles are visible in the centre of the patch (B); video dermoscopy (Canfield D200EVO) performed in the occipital region red and yellow dots, corresponding with hair follicle orifices, are present. The site selected for biopsy is marked with a red circle (C, D)

Dermatological examination showed several slightly depressed confluent foci of alopecia on the vertex arranged in the pattern of “footprints in the snow”. Under dermoscopy, white structureless areas on a predominantly pinkish-whitish background, and focally present honeycomb pigment pattern were observed in the parietal region. The follicular openings were absent. Dermoscopic findings differed in the occipital area, where red-brown dots, large yellow dots and pronounced honeycomb pigment pattern on a pink-white background were observed (Fig. 1). Ultraviolet (UV) enhanced-dermoscopy allowed for better visualisation of perifollicular scaling. In addition, under UV-dermoscopy dark round and oval structures, corresponding to hair follicles, were observed in place of red dots (Fig. 2).

Figure 2. Comparison of the dermoscopic and ultraviolet (UV)-enhanced dermoscopic findings in the parietal and occipital location; Dermoscopy of the occipital part (marked with red circle) showing red and yellow dots (Dermlite DL5, polarized mode) (A); UV-enhanced dermoscopy enabled better visualization of the hair follicle ostia as dark round and oval structures (B); Clinical presentation (C); dermoscopy of the parietal part with discrete honeycomb pigment pattern (Dermlite DL5, polarized mode) (D); UV-enhanced dermoscopy showing an irregular structureless darkly pigment area in the centre of the alopecic patch, no round/oval structures corresponding to follicular ostia are visible (E)

The clinical presentation did not allow for a definite diagnosis. It was most consistent with the pseudopelade of Brocq, a controversial condition considered to be rather an end stage of various scarring alopecias than a separate entity [2–4].

Therefore, the decision to take a biopsy from the most representative region was made. Considering the presence of reddish dots under trichoscopy in the occipital region, this site was selected for biopsy and direct immunofluorescence. The histopathological examination showed dermal perivascular and peri adnexal infiltrate composed of lymphocytes and histiocytes; atrophic epidermis with vacuolar degeneration of the basal layer and some apoptotic keratinocytes; flattening of the rete ridges; lymphocytic infiltrate around hair follicles and vessels; as well as hyperkeratosis with condensed follicular keratotic plugs (Fig. 3). Fibrosis and scarring of the dermis were also present. Histopathology favoured the diagnosis of DLE. In extended laboratory work-up, low titters (1:160) of anti-nuclear (dsDNA) and anti-mitochondrial (AMA) antibodies were detected. Direct immunofluorescence was negative. Complement components C3 and C4 were within reference values.

Figure 3. Histopathology. General overview (HE staining, magnification 100×) (A); epidermal atrophy and vacuolisation of the basal layer (HE staining,
magnification 400×) (B); perifollicular lymphocyte infiltration (HE staining, magnification 400×) (C); apoptosis and vacuolization (HE staining magni-
fication 400×) (D); hyperkeratosis at the hair follicle ostium (HE staining, magnification 400×) (E)

DISCUSSION

The differential diagnosis of scaring alopecia can be challenging and requires invasive biopsy. Dermoscopy is a non-invasive imaging method that is increasingly used for the evaluation of inflammatory skin conditions (inflammoscopy) and scalp diseases (trichoscopy) [5, 6].

When used to examine the scalp, this method can provide valuable assistance in the clinical differential diagnosis of different types of hair loss, both scarring alopecias (e.g. lichen planopilaris, DLE, frontal fibrosing alopecia), and non-scarring alopecias (e.g. alopecia areata, androgenetic alopecia). DLE affects the hairy scalp in up to 60% of patients [7, 8]. It accounts for about 3040% of all scarring alopecias and about 60% of primary lymphocytic alopecias [2]. Despite such a high prevalence of conditions with permanent hair loss, one of the most common mistakes clinicians still make is taking biopsies from areas with completed scarring, as these areas are the easiest to identify. A scalp biopsy should be taken from an area where the hair follicles are affected by the inflammatory process, but still present [7].

The issue of dermoscopy-guided biopsies in scarring alopecias was initially raised by Miteva and Tosti [9]. The authors analysed 80 patients with cicatricial hair loss treated over 2 years at the Department of Dermatology, University of Miami. Patients with central centrifugal alopecia (CCCA), frontal fibrosing alopecia (FFA), lichen planopilaris (LPP), DLE and folliculitis decalvans (FD) were included in the study. Dermoscopy was used to visualize features indicative of disease activity at the margins of hairless patches. Identification of these features allowed for a definitive diagnosis in 95% of cases. When DLE is suspected, the authors strongly recommend taking a biopsy from a site showing follicular red dots under trichoscopy. On histopathological examination, follicular red dots correspond to dilated follicular ostia obstructed by keratin deposits and surrounded by dilated vessels and extravasated erythrocytes [9]. In DLE, these features are indicative of perifollicular infiltration with/without perifollicular fibrosis.

In recent years, the dermoscopic features of DLE have gained interest and have been reported by many other authors. These include red dots, large yellow dots, reduced numbers of follicles, whitish patchy scales, arborising vessels, follicular plugs and speckled pigmentation [10–13]. A summary of these features, including a division into the active and end-stage phases of DLE, is presented in Table 1.

Table 1. Early and late stages of DLE

Early (active) stages of DLE [15]

Late stages of DLE [15]

Thick arborizing vessels

Thick arborizing vessels

Big yellow dots

Yellow dots with thin spide-like vessels

Gentle scaling

Milky red areas

Scattered brown discoloration

White patches

Follicular red dots

Loss of sebaceous lobules

Reduced numbers of follicles

Absence of follicular orifices

Follicular keratotic plug

Chrysalides and rossetes [16, 17]

Peripilar sign [16] (brown hue around the hair follicle)

Knowing the dermoscopic features of the active phase of the disease, it is possible to select the most diagnostic site for taking a skin specimen. This is particularly important in cases of atypical clinical presentation, in which clinical-histopathological correlation is extremely important.

Recently, there has been growing interest in UV-enhanced dermoscopy. UV light emitted by a Wood’s lamp (340450 nm) may be useful in the differential diagnosis of conditions such as tinea capitis due to Microsporum canis or erythrasma, a bacterial infection caused by Corynebacterium minutissimum [14, 15]. The increasing availability of dermoscopy/trichoscopy combined with UV light with a wavelength of 365 nm potentially opens up new possibilities in the differential diagnosis of skin diseases, and thus a new direction for research. Recently, Pietkiewicz and Navarrete-Dechent described a bright-blue fluorescence of the burrow and a bright-green fluorescence of scabies mites under UV-dermoscopy [18].

In the presented patient, the use of UV-enhanced trichoscopy enabled better visualization of the follicular ostia and confirmed the initial selection of the biopsy site. It should be emphasized that the early phase of DLE, without clearly marked scarring, requires early diagnosis, as prompt implementation of appropriate treatment may prevent progression to the chronic phase and the development of permanent hair loss [19].

CONCLUSION

In scarring alopecias, early diagnosis and management are crucial to prevent permanent hair loss. Dermoscopy (trichoscopy) is a non-invasive imaging method of use for the evaluation of scalp conditions. It is postulated, that in all cases of alopecia, picking the spot for an invasive procedure of biopsy should be guided by dermoscopy (trichoscopy).

Article information and declarations

Acknowledgements

The authors would like to thank the patient for her involvement.

Author contributions

All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrality of the work as a whole, and have given their approval for this version to be published.

Conflict of interest

Kinga Kołcz, Magdalena Żychowska, and Ewa Kaznowska declare that they have no conflict of interest. Adam Reich has worked as a consultant or speaker for AbbVie, Bioderma, Celgene, Chema Elektromet, Eli Lilly, Galderma, Janssen, Leo Pharma, Medac, Menlo Therapeutics, Novartis, Pierre-Fabre, Sandoz, and Trevi, and participated as Principal Investigator or Subinvestigator in clinical trials sponsored by AbbVie, Drug Delivery Solutions Ltd, Galderma, Genentech, Janssen, Kymab Limited, Leo Pharma, Menlo Therapeutics, MetrioPharm, MSD, Novartis, Pfizer, and Trevi. Adam Reich is a member of the journal’s Editorial Board.

Ethics statement

Informed consent was obtained from the patient for participation in the study and publication of the article, including publication of clinical photographs.

Funding

No funding was received for the publication of this article.

Supplementary material

None.

REFERENCES

  1. Zhou W, Wu H, Zhao M, et al. New insights into the progression from cutaneous lupus to systemic lupus erythematosus. Expert Rev Clin Immunol. 2020; 16(8): 829837, doi: 10.1080/1744666X.2020.1805316, indexed in Pubmed: 32746644.
  2. Concha JS, Werth VP. Alopecias in lupus erythematosus. Lupus Sci Med. 2018; 5(1): e000291, doi: 10.1136/lupus-2018-000291, indexed in Pubmed: 30397497.
  3. Fabbri P, Amato L, Chiarini C, et al. Scarring alopecia in discoid lupus erythematosus: a clinical, histopathologic and immunopathologic study. Lupus. 2004; 13(6): 455462, doi: 10.1191/0961203304lu1041oa, indexed in Pubmed: 15303573.
  4. Rongioletti F, Christana K. Cicatricial (scarring) alopecias: an overview of pathogenesis, classification, diagnosis, and treatment. Am J Clin Dermatol. 2012; 13(4): 247260, doi: 10.2165/11596960-000000000-00000, indexed in Pubmed: 22494477.
  5. Behera B, Kumari R, Mohan Thappa D, et al. Dermoscopy in the diagnosis of generalized acute cutaneous lupus erythematosus. Int J Dermatol. 2021; 60(8): e306e308, doi: 10.1111/ijd.15413, indexed in Pubmed: 33410507.
  6. Fathy H, Ghanim BM, Refat S, et al. Dermoscopic criteria of discoid lupus erythematosus: An observational cross-sectional study of 28 patients. Indian J Dermatol Venereol Leprol. 2022; 88(3): 360366, doi: 10.25259/IJDVL_207_19, indexed in Pubmed: 35138063.
  7. Cummins DM, Chaudhry IH, Harries M. Scarring alopecias: pathology and an update on digital developments. Biomedicines. 2021; 9(12): 1755, doi: 10.3390/biomedicines9121755, indexed in Pubmed: 34944572.
  8. Yavuz GO, Yavuz IH, Bayram I, et al. Clinic experience in discoid lupus erythematosus: a retrospective study of 132 cases. Postepy Dermatol Alergol. 2019; 36(6): 739743, doi: 10.5114/ada.2018.77726, indexed in Pubmed: 31998004.
  9. Miteva M, Tosti A. Dermoscopy guided scalp biopsy in cicatricial alopecia. J Eur Acad Dermatol Venereol. 2013; 27(10): 12991303, doi: 10.1111/j.1468-3083.2012.04530.x, indexed in Pubmed: 22449222.
  10. Lallas A, Apalla Z, Lefaki I, et al. Dermoscopy of discoid lupus erythematosus. Br J Dermatol. 2013; 168(2): 284288, doi: 10.1111/bjd.12044, indexed in Pubmed: 22985425.
  11. Żychowska M, Reich A. Chronic cutaneous lupus erythematosus in a white population: dermoscopic characteristics by clinical subtype, lesion location and disease duration. Dermatol Ther (Heidelb). 2022; 12(9): 21172133, doi: 10.1007/s13555-022-00786-y, indexed in Pubmed: 35996053.
  12. Chiramel MJ, Sharma VK, Khandpur S, et al. Relevance of trichoscopy in the differential diagnosis of alopecia: a cross-sectional study from North India. Indian J Dermatol Venereol Leprol. 2016; 82(6): 651658, doi: 10.4103/0378-6323.183636, indexed in Pubmed: 27297280.
  13. Karadag Köse Ö, Güleç AT. Evaluation of a handheld dermatoscope in clinical diagnosis of primary cicatricial alopecias. Dermatol Ther (Heidelb). 2019; 9(3): 525535, doi: 10.1007/s13555-019-0304-3, indexed in Pubmed: 31190216.
  14. Dyer JM, Foy VM. Revealing the unseen: a review of wood’s lamp in dermatology. J Clin Aesthet Dermatol. 2022; 15(6): 2530, indexed in Pubmed: 35783566.
  15. Rudnicka L, Olszewska M. Atlas of Trichoscopy: Dermoscopy in Hair and Scalp Disease. Springer, London 2012: 111117.
  16. Żychowska M, Żychowska M. Dermoscopy of discoid lupus erythematosus a systematic review of the literature. Int J Dermatol. 2021; 60(7): 818828, doi: 10.1111/ijd.15365, indexed in Pubmed: 33319363.
  17. Gómez-Quispe H, Elena de Las Heras-Alonso M, Lobato-Berezo A, et al. Trichoscopic findings of discoid lupus erythematosus alopecia: A cross-sectional study. J Am Acad Dermatol. 2021; 84(3): 804806, doi: 10.1016/j.jaad.2020.05.144, indexed in Pubmed: 32502590.
  18. Pietkiewicz P, Navarrete-Dechent C. Scabies mite is bright green under UV dermatoscopy. Dermatol Pract Concept. 2023 [Epub ahead of print]; 13(2): e2023135, doi: 10.5826/dpc.1302a135, indexed in Pubmed: 36795853.
  19. Fernandez-Flores A, Pérez A, Cabo F. An atypical presentation of alopecia in discoid lupus erythematosus. J Cutan Pathol. 2021; 48(1): 194197, doi: 10.1111/cup.13758, indexed in Pubmed: 32441369.