December 2017 | Case of the Month

The differential diagnosis is that of a scarring cicatricial alopecia, a generic term used to describe circular / oval shaped patches of scarring alopecia. The following conditions (and associated clinical features) can all cause a cicatricial alopecia:

Lichen planus

• Follicular erythema and keratotic plugs, which are commonly located at the periphery of expanding areas of alopecia

Discoid lupus erythematosus

• Much more common in women
• Scarring alopecia occurs in 20% of men and 50% of women with DLE
• Although DLE often presents on the face, the scalp can be the only affected site
• The scalp is often itchy
• Affected patches are erythematous and scaly with follicular plugging

Folliculitis decalvans 

• Patients usually present with one or more round patches of scarring alopecia usually surrounded by pustules, crusting and sometimes erosions
   

Our patient did not have features of any of the above, and instead the diagnosis was in keeping with central centrifugal cicatricial alopecia, which is associated with the following features:

• It is condition that predominantly affects women of African ethnicity - our case was male
• It usually presents in the fourth decade with a female to male ratio of approximately 3:1
• Clinically there is a diffuse scarring alopecia that begins at the crown and spreads forwards. The alopecia is incomplete with a number of hairs remaining within the area of scarring. There tends to be little or no erythema
• Mycology to rule out tinea capitis is recommended
• No ideal treatment currently exists. Minimal hair grooming is recommended, but many patients find this difficult. If there are signs of inflammation the use of a potent topical or intralesional corticosteroid may arrest/slow progression. Occasionally pustules are seen in which case a systemic tetracycline such as doxycycline or lymecycline may be of value

For more information please refer to the chapter on alopecia.