Psoriatic scarring alopecia
A 42-year-old Caucasian woman with a 22-year history of severe scalp psoriasis presented\nto our outpatient clinic complaining of itchy scalp and diffuse hair loss for the last\nfive years. Increased hair shedding was associated with episodes of greater inflammation\nand pruritus. Nail and articular psoriasis were absent. Psoriatic lesions had always\nbeen confined to her scalp. Topical clobetasol, oral cyclosporine, methotrexate, UVB-NB\nphototherapy and antibiotics had been used as treatment with only temporary relief.\nOn physical examination, diffuse erythema, infiltration, scales and crusts were present\nall over the scalp. Decreased hair density in the fronto-parietal area was observed. The\nright parietal side was the most severely affected, so both dermoscopy and skin biopsies\nwere performed in this area ( and ). Fungal assessment, from both scalp scales and\nhair shafts, were negative.\nDermoscopy showed interfollicular twisted red loops characteristic of scalp psoriasis\nand lack of follicular openings (). No\npustules or tufted hairs were observed.\nHorizontal sectioning of the biopsy specimen showed follicular drop-out with only one\nfollicle at the subcutaneous level and 3 vellus follicles at the dermis level ( and ). Sebaceous glands were not visualized at all, but isolated pili erector\nmuscles were present and fibrosis could also be observed (). No signs of androgenic alopecia were detected.\nVertical analysis showed epidermal changes compatible with psoriasis and a moderate\nchronic inflammatory infiltrate around vessels and eccrine glands, associated with\nfibrous tracts (). No interface changes\nwere observed at the dermal-epidermal level or affecting the follicular epithelium.\nDirect immunofluorescence was negative for IgG, IgM, IgA and complement.\nFindings were consistent with scarring alopecia associated with psoriasiform epidermal\nchanges.