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 Table of Contents  
LETTER TO EDITOR
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 83-85

Scarring alopecia of scalp: It is not always about the hair!


1 Department of Dermatology, Command Hospital (Eastern Command), Kolkata, West Bengal, India
2 Department of Dermatology, Airforce Hospital, Jorhat, Assam, India

Date of Submission14-Mar-2022
Date of Decision20-Jun-2022
Date of Acceptance04-Aug-2022
Date of Web Publication27-Oct-2022

Correspondence Address:
Richa Kumar
Department of Dermatology, Command Hospital, (Eastern Command), Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdpdd.ijdpdd_20_22

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How to cite this article:
Kumar R, Donaparthi N. Scarring alopecia of scalp: It is not always about the hair!. Indian J Dermatopathol Diagn Dermatol 2022;9:83-5

How to cite this URL:
Kumar R, Donaparthi N. Scarring alopecia of scalp: It is not always about the hair!. Indian J Dermatopathol Diagn Dermatol [serial online] 2022 [cited 2022 Dec 9];9:83-5. Available from: https://www.ijdpdd.com/text.asp?2022/9/2/83/359767



Dear Editor,

Sarcoidosis is an idiopathic granulomatous disorder with cutaneous and extracutaneous manifestations. Cutaneous manifestations in sarcoidosis can be specific or non specific to the disorder and are polymorphic in nature. Scalp sarcoidosis is one the rare cutaneous presentations of this disorder and mimics common causes of scarring alopecia of scalp. We present a rare of scalp sarcoidosis manifesting as scarring alopecia.

Our patient, 63 years old female presented with complaints of localized patch of hair loss with redness and flaking over scalp of one year duration. The complaint was gradually progressive with increase in the size of alopecic patch along with appearance of new patches. She also had associated mild pain and occasional pruritus over the site of hair loss. Patient was a known case of type 2 diabetes mellitus, dyslipidemia, hypertension and hypothyroidism on medication. Examination of the scalp revealed a linear well- defined plaque with scarring alopecia with areas of erythema, crusting and erosion over the parietal scalp of size 5 cm × 2cm. Figure 1] and [Figure 2] Systemic examination revealed no abnormalities in any other organ system. A provisional diagnosis of cicatricial alopecia was made and a punch biopsy was done to differentiate between the various clinical differentials in the form of discoid lupus erythematosus, pemphigus foliaceous, Bowen’s disease and linear morphea.
Figure 1: Linear well defined plaque with scarring alopecia with areas of erythema, crusting and erosion over the parietal scalp of size 5x2cm

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Figure 2: Crusted plaque over the alopecic scalp

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Dermoscopy of the scalp lesion revealed scarring alopecia with thick dilated tortuous vessels. Honeycomb pattern of pigmentation with occasional thick black crusts entangling the hair root (star burst pattern) were seen. No follicular plugging was present [Figure 3].
Figure 3: Dermoscopy of the scalp lesion revealed scarring alopecia with thick dilated tortuous vessels. Honeycomb pattern of pigmentation with occasional thick black crusts entangling the hair root (star burst pattern) were seen

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Histopathological examination of the punch biopsy from the lesions showed numerous discrete non caseating epitheloid cell granulomas with numerous interspersed langhan’s and foreign body type of giant cells with lymphocytes. Occasional intracytoplasmic star shaped eosinophilic inclusions, morphologically consistent with asteroid bodies were seen. No follicular structures were evident. [Figure 4], [Figure 5], [Figure 6] On the basis of these histological findings, a provisional diagnosis of sarcoidosis of scalp was made.
Figure 4: Histopathological examination showed numerous discrete non caseating epitheloid cell granulomas with numerous interspersed langhan’s and foreign body type of giant cells with lymphocytes

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Figure 5: Histopathology seen at a higher power, collection of epithelial cells can be seen with sparse lymphocytes(H&E;100X)

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Figure 6: Eosinophilic asteroid bodies can be seen on high power.(H&E;100X)

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ACE and serum calcium levels were in normal range, 36.39 U/l (12–68 U/l) and 9.23 mg/dl (8.6 -10.2 mg/dl). Haemoglobin was 10.7 mg/dl, which showed dimorphic anaemia on peripheral blood smear. No abnormalities were found on the chest roentgenogram.

Patient was diagnosed as a case of scalp sarcoidosis based on clinical, dermoscopic and histopathological findings. She was started on oral steroids along with hydroxychloroquine with good response to therapy.[Figure 7]
Figure 7: Post treatment response picture showing improvement in the alopecia and crusting

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Sarcoidosis is a multi-system idiopathic disorder with cutaneous sarcoidosis occurring in almost 25% cases of systemic sarcoidosis. This clinical condition morphologically exhibits varied presentation, thus imitating many unrelated dermatologic conditions. Hence, it has been described as a great mimicker in dermatology.[1] Scalp sarcoidosis is a rare clinical entity causing cicatricial alopecia, most commonly encountered in African-American women. The disease shows a strong gender bias with female preponderance.[2] Our case also followed this trend. Diagnosis is made primarily by histopathology along with clinical features.[3] Sarcoidal alopecia has classic non caseating sarcoidal granulomas in dermis, also called naked granulomas because of a sparse lymphocytic infiltrate surrounding the granuloma.[4] A number of giant cells of Langhan’s and foreign body type can also be seen. The dermis can show marked fibrosis with destruction of follicular structures. Occasional intracytoplasmic star shaped eosinophilic inclusions, morphologically consistent with asteroid bodies can be seen.[5] Our case demonstrated all the typical histopathological changes of sarcoidosis.

Early diagnosis of sarcoidosis is important as it involves the risk of multisystemic involvement. Approximately 30% of patients with cutaneous sarcoidosis will develop systemic manifestations within months to years of diagnosis.[3]

Therapy of scalp sarcoidosis with alopecia has been quite unsatisfactory. Various reports of therapy of scalp sarcoidosis with corticosteroids (topical and intralesional and systemic), antimalarials, methotrexate and infliximab have shown poor to moderate response.[2] Our case showed good response to treatment with oral and topical corticosteroids along with hydroxychloroquine with cessation of disease progression.

Not much is known about the overall prognosis of scalp sarcoidosis primarily because of the small number of reported cases. It might be possible that many cases of cicatricial alopecia due to sarcoidosis are often misdiagnosed and left untreated in the absence of proper histopathological evaluation.

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Katta R, Nelson B, Chen D, Roenigk H Sarcoidosis of the scalp: A case series and review of the literature. J Am Acad Dermatol 2000;42:690-2.  Back to cited text no. 1
    
2.
House NS, Welsh JP, English JC 3rd. Sarcoidosis-induced alopecia. Dermatol Online J 2012;18:4.  Back to cited text no. 2
    
3.
Bhushan P, Thatte SS, Singh A Key messages from a rare case of annular sarcoidosis of scalp. Indian Dermatol Online J 2016;7:192-4.  Back to cited text no. 3
    
4.
Prohaska J, Demaree E, Powers J, Cook C Scalp sarcoidosis presenting as cicatricial alopecia. J Am Osteopath Assoc2018;118:824-6.  Back to cited text no. 4
    
5.
Ghosh A, Sengupta S, Coondoo A, Gharami RC Single lesion of sarcoidosis presenting as cicatricial alopecia: A rare report from india. Int J Trichology 2014;6:63-6.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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