Dermatology Online Journal

Transversely sectioned biopsies in the diagnosis of end-stage traction alopecia
Jeff C Donovan¹ MD PhD, Paradi Mirmirani² MD
Dermatology Online Journal 19 (4): 11

1. Division of Dermatology, University of Toronto; Hair Club Medical Group; Cleveland Clinic, Canada
2. Kaiser Permanente Medical Group, Vallejo, California; University of California San Francisco, San Francisco, California; Department of Dermatology, Case Western Reserve University, Cleveland, Ohio

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Abstract

The pathogenesis of scarring alopecia in African American women remains poorly understood. Furthermore, the overlapping clinical and histological features present diagnostic challenges. The diagnosis of end stage traction alopecia secondary to traumatic hair styling practices can sometimes present particular challenges. We present a young African American woman with a scarring alopecia. As we describe, a scalp biopsy processed by transverse sections enabled rapid diagnosis and presented advantages over a biopsy processed with vertical sections.

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Figure 1	Figure 2
Figure 1. Traction alopecia affecting the parietal and temporal areas. Involvement corresponded to the area where the patient had used a glued-in hair weave in prior years. Figure 2. Traction alopecia affecting the occipital scalp.

The pathogenesis of scarring alopecia in African American women remains poorly understood. Furthermore, the overlapping clinical and histological features present diagnostic challenges. The diagnosis of end stage traction alopecia secondary to traumatic hair styling practices can sometimes present particular challenges [1]. We recently evaluated a young African American woman with a scarring alopecia. As we describe, the relationship of the scarring alopecia to traumatic hair care practices became particularly evident following a scalp biopsy processed by transverse sections.

A middle-aged African American woman was referred regarding a three-year history of scarring hair loss prominent over the parietal, temporal, and occipital scalp (Figures 1 and 2). There were no pustules or scale. A pull test was negative. Although the patient described use of weaves, braids, and other potentially traumatic hair practices in the past, the differential diagnosis included both central centrifugal cicatricial alopecia and traction alopecia.

Figure 3	Figure 4
Figure 3. Scalp biopsy from occipital scalp. Low power view showing reduced hair follicle and sebaceous gland density, scarred tracts, and concentric perifollicular fibrosis (H&E x20). Figure 4. Scalp biopsy from occipital scalp. High power view showing loss of sebaceous glands, perifollicular fibrosis, and adjacent mild chronic inflammatory infiltrate (H&E x40).

A 4 mm biopsy was obtained from the occipital scalp and evaluated with transverse sections (Figures 3 and 4). This revealed a decrease in follicular density with multiple scarred follicular sites, four terminal hair follicles and nine vellus hair follicles (terminal-to-vellus hair ratio 1:2.25). Sebaceous glands were reduced in number with only a single gland remaining. Concentric fibrosis was observed surrounding the residual terminal follicles with focal chronic inflammation composed of lymphocytes and scattered plasma cells outside of the concentric fibrosis at the level of the infundibulum. A PAS stain for fungal organisms was negative.

Together, the clinical and pathological features favored a diagnosis of end-stage traction alopecia. The persistence of a near normal number of vellus follicles was more typical of TA than a primary lymphocytic cicatricial alopecia. In this regard, further questioning revealed that the patient had, in fact, used a glued-in hair weave for approximately three years prior to the onset of alopecia. The hair weave itself had been attached to the scalp in a horseshoe pattern, which matched the pattern of alopecia. It was removed and re-glued monthly.

Diagnosis of advanced stages of scarring alopecia is challenging and both vertical and horizontal sections are useful in diagnosing scarring alopecias [2]. Differentiating end stage traction alopecia and CCCA may be challenging and some authors view them as the same process [3]. Indeed, the two conditions commonly coexist [4]. In this case example, however, the use of transverse sections allowed immediate quantitative assessment of the number of terminal and vellus hair follicles and promoted the diagnosis of end-stage traction alopecia. Moreover, the additional clinical details obtained from the patient with respect to her use of a glued-in weave helped confirm the favored diagnosis. Although transverse sections show more hair follicles than vertical sections, it remains to be determined if there would be any difference in the utility of these two methods in certain types of scarring alopecias. Whiting investigated the utility of horizontal sections in the diagnosis of androgenic alopecia and showed that horizontal sections of scalp biopsy specimens provide more diagnostic information than vertical sections [5]. Further studies are needed to evaluate the role of horizontal and vertical sections in the diagnosis of various types of scarring alopecias in African American women. This will enable a more accurate assessment of the histopathologic changes that occur during both early early and late stages of these conditions.

References

1. Borovicka J.H., Thomas L, Prince C, Mehregan, D.R. Scarring alopecia: clinical and pathologic study of 54 African American women. Int J Dermatol 2009; 48: 840-845. [PubMed]

2. Garcia C and Poletti E. Scalp biopsy specimens: transverse vs vertical sections. Arch Dermatol 2007; 143: 268. [PubMed]

3. Ackerman AB, Walton NW III, Jones RE, et al. Hot comb alopecia/follicular degeneration syndrome in African American women is traction alopecia. Dermatopathol Pract Concept. 2000;6:320-36.

4. Samrao A, Price VH, Zedek D and Mirmirani P. The “Fringe Sign” - A useful clinical finding in traction alopecia of the marginal hair line. Dermatol Online J 2011; 17:1. [PubMed]

5. Whiting D.A. Diagnostic and predictive value of horizontal sections of scalp biopsy specimens in male pattern androgenetic alopecia. J Am Acad Dermatol 1993; 28: 755-6. [PubMed]

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