The virtual dermatopathology mentorship.

The Covid pandemic necessitated changes in traditional mentorship and educational roles. We offer our experience in structuring a virtual dermatopathology mentorship in the midst of the pandemic. Virtual mentorships have many benefits including ease of access, lack of geographic restrictions, and financial savings, though there still remains an important and irreplaceable role for in-person relationships.

The role of the scalp biopsy in the evaluation of alopecia.

A biopsy should be performed whenever the diagnosis is in doubt. A 4-mm punch biopsy sectioned horizontally at multiple levels is best. In general, noncicatricial alopecia should be sampled where hair is sparsest (most involved area), and cicatricial alopecia should be biopsied in an area of active disease, which is best determined using a dermatoscope and is most often at the margin of a lesion. The goal with cicatricial alopecia is to capture both follicular scars as well as actively inflamed hairs. Information provided by the clinician to the pathologist can be decisive in rendering a definitive diagnosis. The wording of the biopsy report provides a clue to the confidence of the pathologist's diagnosis.

The histopathologic diagnosis of traction alopecia: An evidence-based model.

BACKGROUND: Traction alopecia (TA) is common, but histopathologic criteria for TA have not been objectively defined. OBJECTIVE: Determine whether the pauci-follicular unit (PFU) can be used as a diagnostic criterion for TA. Compared to a normal follicular unit (NFU), the PFU is a noninflamed follicular unit with an intact sebaceous gland but fewer than 2 follicles. METHODS: A retrospective review of 25 cases of TA and 25 cases of "normal scalp" was performed. Data included all follicles (by size and phase), sebaceous glands, and total follicular units. RESULTS: Comparing data (traction vs normal), we found a significantly higher number of PFUs in cases of TA (median 6 vs 0, P < .001), which can be used as a helpful and easily recognizable diagnostic tool in diagnosing cases of TA. LIMITATIONS: Comparison to other forms of alopecia was not performed. CONCLUSIONS: The number of PFUs in an alopecia biopsy can be used to establish the diagnosis of TA.

The distinctive histopathology of cicatricial alopecia caused by IgG4-related disease.

IgG4-related disease (IgG4-RD) is characterized by masses at multiple sites, a dense lymphoplasmacytic infiltrate containing numerous IgG4+ plasma cells, storiform fibrosis, and often elevated serum IgG4 concentrations. We present a third case of alopecia (in this instance, cicatricial) caused by IgG4-RD. Based on our findings combined with those seen in two other cases, the histopathologic features of IgG4-RD alopecia include: sparing of the epidermis, cicatricial (scarring) alopecia with a markedly decreased number of hairs, miniaturization of residual hairs, and total loss of the sebaceous glands. Groups of follicles with their associated sebaceous glands (follicular units) are replaced by an extremely dense infiltrate of lymphocytes and especially plasma cells. Histiocytic aggregates, both foamy and non-foamy, may also be present. Variable degrees of fibroplasia may be present but are not an important feature in this type of alopecia.

Safety and Efficacy of Clobetasol Propionate 0.05% Emollient Foam for the Treatment of Central Centrifugal Cicatricial Alopecia.

Background: There is currently an unmet need for the treatment of women with central centrifugal cicatricial alopecia (CCCA). Objective: To evaluate the safety and efficacy of Clobetasol propionate 0.05% emollient foam for the treatment of women with CCCA. Methods: Adult women of African descent that presented with clinical evidence of early CCCA were enrolled (N=30). Clobetasol propionate 0.05% emollient foam was applied daily in an open-label fashion. Safety and efficacy assessments were performed at weeks 2, 6, 12, and 14. Results: Subjects achieved substantial improvements in pruritus, pain, tenderness, erythema and scaling. Scalp biopsies revealed considerable improvements in severe inflammation and perifollicular edema. Overall, clobetasol propionate 0.05% emollient foam was well-tolerated. Limitations: This was a nonrandomized, open-label study. Enrollment was limited to subjects with clinically mild CCCA. Conclusion: Subjects with CCCA that applied topical clobetasol propionate 0.05% emollient foam to their scalp daily demonstrated continuous clinical improvement throughout the 14-week study. ClinicalTrials.gov Identifier: NCT01111981 J Drugs Dermatol. 2020;19(7): doi:10.36849/JDD.2020.5201.

Acquired progressive kinking of the hair in an elderly woman: a case report.

Acquired progressive kinking of the hair (APK) is a rare disorder that presents at any age and is infrequently presented in the literature. This diagnosis has been used to describe similar hair changes, though there are significant differences in presentation, population, and individual clinical features. Histologic analysis of hair shafts aids in diagnosis owing to commonly reported features such as irregular twisting, bending, and grooving of hair shafts with polygonal shapes on cross-section. We present a case with classic histologic features in an unusual patient to highlight this rare condition. Additional cases and studies are necessary to evaluate etiology, differentiate subsets of APK, and develop both treatment and prevention strategies.

Lichenoid folliculitis: A unifying concept.

Skin diseases presenting with keratotic papules, atrophy, cicatricial alopecia and/or "lichenoid" histopathologic changes have been described under at least 30 names. This family of diseases contains 2 subgroups, largely based on clinical features: keratosis pilaris atrophicans (KPA; including keratosis pilaris atrophicans faciei/ulerythema ophryogenes, atrophoderma vermiculatum, and keratosis follicularis spinulosa decalvans); and the lichen planopilaris (LPP) subgroup (including LPP, frontal fibrosing alopecia, Graham-Little-Piccardi-Lassueur Syndrome and fibrosing alopecia in a pattern distribution). An interface dermatitis with lichenoid inflammation is characteristic of the LPP group of disorders, but the literature provides scant information about the histopathology of the KPA group. Our experience has been that the 2 subgroups show a unifying histologic similarity as well as considerable clinical overlap. Because these conditions overlap clinically and histologically, we propose that the term lichenoid folliculitis (LF) be used to refer to this group of diseases, thus simplifying cumbersome nomenclature and highlighting the possibility of shared pathogenesis and treatment options.

Primary cicatricial alopecia: Lymphocytic primary cicatricial alopecias, including chronic cutaneous lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia, and Graham-Little syndrome.

Both primary and secondary forms of cicatricial alopecia have been described. The hair follicles are the specific target of inflammation in primary cicatricial alopecias. Hair follicles are destroyed randomly with surrounding structures in secondary cicatricial alopecia. This 2-part continuing medical education article will review primary cicatricial alopecias according to the working classification suggested by the North American Hair Research Society. In this classification, the different entities are classified into 3 different groups according to their prominent inflammatory infiltrate (ie, lymphocytic, neutrophilic, and mixed). Part I discusses the following lymphocytic primary cicatricial alopecias: chronic cutaneous lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia, and Graham-Little syndrome.

Primary cicatricial alopecia: Other lymphocytic primary cicatricial alopecias and neutrophilic and mixed primary cicatricial alopecias.

Primary cicatricial alopecias can be frustrating for both patients and physicians. Proper diagnosis guides more successful management of these challenging conditions. Part II will cover the remaining lymphocytic primary cicatricial alopecias, which include pseudopelade of Brocq, central centrifugal cicatricial alopecia, alopecia mucinosa, and keratosis follicularis spinulosa decalvans. It will also discuss the neutrophilic and mixed primary cicatricial alopecias, namely folliculitis decalvans, dissecting cellulitis, folliculitis keloidalis, folliculitis (acne) necrotica, and erosive pustular dermatosis.

What's eating you? tick bite alopecia.

Tick bite alopecia is seldom reported in the literature. The condition usually presents as a solitary oval zone of alopecia with a central eschar. Histologic findings are not well described but generally indicate dense perifollicular lymphocytic inflammation. The mechanism for hair loss is poorly understood, but the prognosis for hair regrowth appears to be favorable.

How to teach the potassium hydroxide preparation: a disappearing clinical art form.

Using potassium hydroxide (KOH) preparations in the diagnosis of superficial fungal infections is a technique that has been handed down from teacher to apprentice for more than 100 years. The technique is simple, accurate, and inexpensive; however, there is reason to believe it is falling to the wayside in favor of empiric treatment, especially in primary care settings. To continue the use of this valuable diagnostic aid, a system of teaching the KOH preparation to the next generation of physicians (ie, medical students, residents) is proposed with emphasis on facilitating the process by storing viable skin samples infected with dermatophytes for long periods of time. This technique obviates the need to find suitably infected patients before each teaching laboratory. This technique also is appropriate to refresh the skills of practicing physicians as they prepare for point-of-care testing assessments.