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.

Survey of medical student preference for simulation models for basic dermatologic surgery skills: simulation platforms in medical education.

BACKGROUND: The authors investigated the use of simulator platforms in fourth-year medical student education. OBJECTIVE: To evaluate which simulation platform students preferred for learning dermatologic procedures and to assess the effectiveness of the exercise in terms of the change in confidence that the students had performing dermatologic procedures. MATERIALS AND METHODS: After medical students were instructed on how to perform a punch biopsy and then assisted in executing the task, they were surveyed to determine their preferred simulation platform and simulator properties. Students were surveyed at the beginning and completion of the teaching block. RESULTS: One hundred fifty-seven students completed the skills laboratory, and 78 completed the preference questionnaire. Of the 11 surveyed categories, students preferred the pig foot in eight categories. Seventy students responded to a surgical skills questionnaire that assessed their overall confidence in planning and executing the procedure before and after the skills laboratory. The students had a statistically significant increase in confidence in dermatologic procedural skills as a result of the activity. CONCLUSION: Preference data show that the pig foot model is preferred for teaching dermatologic surgical skills. These results re-affirm that the pig foot model is an effective, low-cost solution for training.

Distinctive histopathologic findings in linear morphea (en coup de sabre) alopecia.

Linear morphea en coup de sabre is a localized form of morphea that presents as paramedian face or frontal scalp depression. The histopathology of alopecia in linear morphea is typically characterized by sclerosis and a reduction in the number of follicular units. We present a 26-year-old Caucasian female with a 1.5-year history of linear morphea and alopecia with unique atrophic follicular remnants on scalp biopsy. Transverse and vertical sections of biopsy specimens showed dense, dermal sclerosis with marked eccrine gland atrophy and replacement of much of the adipose by collagenous tissue. All sebaceous glands had disappeared, but erector pili muscles persisted. Numerous vertical, columnar and epithelial structures were present at the sites of formerly viable hair follicles. Transverse sections of these atrophic follicular remnants had a resemblance to telogen follicles but were microscopically different. The morphology of these follicular remnants indicates an end-stage process or permanent alopecia. Similar follicular remnants have been reported in chemotherapy-induced permanent alopecia but not in alopecia secondary to morphea or other cicatricial alopecias. We discuss the significance of these findings and their relationship to other forms of cicatricial or permanent alopecia based on the literature and case review.

Pili annulati associated with hair fragility: cause or coincidence?

Pili annulati is a disorder that produces a spangled appearance to the hair, caused by alternating light and dark banding of hair shafts. This phenomenon is created by abnormal cavities in the cortex of the hair shaft, which produces lighter bands seen on clinical examination. Complications of pili annulati are limited; the most noteworthy complication is increased breakage secondary to weathering of the abnormal hair shafts. We report a case of a 14-year-old adolescent girl with pili annulati and progressive hair loss of 2 months' duration. Most of her hairs were notably short, spangled, and lusterless with light and dark banding observed with handheld magnification. Light microscopy demonstrated alternating light and dark bands, and the dark bands had the typical appearance of air-filled spaces. Gentler hair grooming practices were recommended, and at a follow-up visit, the appearance of the hair had improved with darker and longer shafts. This case should alert clinicians to look for pili annulati when hair fragility is present.

Cytokeratin 15 expression in central, centrifugal, cicatricial alopecia: new observations in normal and diseased hair follicles.

BACKGROUND: Cytokeratin 15 (CK15) is a useful marker for the bulge zone (BZ) and has been used to examine follicles in cicatricial alopecia. We studied the expression of CK15 in hair follicles of patients with central, centrifugal, cicatricial alopecia (CCCA) in an attempt to define BZ integrity. METHODS: A commercially available antibody to CK15 was used on formalin-fixed, paraffin-embedded tissue from clinically and histologically 'normal' scalps, clinically diseased scalps from patients with CCCA and clinically 'normal' scalps from patients with CCCA. RESULTS: In both normal and diseased follicles, CK15 expression was closely linked to anatomical zone cellular morphology. Normal and abnormal inner root sheath (IRS) desquamation occurred in concert with predictable cellular morphological changes and CK15 expression. In most abnormal follicles, once the IRS desquamated, the morphology of BZ epithelium changed and CK15 expression disappeared. CONCLUSIONS: CK15 highlights BZ cells in normal human follicles, but may be unreliable for this purpose in diseased follicles. CK15 should not be the sole marker for studying stem cells in cicatricial alopecia because any disease-induced structural changes could alter CK15 expression. More sophisticated studies of stem cells will be required to reliably define their role in the pathogenesis of cicatricial alopecia.

Psoriatic alopecia/alopecia areata-like reactions secondary to anti-tumor necrosis factor-α therapy: a novel cause of noncicatricial alopecia.

With the increasing use of anti-tumor necrosis factor α (anti-TNF) biologic drugs to treat autoimmune diseases, an expanding array of adverse reactions is emerging. Anti-TNF drug-induced alopecia is a less well-known side effect of this class of drugs. The aim of this study was to define the clinical and histopathological features of alopecia arising in the setting of anti-TNF therapy. Clinical and histopathological features of 3 patients who developed scalp alopecia during anti-TNF treatment were examined. Two of the 3 patients also developed psoriasiform lesions outside the scalp, and biopsies from both scalp and nonscalp sites were reviewed. Clinically, each patient had large scaly patches associated with the scalp alopecia. All scalp biopsies revealed psoriasiform epidermal features and alopecia areata-like dermal changes. Epidermal changes included acanthosis and confluent parakeratosis with neutrophils and frank pustules. Dermal changes included markedly increased catagen/telogen and miniaturized hairs and peribulbar lymphocytic inflammation. Numerous plasma cells and eosinophils were present in all cases. Biopsies from the nonscalp lesions showed psoriasiform changes and prominent eosinophils and plasma cells. Two patients showed significant improvement of the alopecia with topical treatment only. In conclusion, anti-TNF therapy-related alopecia may closely mimic psoriatic alopecia and alopecia areata but can be histologically distinguished from alopecia areata by epidermal psoriasiform changes and dermal plasma cells and from primary psoriasis by the presence of plasma cells and eosinophils. A correct diagnosis can enable effective treatment and, in some cases, allow anti-TNF therapy to continue.