Scalp Biopsy Research Articles

Diffuse Alopecia: Clinical, Trichoscopic, Histopathological and Immunohistochemical Challenges in the Diagnosis

Abstract Background Diffuse alopecia is characterized by a general loss of hair with no patches of full baldness. In dermatology, diffuse hair loss, particularly in women, is a common complaint. Common illnesses such as telogen effluvium, androgenetic alopecia, and widespread alopecia areata can be difficult to distinguish. The clinical signs of these three types of alopecia may be identical. Aim of Work The current study aimed to study the clinical, trichoscopic findings, histopathological in patients with acute diffuse hair shedding: female pattern hair loss (FPHL), acute telogen effluvium (TE) and alopecia areata incognita (AAI). Immunohistochemistry analysis for CD3 was done for differentiation and detection of the prognostic values of these markers. Subjects and methods: The study included 40 patients with acute diffuse hair shedding within the last 6 months with the diagnoses of AAI, TE, FPHL. All patients were subjected to full history recording, general and local examination. Hair evaluation was performed through trichoscopic assessment and punch scalp biopsy that was analyzed by hematoxylin and eosin and immunohistochemical analysis for CD3. Results Trichoscopic assessment of studied patients revealed that hair diameter diversity was significantly presented in FPHL patients. Number of thin hairs in frontal area, number of hair units with one hair, and vellus hairs were significantly presented in FPHL and TE+ FPHL patients compared to TE patients. Short regrowing hair was significantly presented in TE patients and TE +FPHL patients compared to FPHL patients. Peripilar sign and empty hair follicles in frontal area were significantly presented in FPHL patients. Multiple upright regrowing hair in all areas was significantly presented in TE+ FPHL patients. Conclusion FPH and TE represents common types of hair loss disease, each with specific trichoscopic and histochemical findings.

Central centrifugal cicatricial alopecia in males

Central centrifugal cicatricial alopecia (CCCA) is a scarring alopecia seen primarily in women of African descent but rarely reported in men. The etiology of CCCA is unknown, but genetic variants, type 2 diabetes mellitus, and bacterial infections may play a role. We aimed to characterize the demographics, medical histories, and clinical findings of male patients with CCCA with the hypothesis that features may differ from women. This was a case series of adult male patients with biopsy-confirmed CCCA seen at an academic dermatology department between 2012 and 2022. In total, 17 males had a scalp biopsy and clinical findings consistent with CCCA. The average age was 43years, and 88.2% of cases identified as Black race. Scalp pruritus was the most common symptom, and few patients endorsed high-risk hair care practices. None of the cases had diagnosis of type 2 diabetes mellitus, but 17.6% had history of latent tuberculosis, and 47.1% had a positive family history of alopecia. We observed 8 patients with atypical CCCA, and 29.4% had an overlapping scalp diagnosis. This study is limited by the single center, retrospective design and small sample size. It is important to consider CCCA in the differential diagnosis of alopecia in adult Black males.

Imaging Tools for Noninvasive Hair Assessment.

Trichology tools historically have been limited in their ability to provide noninvasive detailed assessments of the hair and scalp. Recent advances in diagnostic and treatment monitoring technologies have begun to fill this gap. Global photography previously relied on a film camera and stereotactic imaging equipment but has been simplified by the advent of cameras that use software analysis and provide adjustable outlines to match facial features for the capture of standardized views. Reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) both enable in vivo visualization of subcutaneous structures and provide new insight into the dynamic subclinical changes of alopecia. Recent efforts focus on training convolutional neural networks to quantify various hair parameters on OCT scans. When scalp biopsy is necessary, trichoscopy, RCM, and OCT can guide in selecting biopsy sites. Because of the growing clinical applications of these technologies, clinicians should be aware of the advantages and limitations of noninvasive hair-imaging tools.

BH03 Lipoedematous scalp occurring in two female siblings: further evidence of a genetic role?

Abstract Lipoedematous scalp (LS) is a rare disorder characterized by thickening of the adipose subcutaneous scalp layer. We describe an unusual case of two female siblings presenting with the same condition. A 58-year-old black Caribbean woman presented with a 7-year history of an itchy, painful and scaly scalp, without any associated hair loss. Mycology had been negative. There was a history of paranoid schizophrenia and bipolar disorder, for which she was taking olanzapine. Body mass index (BMI) was 39 mg kg–2. Examination revealed a thickened scalp with a spongy consistency, with no associated surface change or hair loss. Scalp ultrasound was performed, demonstrating a scalp thickness of 12 mm at the vertex (normal range 5–6 mm). Scalp biopsy revealed prominent fat in the dermis around the hair follicles, with follicular distortion and some focal perifollicular fibrosis. Based on these findings, a clinicopathological diagnosis of LS was made. The patient’s 63-year-old sister presented with similar scalp symptoms. She had a background of diabetes mellitus type 2, migraine and hypomania and was taking metformin, gliclazide, atorvastatin, sodium valproate and mirabegron; her BMI was 26 mg kg–2. Scalp ultrasound revealed diffuse thickening of the subcutaneous fat measuring 9 mm at the vertex, which was also consistent with a diagnosis of LS. The pathogenesis of LS is poorly understood. It is more common in females, and there appears to be an association between LS and obesity (Yasar S, Gunes P, Serdar ZA, Tosun I. Clinical and pathological features of 31 cases of lipedematous scalp and lipedematous alopecia. Eur J Dermatol 2011; 21:520–8). Studies have implicated leptin, a hormone that regulates distribution of adipose tissue. There is limited evidence for a genetic role in LS. We identified three female cases of LS in the literature with a positive family history in their daughters (Yasar et al.) but no cases of siblings with LS. We identified one reported case of the related disorder, lipoedematous alopecia, occurring in a pair of female siblings (Koç Yıldırım S, İğde B. Lipedematous alopecia: report of two female siblings. J Cosmet Dermatol 2022; 21:1324–5). Our case highlights a possible genetic role in the pathogenesis of LS, and further studies are needed to investigate this link further.

Hair Evaluation Methods

The three main Hair assessment methods in alopecia are Non-invasive (questionnaire, daily hair counts, standardized wash test, 60-s hair count, global pictures, dermoscopy, hair weight, contrasting felt examination, phototrichogram, TrichoScan), semi-invasive (trichogram and unit area trichogram), and intrusive procedures (e.g., scalp biopsy). No method is ideal or realistic. These are useful for patient diagnosis and monitoring when interpreted carefully. Daily hair counts, wash tests, etc. are good ways to evaluate a patient's shedding. Hair clinics use procedures like global photography. Phototrichogram is exclusively used in clinical trials. These procedures (like scalp biopsy) require processing and interpretation expertise. In this review article, we discuss the various hair evaluation methods.

Circulating and/or cutaneous irisin resistance: A novel link among androgenetic alopecia, comorbid metabolic syndrome and cardiovascular risks.

Androgenetic alopecia (AGA) is a common cause of hair loss in both genders that may be associated with disturbed systemic metabolism. Irisin is a hormone-like myokine that greatly influences systemic metabolism and is linked to cardiovascular diseases. To detect irisin role in AGA and its associated metabolic syndrome (MetS) and cardiovascular risk. This case-control study included 44 AGA patients of both genders and 22 healthy individuals. Serum irisin level was measured using ELISA and scalp biopsy was taken to detect irisin immunohistochemically. Carotid Doppler ultrasonography was performed to measure carotid intima media thickness (CIMT). Higher serum irisin was significantly detected in AGA patients (p ˂ 0.001), and in males (p = 0.01) particularly severe cases (p ˂ 0.001). It was significantly higher in AGA patients presenting with MetS and those suffering from dyslipidemia (p ˂ 0.001 for both). Multivariate regression analysis proved BMI (p = 0.01) and serum irisin (p = 0.02) as independent predictors of CIMT abnormality among AGA patients. Regarding cutaneous irisin expression, the epidermal H-score was significantly higher in AGA patients with MetS compared to those without (p = 0.04). Epidermal H-score ˃100 was significantly associated with male gender (p = 0.05), severe AGA (p = 0.02), MetS (p = 0.03), dyslipidemia (p = 0.03), and abnormal CIMT (p = 0.03). High serum irisin and upregulated epidermal irisin expression are associated with the incidence of MetS, dyslipidemia, and CIMT abnormality among AGA patients. This may indicate resistance to irisin, which hinders its favorable cardiometabolic actions. Further studies are warranted to investigate the concept of irisin resistance in AGA patients, which was uniquely discussed in the present study.

Alopecia in Patients with Collagen VI-Related Myopathies: A Novel/Unrecognized Scalp Phenotype.

Collagen VI-related myopathies are characterized by severe muscle involvement and skin involvement (keratosis pilaris and impaired healing with the development of abnormal scars, especially keloids). Scalp involvement and hair loss have not been reported among cutaneous changes associated with collagen VI mutations. The aim of this study is to describe the clinical, trichoscopic, and histological findings of the scalp changes in patients affected by COL VI mutations and to estimate their prevalence. Patients with Ullrich congenital muscular dystrophy were enrolled and underwent clinical and trichoscopic examinations and a scalp biopsy for histopathology. Five patients were enrolled, and all complained of hair loss and scalp itching. One patient showed yellow interfollicular scales with erythema and dilated, branched vessels, and the histological findings were suggestive of scalp psoriasis. Two patients presented with scarring alopecia patches on the vertex area, and they were histologically diagnosed with folliculitis decalvans. The last two patients presented with scaling and hair thinning, but they were both diagnosed with folliculitis and perifolliculitis. Ten more patients answered to a "scalp involvement questionnaire", and six of them confirmed to have or have had scalp disorders and/or itching. Scalp involvement can be associated with COL VI mutations and should be investigated.

The role of hair follicle counts and ratios in the histopathological assessment of androgenic alopecia, alopecia areata and telogen effluvium: does counting ‘count’?

The histopathological assessment of scalp biopsies for the diagnosis of alopecia is most commonly undertaken in specialist centers. Occasionally, pathologists encounter such specimens outside a specialist setting or at a low frequency, which makes a confident diagnosis difficult. A methodical approach is essential to identify and interpret the histopathological findings, and one of the diagnostic tools is the use of follicular counts and ratios. This method is particularly emphasized in the context of non-scarring alopecia and, furthermore, for the identification of alopecias with overlapping features. We raised the question as to what is the role of follicular hair counts and ratios in the differential diagnosis of non-scarring alopecia with overlapping features, and sought the answer in our literature review. The English literature on the histopathological assessment of horizontal scalp biopsies taken for the evaluation of non-scarring alopecia, focusing on hair folliclecounting as a diagnostic tool, with particular emphasis on androgenetic alopecia, alopecia areata, and telogen effluvium, was reviewed. Follicular counts and ratios are a helpful diagnostic tool. However, these need to be coupled with the morphological features specific for each alopecia subtype to render a confident diagnosis.

Neuroimmune Mediators of Pruritus in Hispanic Scalp Psoriatic Itch.

Scalp psoriatic itch is a common, bothersome, yet understudied, condition with numerous associated treatment challenges. The aim of this study was to enhance our understanding of the pathophysiology of scalp psoriatic itch. Immunohistochemical analysis of known neuroimmune mediators of pruritus was conducted using scalp biopsies from 27 Hispanic psoriatic patients. Patients were categorized into mild/moderate or severe itch groups according to their itch intensity rating of scalp itch. Protease activated receptor (PAR2), substance P, transient receptor potential (TRP)V3, TRPM8 and interleukin-23 expression all correlated significantly with itch intensity. The pathophysiology of scalp psoriasis is largely non-histaminergic, mediated by PAR2, interleukin-23, transient receptor potential channels, and substance P.

Comparative histopathological analyses of non-scarring alopecia in systemic lupus erythematosus patients in Lagos Nigeria.

Systemic lupus erythematosus (SLE) is known to cause non-scarring alopecia. However, histopathological evaluation is uncommon. The objective of this study was to document the histopathology of non-scarring alopecia and to compare histopathology of alopecic and normal appearing scalp areas in SLE hair loss patients. A cross-sectional comparative evaluation of scalp biopsies from 23 SLE patients; 12 with hair loss and 11 without was conducted over a 7-month period in 2020. A total of 58 scalp biopsies stained with H and E (23 vertical and 35 cross-sectional) were evaluated. Mucin deposit evaluation was done using Alcian blue (pH 2.5). There were no significant differences in the sociodemographic data between the patients. The SLE hair loss patients demonstrated mucin deposition (91.7%), reduced size/number of sebaceous glands (58.3%), epidermal atrophy (50.0%), naked arrector pili muscles (50.0%), lymphocytic infiltration (33.3%), pigment incontinence (16.7%), fibrous stellae (16.7%), increased telogen percentage, and increased terminal versus vellus hair ratios. On comparing the histopathology of those who had hair loss to those without hair loss, the only significant difference was in the number and size of sebaceous gland. There were no significant differences between scalp areas with and without hair loss in the SLE hair loss patients. There are differences in size and number of sebaceous glands on histopathology between SLE patients who have hair loss and those who do not. Also, there are no histopathological differences between alopecic and non-alopecic scalp areas of SLE patient.

Histopathological Diagnosis of Alopecia Clinically Relevant to Alopecia Areata

Objective: To study the histopathological diagnosis of alopecia clinically relevant to AA and to compare the histopathology between acute and chronic AA divided by time to onset at three and six months. Materials & Methods: We conducted a cross-sectional study of 113 patients with typical manifestation of AA. Two scalp biopsies were done horizontally and vertically to confirm diagnosis. Histological findings of AA in the acute group were subsequently compared with the chronic group. Results: Of the 113 eligible patients, 109 (96.5%) were pathologically diagnosed with AA. Other diagnoses included lichen planopilaris, lupus panniculitis, and unspecified scarring alopecia. The percentage of terminal telogen hairs in the acute group was significantly higher than the chronic group (mean % anagen: % telogen ratio = 21.2%:78.8% vs. 36.0%:64.0%; p = 0.016), while the chronic group had a significantly higher number of follicular streamers (mean ± SD; 2.5 ± 2.2 vs. 3.7 ± 2.6; p = 0.023). The number of vellus hairs significantly increased in the acute group at the six-month onset (p = 0.006). The number of nanogen hairs also increased significantly in the chronic group at both the three- and six-month onset (p = 0.020 and p = 0.007). Conclusion: Typical manifestations of AA are not always diagnosed as AA. Acute AA has more terminal telogens and vellus hairs, while chronic AA has more follicular streamers and nanogen hairs.

Evaluation of Hair Follicle Counts of Occipital Scalp Biopsies from Male Hair Transplant Patients in Thailand

Objective: To evaluate the average hair follicle count from the occipital scalp of Thai males with AGA who were candidates for hair transplantation. Materials & Methods: A cross-sectional study of 47 male with AGA undergoing hair transplantation surgery was conducted. The 4-mm punch biopsies from the occipital scalp were evaluated for hair count parameters. The results were compared to prior studies. Results: The average counts of total hair follicles and the density of hair follicle per square millimeter were 18.6±1.2, and 1.5±0.1, respectively. The terminal-to-vellus ratio was 11.1, and the percent ratio of anagen-to-telogen ratio was 91.9:8.1. The hair count number is significantly lower than other ethnicities including Thais in general population (P < 0.001), but greater than the Thai males with AGA in the previous study. (P < 0.001). Conclusion: Our study showed a lower average hair density as compared to the other normal Asian population. The total hair count in the occipital area from this study is less when compared to the previous studies conducted in Thai normal controls but higher than those with more advanced AGA. This result supported the evidence of hormonal effect involving the occipital scalp of male AGA.

Scalp biopsy influences diagnostic accuracy and treatment in Black women with alopecia: A retrospective study

Scalp biopsy influences diagnostic accuracy and treatment in Black women with alopecia: A retrospective study

A comparative study of histopathologic features in alopecia areata and pattern hair loss.

When peribulbar infiltrates are absent, other histopathologic findings are necessary to distinguish alopecia areata (AA) from pattern hair loss (PHL). The purpose of this study is to determine which histopathologic features are most useful for differentiation. A retrospective slide review was conducted of AA and PHL scalp biopsy specimens from 2014 to 2019 at a tertiary referral center. Ninety-six cases were retrieved, of which 38 were AA. Peribulbar infiltrates were identified in 24 AA (63.2%) cases. A catagen/telogen shift was observed more frequently in AA than PHL (25 cases, 65.5% vs. 10 cases, 17.2%; p ≤ 0.0001). Lymphocytes (4 cases, 10.5% vs. 1 case, 1.7%; p=0.058) and melanin (25 cases, 65.8% vs. 5 cases, 8.6%; p ≤ 0.0001) in fibrous tracts were more common in AA. Apoptotic bodies within vellus hairs were more frequently identified in AA (32 cases, 84.2% vs. 37 cases, 63.8%; p=0.030). Small dystrophic follicles were also more common in AA (16 cases, 42.1% vs. 1 case, 1.7%; p < 0.0001). Common features of AA other than peribulbar infiltrates include a catagen/telogen shift, melanin in fibrous tracts, and small dystrophic follicles. Practitioners should consider these features when distinguishing AA from PHL in specimens without peribulbar infiltrates. The retrospective design limits our ability to exclude multifactorial alopecia, such as telogen effluvium.

A case of premature aging with recurrent pancreatitis and lipodystrophy

Werner’s syndrome (WS) is characterized by insulin resistance along with signs of premature aging. It poses great diagnostic challenge because of its unusual presentation. We describe a case of WS in a 30-year-old female, who presented with recurrent pancreatitis and documented hypertriglyceridemia along with hyperglycemia despite getting more than 200 units of insulin per day, without any history of hyperglycemic emergency such as diabetic ketoacidosis (DKA)/ hyperglycemic hyperosmolar state (HHS). Examination showed signs of premature aging (alopecia, progressive sharpening of facial features, loss of upper incisor teeth, wrinkles and freckles) and generalized wasting. Scalp biopsy confirmed the diagnosis.&#x0D; BIRDEM Med J 2023; 13(1): 56-59

Cerebrolysin induces hair repigmentation associated to MART-1/Melan-A reactivation

Hair graying, a prototypical sign of human aging, is a progressive loss of pigmentation from growing hair shafts caused by disease and as a side effect of medications. Cerebrolysin is a neuropeptide preparation that mimics the effect of endogenous neurotrophic factors. Cerebrolysin has been widely used in neurologic conditions, such as cerebral stroke, Alzheimer’s disease, and dementia, among others. Cerebrolysin treatment has achieved to regain or maintain the cognitive ability of affected patients; however, up to date, there are no reports about the reactivation of hair pigmentation. We describe a previously not described effect occurring on patients receiving Cerebrolysin treatment for neurologic diseases and whether this effect is associated in reactivation of melanocytes and melanin expression. Here, we report five patients (mean age, 70.6 years), who also had age-related hair graying and scalp hair repigmentation during Cerebrolysin treatment. Macroscopic analysis revealed hair repigmentation consisted in diffuse darkening of the scalp hair. Impregnation and immunostaining analysis were performed on scalp biopsies taken before and after Cerebrolysin treatment; the results showed greater melanin and melanocyte marker MART-1/Melan-A staining following Cerebrolysin treatment. We present, to our knowledge, the first report on hair repigmentation is a previously not described effect occurring following Cerebrolysin treatment.

584 Dandruff is associated with perturbations of hair follicle immune privilege, and the infundibular and epidermal immune microenvironment

Dandruff is a common scalp condition. The immune-microenvironment of dandruff scalp skin remains poorly characterised and the hair follicle’s physiological immune privilege (HF IP) status in dandruff is completely unknown. We hypothesised that the latter might be important in the context of dandruff-associated inflammation as the HF IP status is expected to impact on overall scalp skin immunophysiology. We analysed the expression of HF IP biomarkers (CD200, MHC class I, β2M, MHC class II) and HF IP guardians (α-MSH and MIF), and quantified intra- and perifollicular immune cells (CD4, CD8 and CD68) in healthy versus dandruff scalp (non-lesional and lesional) biopsies by quantitative immunohistomorphometry(n= 5-8).

Investigation of hub genes and immune infiltration in androgenetic alopecia using bioinformatics analysis

Androgenetic alopecia (AGA) is a type of non-scarring hair loss. Current drugs for AGA are accompanied by adverse reactions and a high recurrence rate. Thus, the discovery of diagnostic biomarkers and therapeutic targets for AGA remains imperatively warranted. The GSE90594 dataset, which contained scalp skin biopsies from 14 male AGA cases and healthy volunteers, was used to identify the differentially expressed genes (DEGs). Functional enrichment analysis was subsequently performed. Next, the Search Tool for the Retrieval of Interacting Genes/Proteins (STRING) database combined with the cytoHubba plugin of Cytoscape were used to obtain the key genes of AGA. Thereafter, the Cell-type Identification by Estimating Relative Subsets of RNA Transcripts (CIBERSORT) algorithm was performed to evaluate the relative abundance of immune cells between male AGA patients and healthy controls. The correlation between key genes and infiltrating immune cells was analyzed to obtain the significant immune-cell related genes (IRGs), then intersected with the DEGs between immortalized balding and non-balding human dermal papilla cells (DPCs) of the GSE93766 dataset as well as the DEGs obtained by the GSE90594 dataset, thus obtaining the hub genes of AGA. Finally, the hub genes were validated using GSE36169, which contained expression profiling of tissues biopsied from haired and bald scalps of five individuals with AGA. A total of 234 DEGs were obtained from the GSE90594 dataset, which were mainly enriched in the extracellular matrix (ECM)-related pathways and immune-related activities. The STRING database and ten algorithms in the cytoHubba plugin of Cytoscape disclosed 21 key DEGs. The results of the CIBERSORT algorithm revealed the relative abundances of 20 kinds of immune cells between diseased and healthy individuals, and yielded 15 IRGs involved in the pathogenesis of AGA. Next, the intersection analysis identified four hub genes of AGA, comprising COL1A2, PCOLCE, ITGAX, and LOX. The GSE36169 dataset validated the expression pattern of hub genes in the haired scalp of AGA patients. We discovered that the hub genes identified are closely linked with the causative factors of AGA, which could be used as the viable diagnostic and therapeutic target in the clinical applications.

Efficacy and Safety of Scalp Microneedling in Male Pattern Hair Loss

Introduction: There are few reports involving scalp microneedling in MPHL patients, and in most of them, physical stimulus is associated with other therapeutic agents. The aim of this study was to evaluate the efficacy and risks of isolated scalp microneedling in MPHL patients. Methods: Thirty patients were included in this randomized single-blinded study and submitted to 4 monthly scalp microneedling sessions. Two different microneedling devices were used: roller (n = 15) and tattoo cartridge (n = 15). Scalp coverage and hair density changes were measured 4 and 16 weeks after the last session. Adverse events were observed throughout the study, and scalp biopsies were performed before and after to investigate scarring changes. Results: Four of 12 participants in the roller group and 2 of 14 participants in the tattoo cartridge group showed an improvement in clinical pictures at the first follow-up visit. Only half of these patients sustained an improvement until the last follow-up visit. No benefit in hair density was observed in either group. No reports of adverse events were made. Neocollagenesis and elastolysis were noted in scalp biopsies. Discussion/Conclusion: Isolated scalp microneedling did not show improvement in scalp coverage or hair density of MPHL participants in this study.

Histopathological study of scalp tumors and tumor like lesions

Introduction: A variety of inflammatory and neoplastic scalp lesions is encountered in clinical practice, which can be attributed to trauma, infection, abscess, allergic reaction, or tumor. Though a majority of scalp involvement is by benign processes, still it can be a site of malignant neoplasm.Aims and objectives 1.To study the morphological, histopathological types and clinico-pathological correlation of various scalp tumors.2.To know the proportion of benign and malignant lesions in the scalp lesions.3.To compare the data and other investigations with similar studies from other regions.Materials and methods: The present retrospective study is conducted in the department of pathology, B.J. Medical college and civil hospital, Ahmedabad over a duration of 5 years. A total of 105 cases of scalp lesions were evaluated. Scalp biopsies with clinical suspicion of a tumor which presented with a swelling, with or without pain or with non-healing ulcer were included in the study. The spectrum of lesions that appeared in the scalp were tabulated. Results: In our study, total 105 cases were observed during period of five years. Out of the total of 105 cases majority of them were benign accounting for 92.38% of all cases and malignant cases accounting for 7.62% of all cases. The sex distribution of scalp lesions in the present study was slightly greater in male accounting for 60% cases. Out of 105 cases majority are non-tumorous keratinous cysts accounting for 53.3% of all cases with trichilemmal cyst being most common. Conclusion: Benign tumors and tumor like lesions are more common than malignant tumors. Although mostly benign diagnosis and treatment of these lesions pose significant challenge due to distinct histopathological features. A high index of clinical suspicion is essential to ensure early detection of malignancies and initiate treatment.