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DENVER – To limit the progression of scarring alopecia, Dr. Jeff Donovan makes it a point to ask his patients about symptoms and shedding, and he always performs a thorough scalp examination to record the affected sites and signs of the condition.
"Everything on the history potentially may be important, but always ask about symptoms of itching, burning, pain, tenderness, and shedding," Dr. Donovan of the department of dermatology at the University of Toronto advised at the annual meeting of the American Academy of Dermatology.
Upon examination, he continued, document sites and signs by considering the following questions: Where is the hair loss – frontal, top, or occipital? Can you still see the follicular ostia? Is there erythema of the scalp? Is there perifollicular erythema or scale, crusting, pustules, or loss of eyebrow or body hair?
"When you perform dermoscopy of the normal scalp, one can see that the hairs are similar in ‘caliber’ (no miniaturization suggestive of androgenetic alopecia), and there are no changes around the hair follicles or between the hair follicles," Dr. Donovan said. "In scarring alopecia, a variety of findings may be present which help point to the correct diagnosis."
A 4-mm punch biopsy is helpful to confirm the diagnosis and is recommended in areas of early active disease, including areas that may have primary morphologic features, areas with a positive pull test (if possible), or areas that are symptomatic (if needed). "Diagnosing a hair disease with a biopsy requires a hair to be present in the biopsy," he noted. "Biopsies of completely scarred areas are not helpful." In scarring alopecias, inflammatory infiltrates are found in the upper parts of the hair follicle, which destroys hair follicle stem cells. "It’s this destruction of stem cells which ultimately leads to permanent hair loss," Dr. Donovan said.
Lichen planopilaris, a common form of scarring alopecia, typically occurs in middle age and is twice as common in women as in men. It most often affects the central scalp but may be present in other sites in up to half of cases. Key symptoms of lichen planopilaris (LPP) include hair loss, scalp pruritus, and pain/tenderness, often a burning sensation at the site of hair loss. On dermoscopy, most LPP cases appear as reduced hair density with scalp erythema and perifollicular scale, also called peripilar casts.
The goal of LPP treatment is to reduce symptoms and shedding and to stop the disease from occurring in new sites. "Regrowth is not possible in most scarring alopecias," said Dr. Donovan, who leads the University of Toronto’s program in hair transplantation and hair loss. "Treatments help to halt the underlying disease process. Disease activity may recur."
Treatment options for localized/limited LPP include intralesional triamcinolone acetonide and/or several treatments at home, including 0.05% clobetasol propionate lotion or foam, clobetasol propionate shampoo to help decrease itching and burning, fluocinolone acetonide oil one time per week to help with removal of scales, and topical 0.1% tacrolimus ointment (or compounded lotion) as needed.
Systemic treatment of LPP is also an option, and he said he relies on the dermatopathology report to guide his treatment decisions. If biopsy reveals minimal lymphocytic infiltrate, Dr. Donovan said he recommends doxycycline 100 mg b.i.d. as his first-line approach. If biopsy reveals moderate lymphocytic infiltrate, he turns to hydroxychloroquine 6 mg/kg.
His recommended second-line systemic treatment is mycophenolate mofetil 500 mg b.i.d. for 1 month, then 1,000 mg b.i.d. thereafter. Third-line systemic treatment options include cyclosporine 3-5 mg/kg per day and retinoids such as isotretinoin, but fewer than 20% of patients benefit from retinoids, he said. Once the disease becomes quiet, hair transplant surgery can sometimes be an option to restore hair density.
Dr. Donovan disclosed that he is the cofounder of Okavana Laboratories, a privately held company devoted to hair.
DENVER – To limit the progression of scarring alopecia, Dr. Jeff Donovan makes it a point to ask his patients about symptoms and shedding, and he always performs a thorough scalp examination to record the affected sites and signs of the condition.
"Everything on the history potentially may be important, but always ask about symptoms of itching, burning, pain, tenderness, and shedding," Dr. Donovan of the department of dermatology at the University of Toronto advised at the annual meeting of the American Academy of Dermatology.
Upon examination, he continued, document sites and signs by considering the following questions: Where is the hair loss – frontal, top, or occipital? Can you still see the follicular ostia? Is there erythema of the scalp? Is there perifollicular erythema or scale, crusting, pustules, or loss of eyebrow or body hair?
"When you perform dermoscopy of the normal scalp, one can see that the hairs are similar in ‘caliber’ (no miniaturization suggestive of androgenetic alopecia), and there are no changes around the hair follicles or between the hair follicles," Dr. Donovan said. "In scarring alopecia, a variety of findings may be present which help point to the correct diagnosis."
A 4-mm punch biopsy is helpful to confirm the diagnosis and is recommended in areas of early active disease, including areas that may have primary morphologic features, areas with a positive pull test (if possible), or areas that are symptomatic (if needed). "Diagnosing a hair disease with a biopsy requires a hair to be present in the biopsy," he noted. "Biopsies of completely scarred areas are not helpful." In scarring alopecias, inflammatory infiltrates are found in the upper parts of the hair follicle, which destroys hair follicle stem cells. "It’s this destruction of stem cells which ultimately leads to permanent hair loss," Dr. Donovan said.
Lichen planopilaris, a common form of scarring alopecia, typically occurs in middle age and is twice as common in women as in men. It most often affects the central scalp but may be present in other sites in up to half of cases. Key symptoms of lichen planopilaris (LPP) include hair loss, scalp pruritus, and pain/tenderness, often a burning sensation at the site of hair loss. On dermoscopy, most LPP cases appear as reduced hair density with scalp erythema and perifollicular scale, also called peripilar casts.
The goal of LPP treatment is to reduce symptoms and shedding and to stop the disease from occurring in new sites. "Regrowth is not possible in most scarring alopecias," said Dr. Donovan, who leads the University of Toronto’s program in hair transplantation and hair loss. "Treatments help to halt the underlying disease process. Disease activity may recur."
Treatment options for localized/limited LPP include intralesional triamcinolone acetonide and/or several treatments at home, including 0.05% clobetasol propionate lotion or foam, clobetasol propionate shampoo to help decrease itching and burning, fluocinolone acetonide oil one time per week to help with removal of scales, and topical 0.1% tacrolimus ointment (or compounded lotion) as needed.
Systemic treatment of LPP is also an option, and he said he relies on the dermatopathology report to guide his treatment decisions. If biopsy reveals minimal lymphocytic infiltrate, Dr. Donovan said he recommends doxycycline 100 mg b.i.d. as his first-line approach. If biopsy reveals moderate lymphocytic infiltrate, he turns to hydroxychloroquine 6 mg/kg.
His recommended second-line systemic treatment is mycophenolate mofetil 500 mg b.i.d. for 1 month, then 1,000 mg b.i.d. thereafter. Third-line systemic treatment options include cyclosporine 3-5 mg/kg per day and retinoids such as isotretinoin, but fewer than 20% of patients benefit from retinoids, he said. Once the disease becomes quiet, hair transplant surgery can sometimes be an option to restore hair density.
Dr. Donovan disclosed that he is the cofounder of Okavana Laboratories, a privately held company devoted to hair.
DENVER – To limit the progression of scarring alopecia, Dr. Jeff Donovan makes it a point to ask his patients about symptoms and shedding, and he always performs a thorough scalp examination to record the affected sites and signs of the condition.
"Everything on the history potentially may be important, but always ask about symptoms of itching, burning, pain, tenderness, and shedding," Dr. Donovan of the department of dermatology at the University of Toronto advised at the annual meeting of the American Academy of Dermatology.
Upon examination, he continued, document sites and signs by considering the following questions: Where is the hair loss – frontal, top, or occipital? Can you still see the follicular ostia? Is there erythema of the scalp? Is there perifollicular erythema or scale, crusting, pustules, or loss of eyebrow or body hair?
"When you perform dermoscopy of the normal scalp, one can see that the hairs are similar in ‘caliber’ (no miniaturization suggestive of androgenetic alopecia), and there are no changes around the hair follicles or between the hair follicles," Dr. Donovan said. "In scarring alopecia, a variety of findings may be present which help point to the correct diagnosis."
A 4-mm punch biopsy is helpful to confirm the diagnosis and is recommended in areas of early active disease, including areas that may have primary morphologic features, areas with a positive pull test (if possible), or areas that are symptomatic (if needed). "Diagnosing a hair disease with a biopsy requires a hair to be present in the biopsy," he noted. "Biopsies of completely scarred areas are not helpful." In scarring alopecias, inflammatory infiltrates are found in the upper parts of the hair follicle, which destroys hair follicle stem cells. "It’s this destruction of stem cells which ultimately leads to permanent hair loss," Dr. Donovan said.
Lichen planopilaris, a common form of scarring alopecia, typically occurs in middle age and is twice as common in women as in men. It most often affects the central scalp but may be present in other sites in up to half of cases. Key symptoms of lichen planopilaris (LPP) include hair loss, scalp pruritus, and pain/tenderness, often a burning sensation at the site of hair loss. On dermoscopy, most LPP cases appear as reduced hair density with scalp erythema and perifollicular scale, also called peripilar casts.
The goal of LPP treatment is to reduce symptoms and shedding and to stop the disease from occurring in new sites. "Regrowth is not possible in most scarring alopecias," said Dr. Donovan, who leads the University of Toronto’s program in hair transplantation and hair loss. "Treatments help to halt the underlying disease process. Disease activity may recur."
Treatment options for localized/limited LPP include intralesional triamcinolone acetonide and/or several treatments at home, including 0.05% clobetasol propionate lotion or foam, clobetasol propionate shampoo to help decrease itching and burning, fluocinolone acetonide oil one time per week to help with removal of scales, and topical 0.1% tacrolimus ointment (or compounded lotion) as needed.
Systemic treatment of LPP is also an option, and he said he relies on the dermatopathology report to guide his treatment decisions. If biopsy reveals minimal lymphocytic infiltrate, Dr. Donovan said he recommends doxycycline 100 mg b.i.d. as his first-line approach. If biopsy reveals moderate lymphocytic infiltrate, he turns to hydroxychloroquine 6 mg/kg.
His recommended second-line systemic treatment is mycophenolate mofetil 500 mg b.i.d. for 1 month, then 1,000 mg b.i.d. thereafter. Third-line systemic treatment options include cyclosporine 3-5 mg/kg per day and retinoids such as isotretinoin, but fewer than 20% of patients benefit from retinoids, he said. Once the disease becomes quiet, hair transplant surgery can sometimes be an option to restore hair density.
Dr. Donovan disclosed that he is the cofounder of Okavana Laboratories, a privately held company devoted to hair.
AT THE AAD ANNUAL MEETING
