Diagnosis of Scarring Alopecia in the Early Stages

Early Diagnosis More Challenging that Late Stage Diagnosis

Diagnosing scarring alopecias in the earliest stages is more challenging because the appearance of the scalp may not look all that unusual.  The photo here is from a patient with lichen planopilaris. There are subtle features like scalp erythema, pili torti and single hairs that might trigger  one to think about scarring alopecia but the features are not specific. This photos could just as easily be from a patient with androgenetic alopecia and seborrheic dermatitis.

EARLY LICHEN PLANOPILARIS: FEATURES ARE NON SPECIFIC IN THIS PHOTO

However, diagnosing scarring alopecia in the early stages is made a lot easier by carrying a simple rule: if there is even the slightest possibility that what a physician is looking at could be a scarring alopecia, then a biopsy should at least be considered.

Not everyone that has scalp itching has a scarring alopecia. There are dozens of causes of itching. Not everyone with itching needs a biopsy.

Not everyone that has excessive shedding and a red scalp has a scarring alopecia. In fact, most don’t. There are many causes of shedding and a red scalp. Not everyone with a red scalp and shedding needs a biopsy.

Patients with Multiple Symptoms May Need A Biopsy

Scarring alopecias (particularly the symptomatic ones like lichen planopilaris and folliculitis decalvans) are very often associated with symptoms and signs that signal to the patient and physician that something is not right.  More times than not, these two diseases shout out clues to the patient and physician that something is not right. (In contrast frontal fibrosing alopecia can often be silent when it first develops and can go on for years without detection). For patients with lichen planopilaris and folliculitis decalvans there are often multiple clues that this is not indeed the diagnosis. The scalp sometimes itches in unusual patterns. The scalp might burn. The scalp is sometimes sore. The scalp feels bruised for some patients. The scalp is warm for many. Shedding occurs when there is otherwise no good reason.

Patients who report several symptoms (“more than itching”) often benefit tremendously from having a scalp biopsy. For example, a patient with scalp itching PLUS burning or a patient with itching PLUS scalp tenderness should at least be given consideration for a scalp biopsy.