Do I need a scalp biopsy if I have scarring alopecia?

Question:

I have been diagnosed with frontal fibrosing alopecia, which I understand to be a type of scarring alopecia. My dermatologist wants to start me on treatment right away. Do I need a biopsy first?

Answer

Dermatologists have many different views as to whether every patient with potential scarring alopecia needs a scalp biopsy or not. These views fall in three main categories:

1) There are some dermatologists who believe that every single patient with hair loss (scarring or non-scarring) gets a biopsy.  

2) There are some dermatologists who conduct a scalp biopsy in every single patient with scarring alopecia. 

3) There are some dermatologists who perform a biopsy if the diagnosis is not certain and there is even the slightest ambiguity in the diagnosis.

I fall in the third category. My decision on whether a patient needs a biopsy comes during the final steps of a typical patient evaluation. First (step 1), I listen to the patient’s story about their hair loss (we call this a history). Second (step 2), I examine the scalp using a dermatoscope. Third (step 3) I review blood tests. Fourth, I decide whether a biopsy is needed given all the information I have collected during steps 1-3. If the diagnosis is clear and there simply can’t be another diagnosis possible, I don’t do a biopsy.

Here’s an example. Suppose a 56 year old female patient comes to see me. She started losing her eyebrows at age 51. At age 54 she started losing hair along her frontal hairline and it’s receded now about 1⁄2 inch. She’s lost her arm hair, pubic hair and leg hair. Examination shows a scarring alopecia along the frontal hairline. Her blood tests are normal. Based on steps 1-3 I’m confident in the diagnosis of a condition known as frontal fibrosing alopecia.

Will I do a biopsy? No. I will not recommend doing a biopsy in this situation. If the biopsy returns showing scarring alopecia, it’s true that I will have confirmed the diagnosis. Not a bad thing of course. But I will have caused the patient an unnecessary scar. Also, there is always the potential that biopsies (or any trauma) can further activate scarring alopecias, so I’d like to stay away from that.

But suppose the biopsy returns showing something else – such as androgenetic alopecia or alopecia areata. Biopsies are not 100 % accurate so once in a while a scenario like this does occur. In a situation like this, I won’t believe the biopsy results. I’ll simply put the biopsy results aside and move on with discussing treatment. In other words, I’d simply have to explain to the patient that biopsies are not perfect. The reality is that I have caused an unnecessary scar. There may also have been unnecessary expense for getting the biopsy done. There may have even been some pain and discomfort for a few days.

Suppose in the above example, we change things a bit. Suppose the patient is a 56 year old female patient like in the above example. She started losing her eyebrows at age 51. At age 54 she started losing hair along her frontal hairline and it’s receded now about 1⁄2 inch. She’s lost her arm hair, pubic hair and leg hair. She has joint pain in her wrists and ankles, unusual rashes, extreme fatigue and prominent lymph nodes enlarged in her neck. She is troubled by headaches and has had 2 seizures this year that nobody can figure out why. She has dry mouth and dry eyes. Examination shows a scarring alopecia along the frontal hairline. Her blood tests are abnormal with low white cells, abnormal kidney function tests, as elevated liver enzymes. Her ANA is borderline positive at 1:160. When I examine her scalp, I have the impression this is a scarring alopecia – resembling very close frontal fibrosing alopecia.

Here’s a good example of where I will do a scalp biopsy. Even though it seems the patient has frontal fibrosing alopecia, I want to rule out other conditions such as cutaneous lupus, discoid lupus, lymphomas, various infiltrative conditions, including some rare cancers.

You may wish to review these helpful articles (below) I've written in the past. Thanks again for the question. 

Top 25 Frequently Asked Questions about Scarring Alopecia

What topical steroids are safe to use in FFA?

Question:

I was diagnosed with frontal fibrosing alopecia and prescribed a topical steroid by my dermatologist. I've been using it for 5 months. I am wondering if it's too strong because my skin seems thin in the area of the hair loss. What topical steroids are best to use for FFA?

Answer:

Topical steroids can be mildly helpful for some patients with FFA. Generally speaking they are not as effective as steroid injections, and oral medications such as finasteride, doxycycline or hydroxychloroquine. Nevertheless, topical steroids do have a role in the treatment of FFA.

There are many classes of topical steroids and they range from class I to class VII. Class I steroids are the strongest and include agents like clobetsol. Class VII steroids include weak steroids like hydrocortisone.  Clobetasol is up to 600 times strong than  hydrocortisone and so has much more potent anti-inflammatory effects.  There's no doubt about it that stronger steroids suppress inflammation better- but that does not mean that stronger steroids are better, especially for FFA. In FFA, we need to consider side effects  - in particular the thinning of the skin that both the steroids and the disease itself can cause. 

Clobetasol, however, carries a greater risk of side effects including thinning of the skin. Patients with FFA already have thin skin to begin with (on account of their disease). So, one needs to be careful when treating FFA not to thin the skin further. Monitoring is needed and photographs are essential in this regard. 

Generally speaking, when someone with FFA notices thinner skin and blue veins appearing it's typically the disease itself that caused this - not the topical steroid. Nevertheless, to limit the side effects of topical steroids, dermatologists frequently prescribe weaker steroids to use on the frontal hairline for those with FFA. Instead of using clboetasol, steroids like fluocinonide or betamethasone are often used. Rather than using daily, these are frequently used every other day to limit side effects.  In addition, a non-steroid medication like pimecrolimus might be used as well. Pimecrolimus does not cause thinning of the skin but the trade off is they are not quite as consistently effective as the topical steroids. 

If clobetasol is going to be used, that is a decision that the dermatologist and the patient must both review together and be comfortable with. Daily use of clobetasol on the frontal hairline for a prolonged period is probably not a good idea when treating FFA. Some physicians might use it a few times per week or daily for a very short period of time. However, daily use of a strong steroid increases the risk of the patient experiencing further thinning of the skin.  

You may wish to review these helpful articles (below) I've written in the past. Thanks again for the question. 

Topical steroids and FFA

General articles on frontal fibrosing alopecia