A 30 yr old male presented to the clinic with history of alopecia since 2 months. On examination, he is found to have Cicatricial alopecia with perifollicular graying. Which of the additional finding he is most likely to have? (AIPG 2011)
|A||Discoid Plaques in the face|
|B||Whitish lesion in the buccal mucosa|
Whitish lesion in the buccal mucosa > A . Discoid Plaques in the face
Scarring alopecia with perifollicular changes D/d:
1). Discoid lupus -associated White patches, branching capillaries, and keratin plugs
2). Lichen planopilaris - associated Perifollicular scales and white dots
3). Frontal fibrosing alopecia - associated Perifollicular scales, perifollicular erythema, and branching capillaries.
1). Lichenoid dermatitis is present in lichen planopilaris (and its clinical variants, regardless of presentation) at the level of the infundibulum and can easily be missed in transverse sections. These are mostly CD8 cells. Concentric lamellar perifollicular fibrosis can develop.
2). Staining with Verhoeff–van Gieson elastin stain may be of value in differentiating advanced cases of discoid lupus erythematosus, lichen planopilaris, and pseudopelade of Brocq, which often have overlap features on routine pathologic examination but display distinct patterns on elastic tissue staining. End-stage lichen planopilaris shows loss of elastic fibers in a superficial dermal wedge-shaped scar, which is better demarcated with elastic stain. Discoid lupus erythematosus elastin stain shows a more diffuse broad dermal scar pattern.
3). Direct immunofluorescence highlights the presence of colloid bodies in the peri-infundibular area after staining with immunoglobulin M (less frequently with immunoglobulins G, A and C3). A linear band of fibrin deposition is present along the basement membrane zone of affected follicles, while the interfollicular epidermis is negative for immunoreactants.
a. Discoid lupus erythematosus presents with vacuolar interface dermatitis, with a few dyskeratotic keratinocytes, cytoid bodies, and a variably dense periadnexal and superficial/deep perivascular lymphocytic infiltrate with dermal mucin. 30Perifollicular inflammation can surround any part of the mid and upper follicle.
b. Sebaceous glands can be atrophied or absent.
c. Distention of follicular ostia with laminated keratin can be prominent (ie, follicular plugging histology).
d. When stained with Verhoeff–van Gieson stain, advanced discoid lesions reveal diffuse loss of elastic fibers.
e. This is compared with lichen planopilaris, which has a wedge-shaped scar in the area of the infundibulum that can often be found with a loss of elastic fibers only in that area.
a. Use of direct immunofluorescence for diagnosis and differentiation from other primary lymphocytic cicatricial alopecias can be helpful.
b. To optimize the yield, the lesion chosen for biopsy should be untreated for at least 2-4 weeks and should be at least 3 months old. Diagnostic features of discoid lupus erythematosus on direct immunofluorescence are deposition of immunoglobulin G, immunoglobulin M, and C3 in a granular bandlike pattern at the dermal interface.
a. At times, differentiation of lichen planopilaris from discoid lupus erythematosus can be challenging in older lesions or those that are not fully developed.
b. However, perieccrine inflammation, deep perivascular inflammation, and dermal mucin are not found in lichen planopilaris.