Vitiliginous alopecia masquerading as frontal fibrosing alopecia.

INTRODUCTION

A 73-year-old female presented at the Dermatology Department with a white shiny band-like patch on the temporal and forehead zones [Figure 1]. She had a 4-year history of vulvar lichen scleroatrophicus (LSA) [Figure 2]. Polarized dermoscopy examination revealed follicular ostium preservation, yellow dots and poliosis of vellus hair [Figure 3]. A biopsy specimen was obtained, and histopathological examination revealed no inflammatory cells, with preservation of the hair follicle and almost no melanocytes were present [Figure 4].

Figure 1

White patch on the frontotemporal region. Madarosis not observed

Figure 2

Characteristic brightness and whitish color of the introit and the mucosa is observed

Figure 3

Dermoscopy view shows preservation of the follicular openings and poliosis of vellus hair. Absence of scar, erythema, and scale. Skin and hair were normal except for the decrease of pigmentation when compared with other normal areas

Figure 4

Preservation of hair follicles without inflammatory infiltrate or fibrosis. Note the absence of melanocytes (H and E original magnification, ×40 and Melan A original magnification, ×20).

What is your diagnosis?

Vitiligo.

DISCUSSION

Despite the initial clinical suspicion of frontal fibrosing alopecia (FFA), a complete physical examination was performed finding a hypopigmented macula in the middle of the chest, which led us to consider in the differential diagnosis vitiligo. In addition, the histologic findings supported this diagnosis because of the decreased number of melanocytes and the absence of inflammatory or cicatricial changes.

Alopecia is classified into two major groups, cicatricial and noncicatricial. Usually clinical findings are enough to make a correct diagnosis, but some skin diseases can simulate cicatricial alopecia, being in these cases very difficult to differentiate. In our case, the patient has a LSA that has been associated either to FFA and vitiligo.[12] A dermoscopic clue, for suspect a primary cicatricial alopecia, is the loss of follicular ostia reflecting the cicatricial phenomenon that were absent. In this case, the first diagnostic hypothesis was of FFA, because of the clinical characteristics and the LSA background. However, vitiligo was considered after trichoscopy examination because of to the presence of poliosis and the finding of the hypopigmented macula on the patient's chest.

We conclude that trichoscopy is a useful technique for the assessment of scalp diseases. It allows the specialist to confirm clinical findings, identifying subtle sub-clinical signs and guiding a biopsy if necessary.