Differences of Nonscarring Alopecia in Systemic Lupus Erythematosus

A man with alopecia
A man with alopecia
Investigators review the various clinical patterns and trichoscopic, histopathological, and direct immunofluorescence characteristics of nonscarring alopecia in patients with systemic lupus erythematosus and confirm its link to disease activity.

Histopathological and direct immunofluorescence changes occur with nonscarring alopecia in systemic lupus erythematosus (SLE), according to study results published in the Journal of the American Academy of Dermatology.

This cross-sectional, analytic study examined the clinical attributes and disease associations in patients with SLE with and without scalp abnormalities. Patients were included in the study if they met the criteria for SLE outlined by either the Systemic Lupus International Collaborating Clinics in 2012 or the American College of Rheumatology in 1997. Data collection included demographic information, trichoscopic results, histopathological examinations, and direct immunofluorescence tests. Patients were categorized into different cohorts according to the evidence of alopecia.

The study population included 32 patients with nonscarring alopecia and 10 patients without alopecia. Both cohorts were similar with regard to age, sex, and SLE duration. Of the patients in the nonscarring alopecia cohort, 81.3% reported ongoing hair loss, 43.8% had mild diffuse alopecia, 15.6% had severe diffuse alopecia, 28% had localized alopecia, and 12.5% had short fragile hair. Trichoscopic examinations indicated scalp and hair shaft abnormalities in this cohort: 81.3% had abnormalities in the small blood vessels, 75% had thin hair shafts, and 43.8% had hypopigmentation. Histopathologic results indicated that 87.5% had interface changes along the dermoepidermal junction, 40.6% had basal vacuolar changes along the follicular epithelium, and 84.4% had mucin deposition. Direct immunofluorescence indicated that 78.1% had homogeneous granular depositions of bound immunoglobulins and complement along the dermoepidermal junction and/or hair follicles.

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In the cohort without alopecia, trichoscopic examinations indicated a significantly lower prevalence of hair shaft thinning (P =.02) and short regrowing hair (P =.03). Histopathologic results showed significantly fewer interface changes along the dermoepidermal junction (P =.006) and the follicular epithelium (P =.018) and significantly decreased mucin deposition (P =.007). Direct immunofluorescence found less homogeneous granular deposition along the dermoepidermal junction (P =.046).

Limitations of this study include the lack of follow-up results, the possibility that some patients have telogen effluvium, and the small sample size.

The researchers concluded, “Histopathological and [direct immunofluorescence] examinations have yielded numerous [lupus erythematosus]-specific findings suggesting that the condition is indeed [lupus erythematosus]-specific and may involve a more complex mechanism than that of [telogen effluvium].”

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Chanprapaph K, Udompanich S, Visessiri Y, Ngamjanyaporn P, Suchonwanit P. Non-scarring alopecia in systemic lupus erythematosus: a cross-sectional study with trichoscopic, histopathological and immunopathological analyses [published online May 28, 2019]. J Am Acad Dermatol. doi:10.1016/j.jaad.2019.05.053