BH10: Central cicatricial centrifugal alopecia or something else?

B. Gaglani

London North West University Hospitals Trust, London, UK

A 58-year-old African woman was referred for the management of scalp alopecia that had started in her thirties over the vertex of her scalp and had progressively involved > 90% of her scalp over the years. She was diagnosed with central centrifugal cicatricial alopecia of many years’ duration and was being managed with annual wigs. On further questioning in the clinic, her chief complaint was a painful area over the vertex of the scalp, which had been affecting her sleep for years. She admitted to having used hair treatments in the past, after her hair loss had started. Clinical examination revealed a soft, tender, boggy swelling at the site of pain; however, the rest of her scalp felt like palpating cotton wool. Trichoscopic examination showed no remnant follicular openings, and histology showed end-stage alopecia. Her body mass index (BMI) was noted to be > 45 and there was an associated ichthyosiform rash on her shins bilaterally. Magnetic resonance imaging of her brain was requested for suspected lipoedematous scalp alopecia. Radiological findings led to a diagnosis by demonstrating 24-mm-thick subcutaneous adipose tissue – the highest recorded for this condition. Normal scalp thickness is suggested to be 6 mm. The patient declined a trial of intralesional steroids and topical Dermovate was unsuccessful. Lipoedematous scalp is a rare disease marked by a soft thickening of the scalp, first recorded in 1935 (Cornbleet T. Cutis verticis gyrata? Lipoma? Arch Dermatol Syphilol 1935; 32: 688). A similar clinicopathological entity associated with nonscarring but permanent acquired alopecia was described in 1961 (Coskey RJ, Fosnaugh RP, Fine G. Lipedematous alopecia. Arch Dermatol 1961; 84: 619–22) and termed lipoedematous alopecia. Our case was associated with a raised BMI and also with an ichthyosiform rash on her shins, which started when she was in her teens and needs further evaluation after the COVID-19 pandemic. It was also associated with scarring alopecia rather than nonscarring alopecia, as seen in other cases. We wonder if there is a genetic cause as the disease predominantly occurs in African patients. Also, lipoedematous alopecia may be associated with nonscarring alopecia, as well as scarring alopecia, as seen in our case.