Article summary by Wonder Edem-Ineama | MD Candidate 2024 | University of California, Riverside School of Medicine

Alopecia can be challenging to diagnose, and in some cases, multiple alopecia types can co-exist. It is not uncommon for the more common forms of alopecia to occur together in some patients. These occurrences often necessitate histopathological examination of scalp biopsies to help diagnose alopecia in patients. This study by Wohltmann et al. looked at dermatopathology biopsies to determine how often patients had multifactorial alopecia and which combinations were more prevalent.¹

The study reviewed 1,360 alopecia specimens from a hair loss clinic. 85.1% of the samples showed a single hair loss diagnosis, 12.5% had more than one type of alopecia present, and 2.5% had a combination of hair loss and a non-hair loss diagnosis such as seborrheic dermatitis.¹ The most common combinations of hair loss were androgenic alopecia (AGA) with central centrifugal cicatricial alopecia (CCCA) in 27.1% of specimens. CCCA and end-stage traction alopecia were found in 18.2%, AGA and end-stage scarring alopecia were found in 17.1%, and AGA and telogen effluvium were found in 7.6%.¹ Additional types of hair loss were also seen in combination with AGA, including but not limited to lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA).¹

The site of hair loss and where on the scalp the sample was taken from were found to help determine a diagnosis.¹ For example, the most common causes of hair loss found in the frontal region are FFA, traction alopecia, and AGA as seen in Table 1.¹ Non-hair loss diagnoses such as seborrheic dermatitis (52.9%), rosacea (17.6%), folliculitis (17.6%), lichen simplex chronicus (8.8%) and tinea capitis (2.9%)were seen in combination with different types of hair losss.¹ It is essential to recognize that if a patient has a non-hair loss diagnosis, treating that condition will likely help improve hair loss.

Overall, making a confident diagnosis of alopecia requires support from both the clinical and histopathological picture. Patients can have more than one type of hair loss, which is more common in Black patients.² A study by Douglas showed that in Black patients that underwent scalp biopsies, their diagnosis changed 70% of the time.² This underscores the importance of scalp biopsies for diagnosing hair loss, ultimately improving patient outcomes.

Figure 1: Traction Alopecia (image provided by Dermnetnz.org)

Figure 2. CCCA (image provided by Dermnetnz.org)

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References: 1) Wohltmann WE, Sperling L. Histopathologic diagnosis of multifactorial alopecia. J Cutan Pathol. 2016 Jun;43(6):483-91. doi: 10.1111/cup.12698. Epub 2016 Apr 8. PMID: 26956781. 2) Douglas A, Romisher A, Cohen A, Zaya R, Wang J, Suriano J, Zachian R, Nikbakht N. Scalp biopsy influences diagnostic accuracy and treatment in Black women with alopecia: A retrospective study. J Am Acad Dermatol. 2023 Jun;88(6):1375-1376. doi: 10.1016/j.jaad.2023.01.022. Epub 2023 Feb 1. PMID: 36736629.