Abstract

We present a case of a 35-year-old man with Fitzpatrick skin type IV with a two-year history of gradual hair loss which started from bilateral sideburn areas extending to involve bitemporal scalp and forearms. On examination, there was perifollicular scale and ashy hyperpigmentation of the face and neck. There was no patchy hair loss throughout the scalp, and there was no eyebrow or eye lash, oral mucosa, nail or genital involvement. He had a background of autoimmune thyroiditis. His ANA was negative and he had a low positive anti-SSA/Ro-60. Biopsies from the scalp showed features of lupus erythematosus. There was follicular plugging and a follicular lichenoid reaction pattern characterised by basal vacuolar change and occasional dyskeratotic keratinocytes. The inter-follicular epidermis was not involved. There was a superficial and deep perivascular and periadenxal lymphoplasmacytic cell infiltrate and increased interstitial mucin deposition. Biopsy from the preauricular area showed features of ashy dermatosis. There was a lichenoid reaction pattern and superficial dermal pigment incontinence. There was overlying basket weave stratum corneum and no significant hypergranulosis. There was also a mild superficial perivascular inflammatory cell infiltrate comprising lymphocytes and histiocytes. There was no deep inflammatory cell infiltrate and no increase in interstitial mucin deposition. He was managed on hydroxychloroquine, methotrexate, folic acid, minoxidil, hydrocortisone and weaning dose of oral prednisone which was changed to tofacitinib. Over a period of nine months, there were some improvements to perifollicular inflammation and fading of hyperpigmentation. There were no new areas of hair loss.