AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Background

Brocq used the term pseudopelade to describe a peculiar form of scarring alopecia resembling alopecia areata. (Pelade is the French term for alopecia areata.) This clinical entity is not a specific disease but a pattern of scarring alopecia, and the term pseudopelade of Brocq eventually should be abandoned. An additional source of confusion is the modern use of the term pseudopelade to describe a different form of scarring alopecia (ie, central, centrifugal, scarring alopecia [CCSA]).

Pseudopelade of Brocq is an end stage or clinical variant of various other forms of scarring alopecia and a diagnosis of exclusion. The same pattern of hair loss can be seen in burnt out (ie, no clinical or histologic evidence of inflammation) discoid lupus erythematosus (DLE), lichen planopilaris (LLP), and other forms of scarring alopecia. If a definitive diagnosis of DLE, LPP, or another condition can be made based on clinical, histologic, or immunofluorescent features, then the term pseudopelade of Brocq cannot be used. A primary form of traditional pseudopelade may exist, but this has yet to be established with certainty.

Frequency

International

Pseudopelade of Brocq is a very uncommon pattern of alopecia.

Race

Whites usually are affected more often.

Sex

Either sex can be affected.

Age

Adults usually are affected more often, although the condition has been reported in children.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

History

The typical patient is surprised to discover discrete asymptomatic areas of scalp hair loss (Image 1). In many patients, the disease is slowly progressive; ie, new areas of alopecia develop over a period of months to years. However, the condition often worsens in spurts, with periods of activity followed by dormant periods. This is distinctly different from the slow but steady disease progression seen in several other forms of scarring alopecia. Disease progression in pseudopelade eventually ends spontaneously.

Physical

Lesions of pseudopelade are randomly distributed, irregularly shaped, and often clustered in patches on the scalp. Cases with exclusive crown or vertex involvement actually may represent examples of burnt-out, central, centrifugal, cicatricial (scarring) alopecia (CCCA). The individual lesion is hypopigmented (porcelain white is the classic description) and slightly depressed (atrophic). Lesions often are shaped irregularly, as opposed to the round or oval patches usually seen in alopecia areata and most cases of CCSA.

The classic description of "footprints in the snow" refers to dermal atrophy causing a slight depression below the surrounding normal scalp. In fact, many cases of pseudopelade do not demonstrate atrophy. Usually, only mild erythema and slight perifollicular scaling are present, and, often, no clinical evidence of inflammation is present. In fact, some authors would argue than any inflammation excludes traditional pseudopelade from the clinical differential diagnosis. Typical of many forms of scarring alopecia, a few isolated hairs may remain within an otherwise smooth, shiny, denuded patch. Include the nails and oral mucosa as well as the skin in physical examination to exclude evidence of other forms of scarring alopecia. Pseudopelade of Brocq is a diagnosis of exclusion.

Causes

Pseudopelade of Brocq is felt to be the end stage of several different forms of scarring alopecia, especially lichen planopilaris and chronic cutaneous lupus erythematosus. Therefore, the cause of pseudopelade of Brocq is linked to the etiology of the underlying skin disease.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Other Problems to be Considered

Central, centrifugal, scarring alopecia
Follicular degeneration syndrome
Lichen planopilaris
Temporal triangular alopecia

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Lab Studies

• No laboratory test has been found useful in establishing the diagnosis of pseudopelade of Brocq. If the history or physical examination suggests evidence of lupus erythematosus, antinuclear antibody testing would be appropriate.

Procedures

• Scalp biopsy is required for determining both diagnosis and prognosis.
• • Ideally, the biopsy specimen is at least 4 mm in diameter and is sectioned transversely (horizontal to scalp surface).
  • At the very least, discovering that follicles have been replaced by connective tissue will confirm the diagnosis of permanent scarring alopecia.

Histologic Findings

The histopathologic findings of traditional pseudopelade have yet to be clearly defined. The criteria established by Pinkus, based on his experience and on the writings of several other authors, are not correlated in any way with clinical features. Thus, pseudopelade as described by Pinkus is a histologic and not a clinical entity. In most cases of traditional pseudopelade, the active lesion is elusive, and the typical histologic findings are those of a burnt-out scarring alopecia. The histologic findings of pseudopelade of the crown more recently described apply to CCCA and not pseudopelade of Brocq. A prospective study of pseudopelade of Brocq with sound clinical correlation has yet to be performed. In most cases, if an active lesion is sampled, the histologic findings are those of the primary process, eg, lichen planopilaris.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Medical Care

When lesions of pseudopelade of Brocq are burnt out, treatment is neither necessary nor possible. Unfortunately, the condition can reactivate episodically and unpredictably. If active inflammation is present, consider an alternative diagnosis, and potent topical corticosteroids, such as fluocinonide or clobetasol, can be tried.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Drug Category: Corticosteroids

Have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.

Drug Name	Fluocinonide (Fluonex, Lidex)
Description	High-potency topical corticosteroid that inhibits cell proliferation; is immunosuppressive and anti-inflammatory.
Adult Dose	Apply sparingly bid/qid as severity warrants
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity; herpes simplex infection; fungal, viral, or tubercular skin lesions
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	May cause adverse systemic effects if used over large areas, denuded areas, on occlusive dressings, or during prolonged treatment periods

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Prognosis

• Unfortunately, the condition can reactivate episodically and unpredictably. There may be a single episode or numerous episodes extending over several decades.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Media file 1:  Irregularly shaped patch of scarring alopecia on the occiput of a middle-aged white woman. This asymptomatic lesion was first discovered by the patient's hairdresser.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

• Brocq L, Lenglet E, Ayrignac J. Recherches sur l'alopecie atrophiante, varie pseudopelade. Ann Dermatol Syphilol (France). 1905;6:1-32, 97-127, 209-237. [Medline].
• Collier PM, James MP. Pseudopelade of Brocq occurring in two brothers in childhood. Clin Exp Dermatol. Jan 1994;19(1):61-4. [Medline].
• Dawber RPR, Van Neste D. Hair and scalp disorders: Common presenting signs, differential diagnosis, and treatment. Philadelphia: JB Lippincott;1995: 124.
• Elston DM, Bergfeld WF. Cicatricial alopecia (and other causes of permanent alopecia). In: Olsen EA, ed. Disorders of Hair Growth. New York: McGraw-Hill;1994: 285-313.
• Headington JT. Cicatricial alopecia. In: Whiting DA, ed. Update on Hair Disorders. Philadelphia: WB Saunders;1996: 773-82.
• Laymon CW. The cicatricial alopecias. J Invest Dermatol. 1947;8:99-122.
• Mirmirani P, Willey A, Headington JT, et al. Primary cicatricial alopecia: histopathologic findings do not distinguish clinical variants. J Am Acad Dermatol. Apr 2005;52(4):637-43. [Medline].
• Pinkus H. Differential patterns of elastic fibers in scarring and non-scarring alopecias. J Cutan Pathol. Jun 1978;5(3):93-104. [Medline].
• Ronchese F. Pseudopelade. Arch Dermatol. Sep 1960;82:336-43. [Medline].
• Solomon AR. The transversely sectioned scalp biopsy specimen: the technique and an algorithm for its use in the diagnosis of alopecia. Adv Dermatol. 1994;9:127-57; discussion 158. [Medline].
• Sperling LC, Sau P. The follicular degeneration syndrome in black patients. 'Hot comb alopecia' revisited and revised. Arch Dermatol. Jan 1992;128(1):68-74. [Medline].
• Sperling LC, Solomon AR, Whiting DA. A new look at scarring alopecia. Arch Dermatol. Feb 2000;136(2):235-42. [Medline].
• Sperling LC. Brocq's alopecia (pseudopelade of Brocq) and "burnt out" scarring alopecia. In: Sperling LC, ed. An Atlas of Hair Pathology: With Clinical Correlations. London: Parthenon; 2003:. 115-8.
• Templeton SF, Solomon AR. Scarring alopecia: a classification based on microscopic criteria. J Cutan Pathol. Apr 1994;21(2):97-109. [Medline].

Article Last Updated: Feb 22, 2007