Rare Cases

Pigmented raised lesion over the forehead with loss of hair

8 yr old boy presented with localised hairloss  for 3 weeks and pigmented raised lesion over the forehead for 2 weeks.

Not associated with itching or pain

No h/o similar lesion anywhere else

No h/o fever in the recent past.

No h/o any drug intake or topical application 

No h/o any liver disease 

No h/o any ulcer over the site.

No h/o any thyroid diseases/vitiligo.

No similar history in the past

D/E

A single linear violaceous  plaque of  size 10*3 cm starting from the forehead extending to the scalp with peripherally raised margins(over the forehead) with central atrophy and diffuse alopecia.

A single localised patch of alopecia of size 2*2 cm present over the parietal  region

Oral mucosa:normal

Nails: Coarse pits present over bilateral ring finger. Toe nails are normal

Palms and soles:normal

Dermascopy: peripilar cast present

Diagnosis: Lichen planopilaris 

Differential diagnosis

1.Evolving en coupe de sabre

2.Lichenoid psoriasis

Lichen planopilaris (follicular lichen planus)

-Clinical variant of Lichen planus.

-May be associated with alopecia of the trunk.

-Follicular lesions in the scalp may be associated with scaling and may lead to scarring alopecia

-Can present in 3 distinct variants in the scalp -lichen  planopilaris, frontal  fibrosing  alopecia,  and  Gram-Little- PiccardiLassueur  syndrome.

Graham Little–Piccardi–Lassueur syndrome :  triad of multifocal scalp cicatricial alopecia, non‐scarring alopecia of the axillae and/or groin, and keratotic lichenoid follicular papules.

Frontal fibrosing alopecia: considered as a variant of Lichenplanopilaris,  that affects elderly women, involves  the scalp and  eyebrows.  

HPE

-An  absence  of  arrector  pili  muscles  and  sebaceous  glands

-Perivascular and perifollicular lymphocytic infiltrate in the reticular dermis 

– Mucinous perifollicular fibroplasia within the upper dermis with an absence of interfollicular mucin, 

– Superficial perifollicular wedge‐shaped scarring

Differential diagnosis:

   Keratosis pilaris, 

   Darier disease, 

   Follicular mucinosis, 

   Lichen scrofulosorum 

   Lupus erythematosus (scalp)

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About Author

Dr. Howthul Alam

MD DVL Postgraduate Madras Medical College

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