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- Presentation
Complex Pediatric Alopecia Case: Mixed Scarring and Alopecia Areata Diagnosed by Biopsy and Trichoscopy
Description
A 10-year-old girl had two years of progressive hair loss beginning with complete eyebrow and eyelash loss, followed by patchy scalp alopecia that did not respond to topical steroids, tacrolimus, or intralesional kenalog. Because the exam showed smooth patches with papules and mixed features, the clinician suspected both alopecia areata and a scarring process and performed biopsy. Initial pathology suggested early scarring alopecia with pigment incontinence, but repeat trichoscopy-guided biopsies using both vertical and horizontal sectioning revealed two concurrent diagnoses: lichenoid/scarring alopecia on the vertex and alopecia areata on the occipital scalp. Workup also found low vitamin D and elevated cholesterol. Treatment included hydroxychloroquine planning, pulse steroids, azithromycin, topical ruxolitinib, and later systemic tofacitinib plus oral minoxidil; after being lost to follow-up, she worsened off therapy, then improved markedly after starting ritlecitinib, with regrowth of scalp hair, eyebrows, and eyelashes. The case emphasizes that unclear or treatment-resistant alopecia may require trichoscopy-guided repeat biopsy with dual sectioning, and that JAK inhibitors may help even in some scarring alopecias.
View moreConclusions
- The case suggests that pediatric alopecia can involve more than one process at the same time, including both alopecia areata and a scarring alopecia such as lichen planopilaris.
- When the clinical picture is unclear or treatment is not working as expected, scalp biopsy should be pursued rather than assuming a single diagnosis.
- Trichoscopy is valuable for identifying mixed disease patterns and for choosing the best biopsy site.
- Multiple biopsies and dual horizontal-vertical sectioning improve diagnostic yield in complex alopecia cases.
- JAK inhibitors may have a role not only in alopecia areata but also in some scarring alopecias.
- Poor response to initial therapy should prompt reconsideration of the diagnosis and repeat biopsy if needed.
- Adjunctive treatments such as oral minoxidil, hydroxychloroquine, steroids, and topical JAK inhibition can be used as part of a broader management strategy.
- Controlling inflammation early may help preserve hair even in scarring alopecia, and regrowth is still possible in some affected areas.
- Tyler Technique; HoVert Technique. JAAD journal webpage header appears at the top, and the slide is framed as an educational comparison of biopsy techniques for diagnosing alopecia and other skin conditions.