Derm Cases · Dermatology / Trichology
OSCE — scarring hair loss: trichoscopy, biopsy margin, FFA and folliculitis decalvans
An 8-minute OSCE on primary cicatricial alopecia recognition, lymphocytic vs neutrophilic groups, urgent anti-inflammatory therapy, and red-flag SCC in chronic neutrophilic disease.
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Study tools
Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE on primary cicatricial alopecia recognition, lymphocytic vs neutrophilic groups, urgent anti-inflammatory therapy, and red-flag SCC in chronic neutrophilic disease.
Brief (to candidate)
A postmenopausal woman has progressive frontal hairline recession with lonely hairs and eyebrow loss; another patient has tufted folliculitis with pustules on the vertex. You have 8 minutes to diagnose scarring alopecia types, plan biopsy, start disease-modifying therapy, and prevent irreversible follicle loss.
[2]Candidate instructions
- Define cicatricial alopecia and trichoscopic hallmark (loss of follicular ostia).
- Classify lymphocytic (LPP/FFA/DLE/CCCA) vs neutrophilic (FD, dissecting cellulitis) groups.
- Plan biopsy from active margin (not burnt-out centre).
- Start appropriate first-line anti-inflammatory regimens.
- State SCC risk in chronic ulcerative neutrophilic disease.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Recognition | Irreversible follicular destruction; trichoscopy: absent ostia, white patches, perifollicular scale/erythema, tufted hairs; urgency because delay = permanent loss[2][4] |
| Lymphocytic group | Lichen planopilaris, frontal fibrosing alopecia (postmenopausal frontal recession ± eyebrows), DLE, CCCA; treat inflammation early with high-potency topical/IL steroids, hydroxychloroquine, etc.[3][6] |
| FFA focus | Band-like frontal recession, lonely hairs, facial papules possible; early therapy may halt progression; consider 5α-reductase inhibitors in selected non-pregnant patients under specialist care |
| Neutrophilic group | Folliculitis decalvans: tufted hairs + pustules — classic rifampicin + clindamycin combination courses; dissecting cellulitis deep abscesses/sinuses — antibiotics/isotretinoin pathways; culture-guided care[3] |
| Biopsy | Two punches preferred by many experts (vertical + horizontal) from active inflammatory margin, not end-stage scar |
| DLE special | Screen SLE labs if DLE scalp; strict photoprotection |
| Red flags | Chronic non-healing ulcer in scarring neutrophilic disease → biopsy for Marjolin/SCC; no response → revisit diagnosis/repeat biopsy |
Model key actions
- Treat any alopecia with lost ostia as scarring until proven otherwise.[2]
- Biopsy the active margin and start anti-inflammatory therapy early.[6]
- Use rifampicin–clindamycin thinking for classic folliculitis decalvans tufted disease.[3]
Common errors
- Treating as AGA with minoxidil alone while inflammation progresses.
- Biopsying burnt-out centre only.
- Missing eyebrow/facial signs of FFA.
- Ignoring SCC risk in chronic ulcerative scarring alopecias.
References5ShowHide
- [2]Pirmez R The dermatoscope in the hair clinic: Trichoscopy of scarring and nonscarring alopecia. J Eur Acad Dermatol Venereol, 2023.PMID 37591567
- [3]Ezemma O, Devjani S, Kelley KJ, et al. Treatment modalities for lymphocytic and neutrophilic scarring alopecia. J Eur Acad Dermatol Venereol, 2023.PMID 37591564
- [4]Mathur M, Acharya P Trichoscopy of primary cicatricial alopecias: an updated review. Int J Dermatol, 2020.PMID 31566830
- [6]Uchiyama M Primary cicatricial alopecia: Recent advances in evaluation and diagnosis. Am J Clin Dermatol, 2022.PMID 34866229
- [9]Heymann WR Central centrifugal cicatricial alopecia: Beyond the hot comb. J Am Acad Dermatol, 2023.PMID 37775048