Value of Direct Immunofluorescence for Differential Diagnosis of Cicatricial Alopecia

Abstract

Background: There are diverse causes of cicatricial alopecia characterized by lack of follicular ostia and irreversible loss of hair. While clinical differentiation between the causes may be difficult, particularly with regard to lichen planus (LP), lupus erythematosus (LE) and pseudopelade of Brocq (PB), it has been suggested that both histopathologic examination and direct immunofluorescence studies (DIF) are necessary for an accurate diagnosis. Objective: The aim of this study was to evaluate the diagnostic value of DIF studies in addition to histopathology in patients with cicatricial alopecia as a clinical feature. Methods: 136 scalp biopsy specimens received for histopathology and DIF during a 5-year period were reviewed. Results: Definitive diagnosis was achieved by careful evaluation of scalp biopsies. The most prevalent diagnoses in order of frequency were LP (26%), LE (21%) and folliculitis decalvans (20%). PB was diagnosed in 10%. In most cases, the diagnosis could be made on the basis of histopathology and independently of DIF. Characteristic DIF patterns showed high specificity, but low sensitivity for LP, and high specificity and sensitivity for LE. The DIF pattern in PB showed no difference to LP. Conclusions: Histopathology permits diagnosis in the majority of cicatricial alopecias. DIF is of value in histopathologically inconclusive cases, particularly when LE is in question.

Primary Scarring Alopecia: Clinical-Pathological Review of 72 Cases and Review of the Literature

“…In the majority of the series, routine histology is usually sufficient for diagnosis, with only 6% of LPP and 7% of LE cases being diagnosed exclusively with DIF. The sensitivity of this technique for LPP is 34%, and the specificity is 95%; for LE, DIF sensitivity is reported as 83% and specificity, 93% (the percentage of positivity ranges between 63 and 100% according to the different reports) [23,24]. In our series, of 48 DIF studies performed, only 18 were positive and, from these, the diagnosis was made solely based on DIF results in only 10 cases due to the fact that histopathology was doubtful or nonspecific.…”

Cutaneous Lupus Erythematosus Presenting as Frontal Fibrosing Alopecia: Report of 2 Patients

“…Increased dermal mucin is usually present both superficially and deep and is best detected in alcian blue-stained sections. Direct immunofluorescence studies demonstrate dense granular deposition of immunoglobulin (most commonly IgG, but IgM and IgA may also be present) and complement factor C3 at the dermal-epidermal junction in 76% of cases [17]. As with the other primary scarring alopecias, specifically LPP, there is no ideal treatment for the alopecias related to LE.…”

The Use of Direct Immunofluorescence in Frontal Fibrosing Alopecia

“…Based on previous studies [3], globular deposits (colloid bodies) of immunoglobulins or C3 on the papillary dermis or around the hair follicles were considered characteristic of LPP. All other findings were considered nonspecific, and the absence of staining was considered a negative finding.…”

“…It has been shown to be useful for differential diagnosis of cicatricial alopecias [3]. DIF patterns in LPP consist of numerous globular deposits of immunoglobulins, particularly IgM (colloid bodies), and deposits of C3 in the papillary dermis.…”

“…Granular deposits in the dermoepidermal junction, comprising IgG, IgM, and C3, are typical of DIF results observed in lupus erythematosus (LE). While most cases of cicatricial alopecia may be differentially diagnosed using histopathology, there are cases that can be aided by the use of DIF [3]. …”