cases. However, in general, the histology is similar, if not identical, to that of lichen planopilaris.

273 It is unclear whether any treatment helps.

OtherFormsof Scarring Alopecia

Central centrifugal cicatricial alopecia (CCCA) is a form of cicatricial alopecia that affects adults of African orgin.43,271 This condition has also been called hot comb alopecia folliculardegeneration or syndrome.This startsat the crownor midline vertex and spreads slowly in a centrifugal fashion. Inflammation has been reported more commonly in affected men than in affected women.282 Histotogkalty, the cadiest and most distinctive change is premature desquamation of the inner root sheath with later changes through the outer root sheath (including migration of the hair shaft), a mononuclear infiltrate primarily at the isthmus, and, finally, loss of the follicular epithelium and replacement with

J Frontal fibrosing lopecia. a lesional steroids, topical etinoids, and hormone re:rapy do not prevent the cssion.(EF,' OF BROCQ clinicalterms, In of Brocq278implies fleshd, irregularly shaped alo'I begin in a "moth-eaten" ic IIfootprints-in-the-snow" eventual coalescence into )f alopecia 43,278 llicular elythema or hyperthe disease may progress tere has been considerable he specificity of this diagn assignation of the term 11 noninflammatory scarincluding the end-stage of tially inflammatory condi)gically, the lesions are by a perifollicular and ymphocytic infiltrate prilevel of the follicular inoss of sebaceous epithebrotic streams into the out interface or follicular ges.Z79Elastin stains may Jseudopelade (persistent round the midshaft of the lichen planopilaris and lutosus (loss of elastic fibers n).280Direct immunofluo:gative in the majority of

n-

brow; tissue.282Although tight braiding, hot combs, and hair straightening agents are often invoked as causative or at least contributory factors and their use discouraged in CCCA, this has not been definitely proven. The distribution of CCCA overlaps that of pattern hair loss but the sex distribution is tremendously skewed toward women. Alopecia mucinosa , also known as follicu/armucinosis, generallypresentsas erythematous, alopecic papules, plaques, or flat patches on the scalp and face.267Biopsy reveals prominent follicular, epithelial, and sebaceous gland mucin, and perifollicular lymphohistiocytic infiltrate, which may be associated with follicular lymphocyte exocytosis, without concentric lamellar fibrosis.265,267,283 adults, In alopecia mucinosa almost invariably represents follicular mycosis fungoides (see Chap. 146).283 is controversial whether It a self-limited variant exists in children.

Keratosis follicularis spinulosa decalvans is a rare, usually X-linked disorder with the gene located at Xp22.13-p22.2 (see Chap. 85).284,285 Folliculitis decalvans is an inflammatory disease characterized by pustular folliculitis leading to scarring hair loss. Surviving hairs may group so that multiple hairs are seen emerging from a single follicular orifice (tufted folliculitis) (Fig. 86-25). Staphylococcusaureus is usually cultured from these pustules, but whether this is a primary or secondary process is unclear. Histologically, early lesions show an acute suppurative folliculitis with neutrophils and eosinophils, later mixed with lymphocytes and histiocytes.265,266 Loss of sebaceous epithelium and perifollicular fibrosis is common.265Systemic antibiotics, particularly in combination with rifampin, systemic and/or topical steroids, and systemic retinoids may also be he1pfuI,289 Dissecting folliculitis or perifolliculitis capitis abscedens et suffodiens is another inflammatory condition of the scalp that can lead to scarring alopecia. African Americans are particularly affected.3his condition begins with deep inflammatory nodules, primarily over the occiput, that progress to coalescing regions of boggy scalp (Fig.86.26). Sinus tracts may form and dislodge purulent material. As in folliculitis decalvans, S. aureus is the most common bacterial isolate. Biopsy of early lesions shows follicular plugging and suppurative follicular or perifollicular abscesses with a mixed inflammatory infiltrate of neutrophils, lymphocytes, plasma cells, or eosinophils.265-267 Later, foreign-body giant cells, granulation tissue, and, finally, scarring with sinus tracts occur. Control is difficult to attain, but small case series have reported success with oral isotretinoin, systemic antibiotics (using similar regimens to folliculitis decalvans), systemic steroids, and dap-

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