Primary Cicatricial Alopecia: Clinical Features and Management

Elizabeth K. Ross, MD

Disclosures

Dermatology Nursing. 2007;19(2):137-143. 

In This Article

Discoid Lupus Erythematosus

Discoid lupus erythematosus (also called chronic cutaneous lupus erythematosus) predominantly affects adult women. Discoid lupus erythematosus on the scalp has the same appearance as discoid lupus elsewhere on the face and body. The scalp is the sole skin site affected in 11% to 20%. The extent can be focal or widespread. Patients typically complain of patchy hair loss associated with pruritus, burning, or stinging. Early disease is marked by a small bare patch that enlarges and shows erythema and follicular hyperkeratosis (called follicular plugging) in the center of the alopecic patch (see Figure 6). In active disease, the pull test usually yields anagen hairs. In late stages, the affected skin becomes atrophic, telangiectatic, and shows hypo and hyperpigmentaion — characteristic of discoid lupus. Recurrences are often seen in former areas of involvement. There is a 5% to 10% risk of developing systemic lupus erythematosus, which is more likely in those with widespread cutaneous disease.

Discoid lupus erythematosus. Source: Photo courtesy of Vera Price, MD.

Treatment of discoid lupus must be energetic and started quickly because the hair loss is potentially reversible (unlike hair loss in most other types of primary cicatricial alopecias). Localized active disease is generally managed with high-potency topical corticosteroids and/or intralesional injections of triamcinolone acetonide into affected hair-bearing scalp, usually with good effect in stopping the disease process and in regrowing the hair. Rapidly advancing or extensive discoid lupus requires the use of systemic agents. Hydroxychloroquine is usually tried first, as there are fewer side effects compared to other antimalarial drugs. Cigarette smoking can reduce efficacy, so patients should be encouraged to quit this habit. Treatment can take some time (4-8 weeks) to take effect, and may require "bridge" therapy with oral prednisone in the interim. The reader is referred to other sources for review of alternative treatment options, of which there are several (Callen, 2005; Ross et al., 2005).

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