Folliculitis decalvans: a rare scarring alopecia misinterpreted as a laceration of the scalp at the scene
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Folliculitis decalvans: a rare scarring alopecia misinterpreted as a laceration of the scalp at the scene Craig James • Neil E. I. Langlois
Accepted: 9 August 2013 / Published online: 24 September 2013 Ó Springer Science+Business Media New York 2013
Case report A 44 year old male was found collapsed on his bedroom floor. Investigators at the scene reported a laceration to the back of his head that they believed occurred during the collapse due to an impact on a bedside cabinet. He had a history of epilepsy, which was presumed to be the cause of his collapse. At postmortem examination the body was observed to be that of a male weighing 92 kg and measuring 169 cm in length. His appearance was consistent with his stated age and he seemed well nourished. Assessment of his scalp for the reported laceration revealed an area posteriorly which had a scarred appearance with widely separated, coarse hair follicles 0.3–0.5 cm in diameter, from which multiple hairs protruded (Figs. 1, 2). The area appeared congested and hemorrhagic, consistent with bruising, but there was no laceration or breach of the skin. From the findings of the postmortem examination, which included neuropathological examination of the fixed brain and toxicological analysis, death was attributed to epilepsy. A section of the skin of the scalp was taken for examination to assess the nature of the abnormality and to histologically assess the age of the contusion, to determine any relationship to the cause of death. Under the
C. James Adelaide Pathology Partners, Adelaide, SA, Australia N. E. I. Langlois (&) Forensic Science SA, 21 Divett Place, Adelaide SA 5000, Australia e-mail: [email protected] N. E. I. Langlois University of Adelaide, Adelaide, SA, Australia
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microscope the skin lesion displayed hemorrhage into the tissue. There was scarring of the dermis with an inflammatory infiltrate comprising predominantly lymphocytes and plasma cells. Sporadically, within the dermis there were abnormal hair structures comprising several coalesced follicles (Fig. 3). These features are consistent with folliculitis decalvans.
Discussion Folliculitis decalvans is a rare neutrophil predominant scarring alopecia [1, 2]. It was first described by Quinquad in 1888 [3, 4]. Its cause is unknown, although an infective etiology is suspected with staphylococcus aureus being implicated, possibly in conjunction with a genetic predisposition for an abnormal immunological response [5]. The scalp is the usual site of involvement, predominantly over the vertex and occipital regions. It tends to affect young to middle age adults, with a male predominance [4, 6]. The presentation may commence with pustules of the follicles with underlying boggy swelling. This progresses to scarring alopecia with coalescent follicles producing the characteristic appearance of multiple hairs emerging from a single follicle orifice. Histologically, early lesions exhibit folliculitis with neutrophils; this becomes a mixed infiltrate of neutrophils, lymphocytes, and plasm
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