BH13 A rare cause of central scalp alopecia

Abstract

Lipo-oedematous alopecia is a very rare scalp disorder characterized by centrifugal hair loss from the scalp vertex associated with abnormal thickening of the subcutaneous adipose tissue. It gives rise to what is described as ‘cotton-wool-like induration of the affected areas’. Since its original description in 1961, fewer than 100 cases have been published, and these are seen predominantly in women. Diagnosis is frequently delayed due to clinical overlap with inflammatory or scarring alopecias, and often nonspecific histopathology. A 63-year-old Afro-Caribbean woman with progressive vertex hair loss attended our general dermatology clinic. The initial clinical diagnosis was central centrifugal cicatricial alopecia, but there was a focal ‘boggy’ texture of the affected scalp. Topical clobetasol was initiated and scalp biopsies organized alongside follow-up at a combined clinic. Clinical review coupled with subtle and nondiagnostic histology suggested the diagnosis of lipo-oedematous alopecia. A subsequent magnetic resonance imaging (MRI) scan demonstrated abnormal thickening of the subcutaneous fat layer of the scalp, a characteristic feature recognized as supportive of this condition, and helpful in distinguishing it from scarring alopecias and conditions such as cutis verticis gyrata. There is currently no established gold standard of treatment for lipo-oedematous alopecia and published management strategies are diverse. Reported cases describe variable responses to topical or systemic corticosteroids, surgical scalp reduction and immunomodulatory therapies. Our patient has been started on mycophenolate mofetil (MMF) 500 mg twice daily. Published cases have reported the successful use of MMF, describing hair regrowth and clinical improvement of symptoms. This suggests a potential role for systemic immunosuppression in selected progressive cases. This case highlights the importance of recognizing the clinical clue of a boggy scalp, considering lipo-oedematous alopecia in the differential diagnosis of alopecia with nondiagnostic biopsies, and utilizing MRI to support diagnostic confidence. Further case reporting is essential to improve diagnostic awareness and inform management strategies.