Sir,

Pseudopelade of Brocq (PPB) is a primary lymphocytic cicatricial alopecia that usually presents as patchy alopecia of the parietal and vertex portions of the scalp. Diagnosis is based on clinical presentation, trichoscopy, and pathology. Herein, we report the case of Pseudopelade of Brocq in a 38-year-old female.

A 38-year-old female with no particular history presented with chronic hair loss persistent for the previous twelve months. No associated signs were noted.

A clinical examination revealed Fitzpatrick phototype IV and multiple alopecia patches that were asymmetrical, smooth, and slightly atrophic. They merged on the vertex, realizing the aspect of “footprints in the snow” (Fig. 1a). Trichoscopy showed the absence of follicular openings (Fig. 1b).

Figure 1: (a) Clinical presentation of pseudopelade of Brocq; multiple alopecia patches of the vertex and footprints with the snow appearance. (b) Trichoscopic presentation of pseudopelade of Brocq (DermLite, *10, polarized light) showing the absence of follicular openings.

A skin biopsy was performed, which showed the absence of follicles and sebaceous glands, associated with a low density of lymphocytes around the hair follicles. Direct immunofluorescence was negative.

Based on the clinical, trichoscopic, and histological findings, the diagnosis of pseudopelade of Brocq was established. Therapeutic management consisted of three intralesional corticosteroid injections (1 injection per month), followed by hydroxychloroquine at a dose of 200 mg twice a day. A follow-up showed the progression of alopecia with stabilization after one year of treatment.

Pseudopelade of Brocq (PPB) is a rare form of progressive scarring alopecia that usually affects middle-aged women [1]. It usually concerns the parietal and vertex portions of the scalp, yet PPB of the beard has also been reported [2].

There are numerous controversies concerning whether it is a distinct clinicopathological entity or a common final stage or clinical variant of other forms of scarring alopecia, such as lichen planopilaris and discoid lupus erythematosus [3].

Its clinical features consist of non-inflammatory alopecia, made of small, multiple plaques that may be atrophic, white, smooth, or sometimes discreetly pink. They are often disseminated on the scalp, creating the appearance of “footprints in the snow” [4]. Three patterns of pseudopelade are reported, including scattered, large plaques, and a combination of both [3].

Trichoscopy confirms the scarring appearance by showing the absence of hair follicles in the centers of the plaques associated with the absence of signs of other scarring alopecias, especially lichen planopilaris and lupus discoid [5].

There are no pathognomonic pathologic features of PPB [6]. Histopathological characteristics include low or only moderate lymphocytic infiltrate, the absence of significant follicular plugging, and the absence or decrease of sebaceous glands. Direct immunofluorescence is negative [7].

The effectiveness of therapeutic options is often disappointing. Several treatments are reported in the literature, including very strong local steroids, antimalarials such as hydroxychloroquine (400 mg/day), and general corticosteroids [8].

Pseudopelade of Brocq is a rare and slowly progressive form of scarring alopecia that is difficult to treat in clinical practice. The prognosis must be explained to the patient associated with psychological counseling when needed.

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