Differentiating between Central Centrifugal Cicatricial Alopecia, Traction Alopecia, and Alopecia Areata in Black Patients: Photographic Examples from a Clinical Trial

Abstract

Introduction. Following the initial BRAVE-AA1 clinical trial, a study addendum was added in which Black patients with severe alopecia areata (AA) were entered into open label treatment with baricitinib 4 mg for 52 weeks. Photographs were taken at screening to confirm eligibility and were reviewed by a central expert reviewer. These photographs provide an opportunity to examine diagnostic challenges in AA, in Black patients, especially women.

Methods. In the BRAVE-AA1 addendum 5 study, photographs of five planes of the scalp (left, right, posterior, frontal, and top of head) were obtained at screening and post-baseline. Camera equipment and a study-specific photography manual was provided to all sites, personnel were trained to conduct photography under similar lighting conditions and magnifications. Images were taken with polarization and cross-polarization lenses and reviewed for compliance with standardization procedures. At screening, all images were reviewed centrally by the external reviewer to determine consistency with AA. For this disclosure, images of both AA and non-AA cases were selected by the authors to illustrate key signs that can aid in differentiating AA, from the other alopecias that were observed in the screened patient population.

Results. Of the 36 patients with photographs reviewed by the central expert reviewer, 12 (33%) were diagnosed with CCCA or other scarring alopecia; 11 of these patients were female. Based on photography review, presentations involving the vertex, midscalp and parietal scalp, with sparing of the occipital scalp was suggestive of CCCA. The presence of scalp hypopigmentation and hyperpigmentation reflected the inflammatory processes and scarring associated with CCCA. The presence of “fringe sign” suggested traction alopecia; while AA was characterized by the presence of asymmetrically distributed, circular smooth bald patches. The photographic images portrayed the complexities of hair loss patterns that can occur within a single patient, and some patients had co-occurrence of more than one pattern of alopecia. Scalp biopsies were not performed which is limitation of these data.

Conclusions. Misdiagnosis of AA can occur in some patient populations with other forms of hair loss that mimic the disease. More than one type of hair loss can co-occur in a single patient, thereby limiting the maximal potential improvement a patient may experience with treatment. While photographic evidence alone may not conclusively determine the diagnosis, the present disclosure provides visual examples of helpful signs that can assist dermatologists to diagnose and to support an appropriately tailored treatment plan.