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Keywords:

  • alopecia;
  • dermatopathology;
  • histopathology

To the Editor,

We read with interest the recent article by Tailor et al.,[1] which reviews the currently employed methods of alopecia specimen processing. The authors describe a variety of grossing techniques that include procedures that require one, two or three biopsy specimens to be obtained from the patient during a clinic visit to optimize the diagnostic process. Each of the methods described have their own advantages and disadvantages, as is noted in Table 2 of the manuscript. The authors report good diagnostic outco mes from their own St. John's Protocol, which utilizes two biopsy specimens, one of which is grossed horizontally and the other vertically if the clinician suspects a scarring alopecia, while both are grossed horizontally if the clinician suspects a non-scarring alopecia. The authors also introduce the ‘I don't know where to biopsy’ protocol, which can be used if the type of alopecia is ambiguous during clinical examination. With this method, two biopsies are obtained, and one is grossed horizontally and the second is grossed vertically, just like the recommended approach for a cicatricial alopecia.

As dermatopathologists with an interest in alopecia, we applaud this manuscript and its educational value. Diagnosis of alopecia can be difficult, and we can understand the desire for the increased information two or three biopsy specimens can provide. However, as in many dermatopathologic diagnostic situations, more information may not always be better, and obtaining multiple biopsy specimens may not significantly increase diagnostic efficiency. In these cost-conscious times, dermatopathologists need to balance diagnostic accuracy with cost. Therefore, we advocate the use of a single 4-mm punch biopsy as the new standard for the initial diagnostic evaluation of alopecia. Clearly one specimen can be processed and interpreted more efficiently and inexpensively than two or three.

The manuscript describes three grossing techniques for a single biopsy specimen submitted for an alopecia evaluation: the HoVert technique, the Tyler technique and the method described by Frishberg et al. The HoVert technique is accomplished by horizontally transecting the specimen 1 mm below the skin surface, bisecting the resulting epidermal disc vertically, and sectioning the remaining dermal portion of the specimen horizontally. The Tyler technique is accomplished by vertically bisecting the specimen, and then horizontally bisecting one of the resulting specimen halves. The method described by Frishberg et al. is accomplished by multiple horizontal cuts in the specimen. There are other grossing techniques for a single alopecia biopsy that are not as well documented. We have found the HoVert technique to be very effective in the diagnosis of alopecia, as it allows the evaluation of the epidermis in vertical orientation as well as the dermis in horizontal orientation. It is generally accepted that if one is choosing between horizontal sections or vertical sections for the evaluation of alopecia, horizontal sections are superior, as all follicles within the specimen can be evaluated, and additionally the technique allows for the calculation of hair cycle ratios or extent of scarring. The technique described by Frishberg et al. is similar to how many dermatopathology labs process alopecia specimens for horizontal sections. Our laboratory occasionally will pursue a similar method if the submitted specimen is not large enough to process through the HoVert method (including most biopsy specimens smaller than a 4-mm punch). However, we find the additional information seen by evaluating the epidermis in vertical sections to be of great value. We do not have experience with the Tyler technique, but we understand the value it provides in alopecia evaluation with the combination of horizontal sections and vertical sections that allow the evaluation of the epidermis and junctional zone. To date, there have not been any studies which compare the different possible alopecia grossing methods in a critical, unbiased fashion.

Not only does the use of a single biopsy specimen decrease costs and increase diagnostic efficiency, it also is more palatable for patients, as it decreases patient risk and morbidity and reduces the time spent in the clinician's office. A single biopsy specimen processed in a manner described above can also be used if the clinician is unclear if the alopecia is scarring or non-scarring.

We particularly emphasize the benefit of obtaining a single alopecia biopsy specimen in the pediatric population. While pediatric alopecia may be unusual in the general population, at our referral center these specimens are evaluated routinely. For pediatric alopecia patients, everyone involved in their care (parents, the dermatologist, as well as the patient) appreciates the least traumatic approach that can be completed efficiently and with a minimal chance of a surgical complication.

We are not totally discounting the use of multiple biopsy specimens for the evaluation of alopecia. Certainly, if an initial biopsy specimen is inconclusive, additional specimens may need to be obtained to provide supplemental diagnostic information. However, in our experience, one biopsy is enough for the vast majority of patients.

In our opinion, the initial evaluative biopsy for alopecia should consist of a single specimen, preferably one that combines in some manner evaluation of the epidermis in vertical section as well as the dermis in horizontal section. As we proceed in the era of health care reform, it will be essential for dermatopathologists to be aware of efficiencies we can employ to optimize diagnostic ability with patient satisfaction and cost containment.[2]

  • Adam I. Rubin, MD

  • John T. Seykora, MD, PhD

  • Department of Dermatology

  • Division of Dermatopathology

  • Perelman School of Medicine at the University of

  • Pennsylvania

  • Philadelphia PA 19104

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