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A case of multifocal scarring alopecia

A Chinese woman in her fifties presented with discrete areas of hair loss over her scalp for the past 2 months associated with pruritus over the affected areas. Systemic review revealed progressive effort dyspnea over the past month. Her medical history showed significant Stage 3 (pT3N2aM0) invasive ductal carcinoma of the right breast post right mastectomy and adjuvant chemotherapy 1 year ago, and borderline personality disorder with schizophrenia. Clinical examination revealed multiple scattered areas of alopecia infiltrated by slightly erythematous plaques and nodules with obliteration of follicular ostia (Fig. 1a and b). Similar plum-colored dermal nodules were seen along her mastectomy scar site (Fig. 2). A punch biopsy from the right occipital scalp was obtained (Figs. 3, 4, and 5). A punch biopsy of an infiltrated scalp nodule revealed infiltrative cords of atypical cells throughout the dermis, dispersed in a dense fibrous stroma in an “Indian-file” pattern. These cells exhibited marked pleomorphism with large atypical nuclei. Intracytoplasmic lumina were seen. These findings are consistent with metastatic breast carcinoma. In addition, hair follicle units decreased in number, and some follicular units were destroyed and replaced by tumor cells. It was subsequently delineated that the patient’s dyspnea was due to a malignant pleural effusion, and further investigations demonstrated pulmonary, osseous, and cutaneous metastases. She opted for supportive care and expired 2 months after the onset of scalp lesions. Figure 2 Plum-colored indurated plaques over mastectomy site (a)