Brocq Pseudopelade Treatment & Management

When the lesions of pseudopelade of Brocq are burnt out, treatment is neither necessary nor possible. Unfortunately, pseudopelade of Brocq can reactivate episodically and unpredictably. If active inflammation is present, treatment may be reasonable and should focus on preventing disease progression. Even with treatment, pseudopelade of Brocq may worsen. Standardized treatment does not exist. Alzolibani et al from the University of British Columbia published the following treatment recommendations based on their clinical experience^[2] :

• Patients with active lesions with less than 10% scalp involvement: Use a combination of a topical steroid (class I or II) applied twice daily with monthly intralesional corticosteroid injections with or without topical tacrolimus.
• Patients who do not respond to topical treatment, those with greater than 10% scalp involvement, or those with rapidly progressive and aggressive disease:
• Use hydroxychloroquine with or without oral prednisone initially. The oral prednisone is only used until the antimalarial has had time to take effect, and it should then be tapered appropriately over 2 months.

When starting any patient on hydroxychloroquine, baseline laboratory evaluations (CBC count, liver function testing) and an ophthalmologic (including retinal) examination should be preformed. Blood work should be repeated every 3 months. The ophthalmologic examination should be completed annually. Clinical improvement should be noted within 3-6 months. If the patient does not respond after 6 months of therapy with hydroxychloroquine, other treatment modalities should be pursued. If improvement is seen, continuing it an additional year and then tapering the dose is reasonable. While Alzolibani et al refer to hydroxychloroquine as first-line systemic therapy, some argue that it is only useful in patients with underlying discoid lupus erythematosus (DLE).^[16]

Treatment with isotretinoin and mycophenolate mofetil (CellCept) have also been used separately, with limited success.^[2] Frequent blood work and pregnancy testing are required for both medications.

Systemic therapy should be initiated and followed by a dermatologist who is familiar with the condition and experienced with using the above systemic medications. Pseudopelade, like most scarring alopecias, is difficult to treat and, in general, responds poorly to treatment. This should be taken into account when the clinician is determining treatment options. The risks and benefits of systemic therapy should be closely scrutinized by the prescribing clinician.

Surgical correction has been used to treat scarring alopecia. As a general rule, the disease process should be dormant or stable for at least 1 year. The progressive and intermittent nature of pseudopelade (unstable alopecia) makes this determination difficult. In terms of unstable forms of alopecia, excision is the preferred surgical treatment.^[17] Factors such as scalp laxity and location are important when considering a patient for alopecia reduction. The patient should clearly know that the surgical repair may be affected by future recurrences of their disease. Hair transplantation and flap procedures are less preferred surgical methods for treating unstable alopecia.

Consultations may include a dermatologist and a plastic surgeon (if the patient is a candidate for surgical correction).