What is the recommended treatment for pseudopelade of Brocq?

Treatment for Pseudopelade of Brocq

There is no standard, evidence-based treatment for pseudopelade of Brocq (PPB), as it is a rare cicatricial alopecia with no controlled trials to guide therapy; however, based on the pathophysiology of lymphocytic scarring alopecias and clinical experience, ultrapotent topical corticosteroids (clobetasol propionate 0.05%) applied to active margins represent the most rational first-line approach to halt progression. 1, 2, 3

Understanding the Disease Before Treatment

PPB is a diagnosis of exclusion, requiring you to rule out other cicatricial alopecias that can mimic its appearance:

• Exclude lichen planopilaris (LPP) through histopathology showing lymphocytic infiltrate around follicles, follicular plugging, and direct immunofluorescence (DIF) showing IgM at the basement membrane 4, 5
• Exclude discoid lupus erythematosus (DLE) through histopathology and DIF showing immunoglobulin deposition patterns typical of lupus 4
• True primary PPB shows minimal lymphocytic infiltrate, absence of significant follicular plugging, absent or decreased sebaceous glands, and negative DIF (occasionally only IgM at basement membrane) 5

The controversy persists: 66.6% of clinically diagnosed PPB cases are actually end-stage LPP or DLE, meaning what appears as "primary PPB" may simply be burned-out inflammation from these conditions 4

Treatment Algorithm

First-Line: Ultrapotent Topical Corticosteroids

Apply clobetasol propionate 0.05% ointment to the active, advancing margins of alopecic patches using the following regimen adapted from lichen sclerosus guidelines (the closest evidence-based approach for lymphocytic scarring conditions):

• Once daily application at night for 4 weeks 6
• Then alternate nights for 4 weeks 6
• Then twice weekly for 4 weeks before reassessment 6
• Target visible erythema or any signs of active inflammation at patch borders 2, 5

Rationale: PPB shows lymphocytic inflammation (albeit minimal) destroying follicular stem cells, and ultrapotent corticosteroids suppress this inflammation 5, 3. The once-daily application is based on pharmacodynamic studies showing ultrapotent steroids need only once-daily application 6

Second-Line: Intralesional Corticosteroids

If topical therapy fails to halt progression after 3 months, inject triamcinolone acetonide 5-10 mg/mL into active margins:

• Use the same technique as for alopecia areata (the only hair loss condition with guideline-level evidence for intralesional steroids) 6
• Inject at 1 cm intervals along the advancing border 6
• Repeat every 4-6 weeks if tolerated 6

Critical caveat: Unlike alopecia areata, PPB causes permanent scarring, so the goal is halting progression, not regrowth 1, 2

Third-Line: Systemic Immunosuppression

For rapidly progressive disease unresponsive to topical and intralesional steroids, consider hydroxychloroquine 200-400 mg daily:

• This is extrapolated from DLE treatment, given the overlap between PPB and DLE in many cases 4
• Monitor with baseline and 6-month ophthalmologic exams (standard hydroxychloroquine monitoring)
• Alternative: oral corticosteroids (prednisone 0.5 mg/kg daily) for acute flares, tapered over 8-12 weeks 4

What NOT to Do

Do not use minoxidil or finasteride - these treat androgenetic alopecia through completely different mechanisms (follicular miniaturization, not inflammation-induced scarring) and have no role in cicatricial alopecia 2

Do not use contact immunotherapy (DPCP) - this is for alopecia areata, an autoimmune non-scarring alopecia with intact follicles capable of regrowth 6. PPB has destroyed follicles that cannot regenerate 1, 2

Do not delay biopsy - clinical diagnosis alone misses the majority of cases that are actually LPP or DLE, which may respond better to specific therapies 4

Monitoring and Expectations

PPB is slowly progressive over years, eventually becoming stationary with little or no visible erythema 5:

• Assess every 3 months for new patches or expansion of existing patches 2, 5
• Success is defined as halting progression, not hair regrowth - the scarring is permanent 1, 2, 3
• Most patients require long-term maintenance therapy with topical corticosteroids used intermittently when activity recurs 6

Surgical Options

Hair transplantation can be considered only after disease has been quiescent for at least 2 years, as active inflammation will destroy transplanted follicles 2