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Elastic Staining in Differentiating Between Follicular Streamers and Follicular Scars in Horizontal Scalp Biopsy Sections

Tan, Timothy DO*; Guitart, Joan MD†,‡; Gerami, Pedram MD†,‡; Yazdan, Pedram MD

The American Journal of Dermatopathology: April 2018 - Volume 40 - Issue 4 - p 254–258
doi: 10.1097/DAD.0000000000000973
Original Study

Background: Accurate identification of follicular streamers versus follicular scars on horizontal scalp biopsy sections is important to differentiate between cicatricial and noncicatricial alopecias. However, distinguishing between them can be difficult especially in nonoptimal specimens. The utility of elastic Verhoeff–Van Gieson (EVG) stain in cicatricial alopecias has been described on vertical sections, but its evaluation on horizontal sections has not been performed.

Methods: Sixty-four cicatricial alopecias (25 lichen planopilaris, 29 central centrifugal cicatricial alopecias, and 10 discoid lupus erythematosus) and 53 noncicatricial alopecias (34 androgenic alopecia, 8 telogen effluvium, and 11 alopecia areata) were identified, and EVG staining was performed on horizontal sections.

Results: In follicular streamers, EVG highlighted an intact elastic network composed of delicate and thin elastic fibers circumferentially surrounding the angiofibrotic streamer without elastic network attenuation, loss, clumping, thickening, or recoil. In follicular scars, EVG demonstrated central attenuation and loss of the elastic network with peripheral clumping and recoil of elastic fibers.

Conclusions: In cases where distinguishing between follicular streamers and scars is difficult, EVG may be a helpful adjunctive tool in this regard and aid in allowing better discrimination between cicatricial and noncicatricial alopecias.

Departments of *Pathology, and

Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL; and

Robert H. Lurie Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.

Correspondence: Pedram Yazdan, MD, Department of Dermatology, Northwestern University, 676 N. Saint Clair Street, Suite 1600, Chicago, IL 60611 (e-mail:

Dr. Gerami has served as a consultant to Myriad Genomics, DermTech Int., and Castle Biosciences and has received honoraria for this. Dr. Guitart has served as a consultant for and received grants from Actelion, Therakos, Medivir, and Leo Pharma. The other authors declare no conflicts of interest.

Presented in part at the International Society of Dermatopathology, Nineteenth Joint Meeting; March 2, 2016–March 3, 2016; Arlington, VA.

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