Can you cut your alopecia biopsy needs in half?

Acta Eruditorum

Abby Van Voorhees

Dr. Van Voorhees is the physician editor of Dermatology World. She interviews the author of a recent study each month.

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In this month’s Acta Eruditorum column, Physician Editor Abby S. Van Voorhees, MD, talks with John Seykora, MD, PhD, about his recent Journal of Cutaneous Pathology article, “The HoVert technique: a novel method for the sectioning of alopecia biopsies.”

Dr. Van Voorhees: Why is there debate about the optimal means for microscopic analysis of alopecia?

Dr. Seykora: Non-scarring alopecias like androgenic and telogen effluvium are best diagnosed by assessing the phenotypes of all the follicles present in the biopsy specimen. Whereas analyzing inflammatory scarring alopecias like lichen planopilaris (LPP) and discoid lupus erythematosus (DLE), which have inflammatory changes at various levels in the biopsy specimen — the dermal/epidermal junction, the superficial portion of the hair follicle, and the dermal subcutaneous region of the biopsy specimen — requires looking at different zones of the biopsy specimen. Therefore, horizontal sections are optimal for assessing non-scarring disorders where you need to look at all the follicles in the biopsy specimens, while vertical sections provide easy visualization of all levels of the biopsy specimen in the vertical dimension, which is useful for diagnosing entities like LPP and discoid lupus. The debate usually centers around the best means of processing a biopsy to obtain the information needed to make the diagnosis. In the past we’ve been limited to horizontal or vertical sections and I think that this is an artificial limitation; we don’t need to limit ourselves to only getting horizontal or vertical sections from a single biopsy. We can get both.

Dr. Van Voorhees: How does your technique work?

Dr. Seykora: The HoVert technique is basically a technique to maximize the amount of histologic information obtained from a single punch biopsy specimen. The idea is that there are different zones in the biopsy where important diagnostic information is located. We want vertical sections of some zones and horizontal sections of other zones to maximize the information we get from a single biopsy specimen. If you think about the value of vertical sections, usually the area that’s most important is the dermal-epidermal junction. Do you have an interface reaction?

A lichenoid reaction? Does it look like LPP or lupus? Is there a spongiotic process? We’ve even had cases where we’ve diagnosed an epidermal nevus associated with localized telogen effluvium and the vertical sections of the epidermis provided us with that information and the ability to link the two. [pagebreak]

Dr. Van Voorhees: Who decides which approach to sectioning is preferred the dermatologist or the person reading the slides?

Dr. Seykora: Ideally, the dermatologist should instruct the laboratory to process the biopsy specimen the way they see fit. In most disorders, depending on the differential, but especially with telogen effluvium or androgenic alopecia, they should request horizontal sections. If there’s an epidermal process associated with the clinical differential, then we use the HoVert technique, whereas most other laboratories might do vertical sections.

Dr. Van Voorhees: Is the HoVert technique complicated? Does it add significantly to the cost of processing a specimen? Does it require special equipment? Does the clinician perform the preparation of the epidermal disc or is this done in the lab once the specimen is received?

Dr. Seykora: It can be performed in any pathology lab. It’s not complicated — we’ve got detailed diagrams that we print out for the histotechs in our lab. The technician makes horizontal cuts at various levels on a punch biopsy specimen beginning 1.2 mm below the epidermal surface. The epidermal disc that’s shaved off, composed of the top 1.2 mm, is bisected and embedded for vertical sections.

Dr. Van Voorhees: What are the advantages of the HoVert technique from a medical perspective? What is gained from this approach?

Dr. Seykora: It allows you to have both the horizontal and vertical section view from the same single biopsy sample. It’s the high-yield view of each — the high-yield view of the vertical section is at the dermal-epidermal junction, while the horizontal sections show you all the follicles and can tell you where the inflammation is located. This approach can save the patient a biopsy, it saves processing a second biopsy, and the dermatopathologist reads one fewer biopsy.

Dr. Van Voorhees: Can immunofluorescence studies be done as well on the same specimen or is this option lost?

Dr. Seykora: Usually, if people want immunofluorescence for alopecia (and this is usually for lupus erythematosus or LPP) they submit two biopsy specimens, one for formalin-fixed studies and one for direct immunofluorescence studies. In the future I think we’ll be able to do immunofluorescence studies on the same specimens that have been processed using the HoVert technique. A lot of the immunoreactants that we detect in immunofluorescence now have antibodies that we can use on formalin-fixed tissue, so we’re transitioning more toward detecting C3 or IgG at the dermal-epidermal junction using standard immunohistochemistry which we could do on these biopsies. Currently, I wouldn’t recommend that standard immunofluorescence be performed on the same specimen. [pagebreak]

Dr. Van Voorhees: Have you found that this approach to processing specimens has allowed you to more definitively distinguish between LPP and DLE?

Dr. Seykora: We’ve had good success over the last year and a half using the HoVert technique to distinguish LPP from DLE primarily because we can look at the dermal-epidermal junction and see: Is there an interface reaction associated with basement membrane thickening, which we detect using PAS stains? Or is there a lichenoid reaction associated with irregular acanthosis, hypergranulosis, and features of LPP? After analyzing the dermal-epidermal junction, we then examine the horizontal sections for the degree of inflammation, the degree of scarring, are the ecrine coils involved, and so forth. This method has provided significant value in distinguishing LPP vs. DLE; it’s very rare that we can’t lean one way or the other.

Dr. Van Voorhees: Is there a role for this technique in other types of alopecia?

Dr. Seykora: The HoVert technique is optimal for complex cases of alopecia where there are epidermal changes due to an inflammatory condition, mycosis fungoides, epidermal nevi, or situations where you have an epidermal process associated with an alopecia. It should also have value for central centrifugal cicatricial alopecia (CCCA) because it will show an absence of epidermal changes associated with more characteristic inflammatory and fibrotic changes that you see in CCCA. I don’t know if there would be value applying it to androgenic alopecia or telogen effluvium.

Ultimately, the goal is to decrease the need for doing two biopsies while obtaining a similar amount of information. That’s why we think this is a step forward in the histologic approach to diagnosis alopecia. I would encourage clinicians around the country, if they think this technique is helpful, to discuss it with their laboratory providers. The paper is in the Journal of Cutaneous Pathology and there are clear diagrams about how to process the biopsy specimen.

Dr. Seykora is associate professor of dermatology at the University of Pennsylvania Medical School. His article was published online in the Journal of Cutaneous Pathology on Jan. 19. J Cutan Pathol. 2011. doi: 10.1111/j.1600-0560.2010.01669.x.