A 30-year-old man presents with patchy hair loss, and trichoscopy reveals 'yellow dots' and 'cadaverized hairs' (black dots). The dermal pathology in alopecia areata is characterised as:

• A Fibrosis around the follicular isthmus (fibrous tract replacement)
• B Neutrophilic folliculitis with follicular destruction
• C 'Swarm of bees' peribulbar lymphocytic infiltrate targeting anagen follicle bulbs ✓
• D Non-specific perifollicular lymphocytic infiltrate without follicular destruction

Explanation

Alopecia areata shows a characteristic 'swarm of bees' pattern on histopathology — dense peribulbar CD8+ T lymphocyte infiltrate targeting anagen phase follicle bulbs. This is a Th1/CD8+ CTL-mediated process driven by IFN-γ signalling (JAK-STAT pathway). JAK inhibitors (baricitinib, ritlecitinib, deuruxolitinib) are now approved treatments for severe AA based on this mechanism. Fibrous tract replacement (permanent follicular destruction) is seen in scarring alopecias like lichen planopilaris.

Reference: Neena Khanna Illustrated Synopsis of Dermatology & STD, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.