Trichotillomania or alopecia areata?

We report an adult Saudi male with trichotillomania involving the left eyebrow. The age and sex of the patient, and the site of alopecia, are atypical, making the case worth reporting. The nearest differential diagnosis, alopecia areata, is discussed in detail with comparisons between both conditions.     

Diffuse alopecia with stem cell folliculitis: chronic diffuse alopecia areata or a distinct entity?

A 34-year-old woman presented with an 8-year history of slowly progressive diffuse nonscarring alopecia with loss of hair density. Scalp biopsy specimens showed increased miniaturized follicles and an asymmetric wedge-shaped lymphocytic infiltrate concentrated on the stem cell-rich region at the point of entry of sebaceous ducts and at bulge-like regions of multiple follicles. Several hair bulbs emerging at the stem cell compartment also were inflamed, but the hair bulbs in the deeper dermis and subcutis were spared. I speculate whether these findings may represent a stem cell folliculitis similar to the reaction pattern previously observed in graft versus host disease and in androgenetic alopecia. The additional presence of peribulbar lymphocytic inflammation could indicate that the patient had a variant of alopecia areata. The clinical presentation of a slowly progressive diffuse alopecia without progression to clinically recognizable alopecia areata and the prominent lymphocytic inflammation involving the stem cell compartment may prompt a reexamination of similar cases currently classified as chronic diffuse alopecia areata. The concept that lymphocytes can inhibit stem cell function without destroying the stem cells themselves needs consideration.     

Transverse sections for diagnosis of alopecia?

Several authors have claimed usage of sections cut horizontally as being preferable to conventional cuts in vertical direction in the diagnosis of alopecias. In this article, we address in critical fashion, all statements that have been made in the literature that seem to favor sections cut horizontally in contrast to sections cut conventionally (ie, vertically) in coming to a diagnosis of diseases of the scalp. Our assessment reveals that the idea of horizontal sections being advantageous compared with sections cut vertically is based largely on the assumption that counting of follicles is the key to a diagnosis with specificity of diseases of the scalp. But a quantitative approach to diagnosis of alopecias is flawed; it does not allow differential diagnosis of common alopecias to be made with certainty. A qualitative approach, however, based on reliable and repeatable criteria applied in sections cut vertically, allows in most instances a diagnosis to be rendered precisely.     

Diagnosis: alopecia areata or not?

Alopecia areata is a common cause of hair loss in children and adults. In most cases, the diagnosis is straight forward and is easily made based on the patient's history and clinical presentation. However, in two specific scenarios, the diagnosis can be difficult and may require a scalp biopsy. We present four cases that illustrate these two problematic differentials: alopecia areata versus trichotillomania in adolescent females; and diffuse alopecia areata versus telogen effluvium versus androgenetic alopecia in adult women. Tables compare and contrast the clinical and histopathologic features of these nonscarring localized and diffuse alopecias.     

Is androgenetic alopecia a photoaggravated dermatosis?

Progressive thinning of the scalp hair in androgenetic alopecia (AGA) results in a gradual decline in natural protection of the scalp from ultraviolet radiation (UVR). A number of pathologic conditions of the scalp are evidently related to UVR, particularly photosensitive diseases and disorders of the chronically photodamaged bald scalp. The most important chronic effects of UVR are photocarcinogenesis and solar elastosis. Besides these, erosive pustular dermatosis and 'red scalp' are distinct disorders peculiar to the balding scalp. While the consequences of sustained UVR on the unprotected scalp are well appreciated, the effects of UVR on hair loss have widely been ignored. However, clinical observations and theoretical considerations suggest that UVR may have negative effects: acute telogen effluvium from UVR has been described, and the production of porphyrins by Propionibacterium sp. in the pilosebaceous duct, with photoactivation of porphyrins leading to oxidative tissue injury, has been implicated in follicular microinflammation. Alternatively, keratinocytes themselves may respond to physicochemical stress from UVR, besides irritants and pollutants, by producing radical oxygen species and nitric oxide and by releasing proinflammatory cytokines, eventually leading to injury of the putative site of follicular stem cells in the superficial portion of the hair follicle. Since all of these processes involved in hair loss share the common feature that they are induced or exacerbated by exposure to sunlight, it is proposed that AGA is a photoaggravated dermatosis that requires photoprotection.     

Chronic telogen effluvium or early androgenetic alopecia?

A 16‐year‐old girl presented with a 12‐month history of generalized hair shedding from the scalp. The onset of shedding coincided with the development of Hashimoto's thyroiditis and iron deficiency. At the time of initial presentation, the Hashimoto's thyroiditis had been treated with Neo‐Mercazole and she was euthyroid. Her iron stores were low, with a ferritin level of 13 µg/L. As she was vegetarian, oral iron replacement therapy was commenced without further investigation. On follow‐up 6 months later, her iron stores were normal (ferritin, 36 µg/L), but the hair shedding had continued. On examination, there was a positive hair pull test from both the vertex of the scalp and the occipital scalp. There was mild bitemporal recession, but no widening of the central part, and she appeared to have a full, thick head of hair ( Fig. 1 ). Additional investigations at that time revealed normal thyroid function and negative antinuclear antibody (ANA) and syphilis serology. She was on no medication other than Neo‐Mercazole. Serum testosterone, dihydroepiandosterone sulphate (DHEAS) and sex hormone binding globulin (SHBG) were normal. Two 4‐mm punch biopsies were taken from the vertex of the scalp; one was sectioned horizontally and the other vertically. The vertical section was unremarkable. On the horizontal section, there were 32 hair follicles in total, 30 of which were terminal hairs and two of which were vellus hairs. One hair was in telogen. The ratio of terminal to vellus hairs was 15 : 1.

Figure 1 Open in figure viewer PowerPoint Initial presentation     

Fibrosing alopecia in a pattern distribution: patterned lichen planopilaris or androgenetic alopecia with a lichenoid tissue reaction pattern?

BACKGROUND: Androgenetic alopecia is characterized by a defined area of progressive nonscarring alopecia. The clinical and histological findings in 15 women and 4 men with progressive scarring alopecia in a pattern distribution were studied. The results were evaluated and compared with clinicopathologic entities that feature scarring of the central scalp area, specifically, lichen planopilaris, pseudopelade, and follicular degeneration syndrome. OBSERVATIONS: Patients developed progressive fibrosing alopecia of the central scalp, without the multifocal areas of involvement typical of lichen planopilaris and pseudopelade. Perifollicular erythema, follicular keratosis, and loss of follicular orifices were limited to a patterned area of involvement. Biopsy specimens of early lesions demonstrated hair follicle miniaturization and a lichenoid inflammatory infiltrate targeting the upper follicle region. Advanced lesions showed perifollicular lamellar fibrosis and completely fibrosed follicular tracts indistinguishable from end-stage lichen planopilaris, pseudopelade, or follicular degeneration syndrome. CONCLUSIONS: Some patients with androgenetic alopecia might have additional clinical and histological features of inflammation and fibrosis limited to the area of androgenetic hair loss. In these patients, the histological findings of early lesions are identical to those seen in lichen planopilaris. The lichenoid tissue reaction leading to follicular destruction in these patients might be pathogenetically related to the events underlying androgenetic alopecia.     

Cicatricial marginal alopecia: is it all traction?

Background  In a specialized hair loss clinic, a group of patients was identified with focal or complete hair loss at the scalp periphery, with a normal scalp surface. Biopsy revealed complete loss of individual hair follicles, indicative of scarring alopecia. Not all patients had a history supportive of a diagnosis of traction alopecia.
Objectives  To identify and characterize further patients with scarring alopecia of the scalp margin using a retrospective review.
Methods  All biopsies of scarring alopecia carried out by a single clinician between 1 January 1999 and 29 September 2006 were reviewed. Patients in whom the hair loss was located at the periphery of the scalp were selected for retrospective chart review.
Results  A total of 15 patients met the study criteria, which included histological scarring alopecia and hair loss of the scalp margin. Six of the patients gave a history of relaxing or straightening their hair. Six denied hair care practices sufficient to cause traction alopecia. In three patients, the hair care history was unknown. Occipital hair loss was a common clinical finding, mimicking alopecia areata. The presence of scarring was often subtle histologically.
Conclusions  A group of patients with moderate to severe cicatricial alopecia of the scalp margin is described. The presence of scarring is difficult to diagnose both clinically and histologically. The lack of a history of severe traction or harsh styling practices in half the patients casts doubt on whether or not traction is the only pathogenic factor.     

How real is senescent alopecia? A histopathologic approach

Senescent alopecia was originally thought to affect people aged 50 years or older with no family history or evidence of pattern balding. It was described as a diffuse thinning involving the whole scalp due to a steady decrease in thick terminal hairs, but without evidence of increased miniaturization. Senescent alopecia is not a primary diagnosis in this clinic. Most possible examples of it are assumed to be androgenetic or diffuse alopecia. In the study reported here, horizontal sections of 2149 scalp specimens from individuals with male and female pattern and diffuse alopecia, as well as from normal controls, were examined, and their follicular counts were recorded and sorted into decades. The decade of 20 to 29 years contained a significant number of patients and was used for baseline follicular counts for comparison with all succeeding decades up to age 99 years. A reduction of 15% below baseline was considered significant. In 10.6% of patients with male pattern alopecia, the age of onset of a significant reduction in follicular counts was 50 years; in 5.7% of patients with female pattern alopecia it was 70 years, and in 2.0% of patients with diffuse alopecia it was 80 years. These data suggest that most cases of significant hair loss in the elderly are androgen driven. The few patients with deteriorating diffuse alopecia may be the exception. The study concluded that old age is not a significant cause of hair loss.     

Is Helicobacter pylori infection associated with alopecia areata?

Background  Alopecia areata (AA) is an immune-mediated form of hair loss that occurs in all ethnic groups, ages, and both sexes. Helicobacter pylori has been associated with certain extra-digestive dermatological conditions, including chronic urticaria, rosacea, Schönlein-Henoch purpura, Sweet syndrome, systemic sclerosis, and atopic dermatitis.
Objective  The causal relation between alopecia areata and H. pylori is discussed. We have screened for the presence of H. pylori in patients with AA in order to determine any potential role in its pathophysiology.
Patients and methods  We have prospectively studied 31 patients with AA and 24 healthy volunteers of similar gender for the presence of H. pylori surface antigen (HpSag) in stool.
Results  Optical density values for H. pylori infection were positive in 18 of all 31 patients evaluated (58.1%), while in 13 patients, values did not support H. pylori infection (41.9%). While in the control group, 10 of 24 (41.7%) had positive results. Within the group of AA, there was no significant difference between HpSag-positive and HpSag-negative patients.
Conclusions  Based on these results, the relation between H. pylori and AA is not supported. We advise that H. pylori detection should not be included in the laboratory workup of AA.     

Epidemiología clínica de la alopecia areata

. —Since Ikeda described in 1965 her four clinical forms of alopecia areata (common, atopic, prehypertensive, combined), several epidemiological studies have deepened in the knowledge of this disease, confirming or questioning many of the initial findings. The series of cases made with inpatient samples can overlue the frequency of severe forms (total and universal alopecia) and the prognosis of alopecia areata. Studies carried out in general population gives an incidence of 20.2 new cases/100,000 people/year, and a lifetime-prevalence figure of 1.7%. Slight and moderate cases are frequent, developing a total/universal alopecia in the evolution only 7% of patients. It was described also a distribution of uniform beginning of alopecia areata in all ages, and a gender- ratio next to 1:1. Finally, current genetic studies and clinical- epidemiological ones have found two clinical forms of disease («genetic» or severe, and «benign» or stress-related), with different HLA markers, evolution, clinical presentation and relationship with psychosocial stress. However, more population studies than clarify some unclear features of disease are needed.     

Androgenetic alopecia: Does its presence change our perceptions?

BACKGROUND: The aim of this study was to evaluate the effects of androgenetic alopecia on males with and without hair loss and to delineate the level of stress gained by this type of alopecia. METHODS: Two hundred and 52 males (175 with hair loss, 77 without hair loss), between 16 and 72 years of age, participated in the study. A hair loss form (five questions for sociodemographical features, eight questions for dermatological features, eight questions for psychological evaluation) and a list of stressful life events were used. RESULTS: Desire for treatment was significantly different between the participants with and without androgenetic alopesia (AGA; chi(2) = 5.877, d.f. = 1, P = 0.015). Regardless of the presence of AGA, 61.4% accepted AGA as a natural condition with a solution that should be sought, 38.5% as a cause for increased attention, and 56.2% thought that the psychological effects of AGA would mostly be negative. The negative effects of their AGA on other family members, relationships with the opposite sex and occupation/academic life were considered by 37.1%, 43.0% and 36.3% of the participants, respectively. None of the psychological parameters differed significantly between the participants with and without AGA. A small portion (5%) of the variance in perception of stress (0.22(2) = 0.048) might be explained by the degree of alopecia. CONCLUSION: Social and cultural differences might alter perceptions concerning AGA regardless of its presence in an individual.     

Migratory poliosis: A forme fruste of alopecia areata?

We describe a 19-year-old African-American man with a 14-year history of migratory poliosis. We suggest that this phenomenon may represent a forme fruste of alopecia areata.     

Serum anti-Fcγ receptor autoantibodies in patients with alopecia areata

Although anti-Fcgamma receptor antibodies (Abs) are detected in various autoimmune diseases, there have been no studies about the anti-Fcgamma receptor Abs in alopecia areata (AA). To detect the anti-Fcgamma receptor Abs in patients with AA and their clinical correlations, Serum samples from 72 patients with AA and 23 normal controls were examined by enzyme-linked immunosorbent assay assessing anti-Fcgamma receptor Ab levels. Anti-Fcgamma receptor I Abs were significantly frequently detected in patients with AA compared with normal controls. Furthermore, the detection of anti-Fcgamma receptor I Abs significantly inversely correlated with the disease duration. These results suggest that anti-Fcgamma receptor I Ab and Fcgamma receptor I play an important role in the regulation of AA, are useful for a marker of the disease prognosis and are worth intense research for the reasonable and specific therapy of AA.