Concurrence of alopecia areata and vitiligo at the same anatomical site

Both alopecia areata and vitiligo are common skin disorders that are considered to be caused by an autoimmune response targeted to hair follicle and melanocyte antigens, respectively. The association of these two diseases in the same patient is well known, however, coexistence of alopecia areata and vitiligo within the same lesion is very rare. Herein, we report an 8-year-old boy who had colocalization of alopecia areata and vitiligo on the frontal portion of his scalp.     

Therapeutic spot and regional dermabrasion in stable vitiligo

Therapeutic spot or regional dermabrasion was carried out at 64 sites located over cosmetically unimportant hairy areas (52) and non-hairy areas (12) in 15 cases of stable vitiligo. Lesions were individually dermabraded first with either electric or manual dermabraders till pinpoint bleeding occurred. They were further deep demabraded to an appropriate depth manually. On healing, all the 64 sites were further treated with PUVA or PUVASOL. Out of 52 hairy sites 46 sites (88.5%) showed total pigmentation, 2 showed partial pigmentation and in 4 sites there was no pigmentation. Out of 12 non-hairy sites, 10 sites (88.3%) showed only perilesional hyperpigmentation along the borders with no change in the remaining 2 sites. Side effects were superficial scarring (5) and hypopigmentation (4) which improved over next 6 months. Complications were deep scarring (3) and secondary infection (1). Therapeutic spot or regional dermabrasion is useful alone or in combination with PUVA/PUVASOL for treating stable vitiligo (hairy areas).     

Alopecia areata in children: treatment with diphencyprone

Summary We assessed the efficacy of diphencyprone (DPCP) treatment in a total of 26 children with alopecia areata (AA). Sixteen children had alopecia areata totalis (AAT) and 10 had alopecia areata localis (AAL), DPCP is an absolute contact sensitizer. Twenty-five children could be sensitized with a 2% DPCP solution, whereas one child could not be sensitized. Patients were treated, once a week for at least 3 months, for up to 1 year. Twenty-one of the 25 (84%) children showed hair regrowth to a greater or lesser extent after DPCP treatment. Eight of the 25 (32%) children showed cosmetically acceptable hair regrowth. Cosmetically acceptable regrowth at the end of the study was seen in four of the 15 (27%) children with AAT and in four of the 10 (40%) children with AAL. These results are comparable with those reported in an earlier study in children with AA. Our opinion is that DPCP is a beneficial therapeutic agent in children with severe AAT and AAL showing no spontaneous remission.     

Direct immunofluorescence studies in alopecia areata and male pattern alopecia.

Direct immunofluroescence studies were performed on hairy and alopecic areas of scalp in patients with alopecia areata, alopecia totalis and male pattern alopecia. Abnormal deposits of C3 and occasionally of IgG and IgM were found in 92% of 12 patients with alopecia areata and in 21% of patients with male pattern alopecia. No abnormalities were seen in 4 patients with alopecia totalis. In both alopecia areata and male pattern alopecia, the deposits were most common along the basement zone of the inferior segment of hair follicles and occurred with equal frequency in alopecic and normal scalp. These observations suggest that immune factors may play a role in the pathogenesis of alopecia areata.     

Alopecia areata: Clinical presentation, diagnosis, and unusual cases

Alopecia areata (AA) is a nonscarring hair loss disorder with a 2% lifetime risk. Most patients are below 30 years old. Clinical types include patchy AA, AA reticularis, diffuse AA, AA ophiasis, AA sisiapho, and perinevoid AA. Besides scalp and body hair, the eyebrows, eyelashes, and nails can be affected. The disorder may be circumscribed, total (scalp hair loss), and universal (loss of all hairs). Atopy, autoimmune thyroid disease, and vitiligo are more commonly associated. The course of the disease is unpredictable. However, early, long‐lasting, and severe cases have a less favorable prognosis. The clinical diagnosis is made by the aspect of hairless patches with a normal skin and preserved follicular ostia. Exclamations mark hairs and a positive pull test signal activity. Dermoscopy may reveal yellow dots. White hairs may be spared; initial regrowth may also be nonpigmented. The differential diagnosis includes trichotillomania, scarring alopecia, and other nonscarring hair loss disorders such as tinea capitis and syphilis.     

Stress in patients with alopecia areata and vitiligo

OBJECTIVE: To study the involvement of stress before the onset/development of alopecia areata and vitiligo. PATIENTS AND METHOD: Forty-five outpatients with alopecia areata and 32 outpatients with vitiligo were enrolled. The design was a case-control study (controls had skin diseases unrelated to stress). Stressful events were evaluated using Holmes and Rahe's social readjustment rating scale. RESULTS: Mean age was around 30 years in both conditions. More than 65% of cases (both alopecia areata and vitiligo) experienced stressful events compared to 22% of controls. The odds ratio was 7.75 for alopecia areata and 6.81 for vitiligo. There was a significant difference in the mean number of stressful events between alopecia areata patients and controls (P = 0.005), and also a significant difference in the number of stressful events between men (P = 0.05) and women (P = 0.001) across these two groups. In the vitiligo group there was a significant difference in the mean number of stressful events between patients and controls only in women (P = 0.02). A potential stressful situation occurred more often in both patient groups. Alopecia areata patients described family problems in 45.6% of patients (especially women), which was statistically significant when compared to controls (P = 0.0004). Personal problems were reported by 35.7% of alopecia areata patients (P = 0.04 compared to controls). Vitiligo patients mentioned personal problems in 47% of cases (one-third were related to exams) and 31% of cases were related to job/financial problems. Again, this was statistically significant when compared to controls (P = 0.0002). CONCLUSIONS: Stress seems to play an important role in the onset and aggravation of both alopecia areata and vitiligo, mostly with one stressful event before disease onset.     

The pattern and profile of alopecia areata in Singapore--a study of 219 Asians

BACKGROUND: Alopecia areata is believed to be an autoimmune condition with a worldwide occurrence. It usually presents as patchy, nonscarring hair loss. There is a paucity of clinical data in Asians. OBJECTIVE: To study the epidemiology, clinical aspects, associations, and treatment of alopecia areata in an Asian population over a 1-year period. METHODS: Records of all newly diagnosed alopecia areata cases seen from May 1998 to April 1999 at the National Skin Center were collated with regard to the epidemiology, pattern of alopecia, and associations according to the investigational guidelines published by Oslen et al. The treatment and psychologic impact of alopecia areata were also assessed. RESULTS: Two hundred and nineteen new case referrals of alopecia areata were seen from May 1998 to April 1999. The incidence of alopecia areata was 3.8%. There were 173 Chinese (79%), 35 Indians (16%), and 11 Malays (5.0%). The male to female ratio was 1 : 1.3. The median age at presentation was 25.2 years. The majority of patients (85.5%) had their first episode of alopecia areata before the age of 40 years. Of the patients with onset of alopecia areata before the age of 40 years, 36.5% presented with extensive alopecia, compared with 5.5% above the age of 40 years (P < 0.05). Nail changes, consisting of pitting, trachyonychia, and longitudinal ridging, were reported in 23 patients (10.5%). A significant percentage of patients had an associated personal and family history of atopy (60.7%). There was no significant association between a personal history of atopy and the extent of alopecia areata. The frequencies reported for the following associated diseases were: thyroid disease, 2.3%; vitiligo, 4.1%; diabetes mellitus, 3.2%; Down's syndrome, 1.4%; and rheumatic arthritis, 0.9%. A family history of alopecia areata was reported in 4.6%. Intralesional triamcinolone acetonide was the first-line treatment for limited alopecia areata, while squaric acid dibutyl ester was used for extensive involvement. The majority of patients with limited alopecia areata (82.1%) had more than 50% improvement with intralesional triamcinolone acetonide after 3 months. The majority of patients who received squaric acid dibutyl ester (87.5%) achieved more than 50% regrowth at the end of 6 months. Poor prognostic factors for alopecia areata were extensive involvement, early age of onset, and Down's syndrome. Thirteen out of 132 respondents (9.8%) recalled stressful events preceding hair loss. Patients with extensive alopecia areata experienced more psychologic adverse effects than those with limited alopecia areata (P < 0.05). Males with extensive alopecia areata experienced more severe psychologic ill-effects, such as depression and feelings of inability to improve hair loss. CONCLUSIONS: Our findings are similar to those reported in the Western literature where alopecia areata is predominantly a disease of the young. A holistic approach is important in the management of alopecia areata as the disease can have a severe psychologic impact on an individual's well-being.     

'Black dots' seen under trichoscopy are not specific for alopecia areata

Background. ‘Black dots’ are macrocomedo‐like round structures localized to the follicular ostium, and are considered a specific trichoscopic feature of alopecia areata (AA). Aim. To characterize specific features of ‘black dots’, and assess their possible presence in common hair and scalp disorders. Methods. In total, 107 patients with hair loss [30 with alopecia areata (AA), 37 with androgenetic alopecia (AGA), 17 with chronic telogen effluvium (TE), 23 with other hair and scalp diseases] and 93 healthy controls were examined, using a videodermoscope with 20–70 times magnification. Results. There was a correlation between the black dots and the early acute phase of the various alopecia types with the presence of the black dots. Black dots were found in 11% (22/107) of patients with hair loss, including 53.3% (16/30) with AA; in 40% (2/5) of patients with severe chemotherapy‐induced alopecia, and in 100% of patients with dissecting cellulitis of the scalp (n = 2), hypotrichosis simplex (n = 1), and congenital aplasia cutis (n = 1). No black dots were seen in patients with AGA or TE. Conclusions. Black dots are not specific for AA, and may be present in other hair and scalp diseases.     

Higher concentrations of dithranol appear to induce hair growth even in severe alopecia areata

Alopecia areata (AA) is the commonest autoimmune cause of non‐scarring alopecia. Topical treatments including corticosteroids and irritants maybe beneficial. Studies report variable hair regrowth with dithranol (anthralin) but all used low concentrations (0.1–1.25%) and inconsistent measurements of AA severity. We report retrospective data (2005–2014) of 102 patients who had failed ultra‐potent topical steroids and were referred to a specialist hair clinic for treatment with dithranol up to 3%. The severity of alopecia areata tool was used and participants graded as mild (<25%), moderate (>25 to 75%), and severe (>75%) hair loss. Compared with baseline any and at‐least 50% hair regrowth [72%, 68%, 50% and 61.5%, 48.4%, 37.5%, in mild, moderate and severe AA respectively] occurred in all groups (median treatment duration 12 months). Twenty‐nine patients (28.4%) were discharged with complete regrowth; with no difference in proportions in severity groups (33.3%, 29%, and 21.9%) but in the period to discharge [7.9, 6.3, and 29.4 months (p‐values <.05)] for mild, moderate, and severe AA. Treatment trials of 12 months with dithranol at higher concentrations may be an option in patients who failed potent topical or intra‐lesional steroids) regardless of AA severity. Randomized trials (of less staining formulations) of dithranol are warranted.     

Topical immunotherapy with diphenylcyclopropenone in the treatment of chronic extensive alopecia areata

Highly variable results have been described for the use of topical diphenylcyclopropenone (DPCP) in the treatment of alopecia areata (AA). We enrolled 41 patients in a prospective open clinical trial. Of these, 17 patients had either AA totalis (AAT) or AA universalis (AAU), and 24 had severe alopecia (> 50% scalp involvement). After sensitization with DPCP 2% in acetone, progressively higher concentrations were applied once a week for a period of 6-12 months. Of the 41 patients, 38 (16 with AAT or AAU and 22 with extensive AA) completed therapy. Significant hair regrowth was observed in 15 of the 38 patients (39.5%) at 6 months: 5 with AAT or AAU (31.25%) and 10 with extensive alopecia (45.4%). The above results were sustained in 66.6% of patients for a 12-month-follow up- period. In our study, topical immunotherapy with DPCP proved to be an effective treatment, with prolonged therapeutic results.     

PROFILE OF ALOPECIA AREATA IN NORTHERN INDIA

Background. Epidemiologic studies of alopecia areata (AA) are available from USA, Japan, and European countries, but there is a paucity of literature on AA from Asian countries, especially from the Indian subcontinent. Methods. In a prospective, hospital-based study lasting for a decade (1983–1992), the epidemiology of AA was studied, including associated diseases and risk factors for development of severe AA. Simultaneously a similar study was carried out in age- and sex-matched controls. Results. Eight hundred and eight patients (532 men, 276 women) and 572 age- and sex-matched controls (370 men, 202 men) were studied. The incidence of AA was 0.7% of new dermatology outpatients. The majority of patients (712, 88%) were below 40 years of age, including 196 children < 16 years of age (24%). Almost half (46%) of the women patients had onset of AA in childhood, compared to only 19% in men (P < 0.001). Alopecia was total, universal, or extensive in 154 patients (19%). An onset in the first two decades was more often associated with severe alopecia (P < 0.001), especially in men (P < 0.01). Alopecia areata was recorded in family members of 70 patients (9%), being more frequent in the severe forms of AA (16%). Evidence of atopy was recorded in a total of 146 instances (18%). The frequency of atopy was the same in circumscribed alopecia (18.1%) and severe alopecia (18.2%). Nail changes were found in 162 patients (20%) and were more frequent in 76 (47%) with the severe form of AA (P < 0.001). On 39 occasions (5%), autoimmune-related diseases were detected: vitiligo in 15 (1.8%), thyroid disorders in 8 (1%), lichen planus in 6 (0.7%), collagen vascular diseases in 5 (0.6%), diabetes mellitus in 4 patients (0.4%), and pemphigus foliaceus in 1 (0.1%) patient. Patients with family members having vitiligo (recorded in 5.9% of patients), were more frequently affected with severe alopecia (P < 0.001). Conclusions. Alopecia areata in North Indians showed a preponderance in men (M:F = 2:1) and the majority of persons with disease (88%) were below 40 years of age. Onset in childhood was more frequent in girls or women, but the incidence of severe alopecia was higher in boys or men with onset at an earlier age. Diseases associated with autoimmunity were seen in only 5% of patients. Atopy was found to be associated in 18% of patients, but its reported association with younger age of onset and severe alopecia was not confirmed. Presence of vitiligo in family members and onset before 20 years of age, especially in boys or men, were found to be risk factors for severe alopecia. Int J Dermatol 1996; 35:22–27     

Trichotemnomania: obsessive-compulsive habit of cutting or shaving the hair

A 28-year-old woman presented with a completely hairless scalp. The disorder had started 1 year ago, and at the same time she had developed dysphonia. During the past year, her hair disease had been diagnosed as alopecia areata totalis by many specialists, including several dermatologists. A close inspection of her scalp, however, revealed that no alopecia was present, because all infundibula were filled with a hair shaft that, on microscopic examination, showed cleanly cut surfaces. A scalp biopsy specimen showed completely normal structures. The pubic area was found to be covered with hair stubs of the same length. Therefore, a diagnosis of trichotemnomania was made. This term is derived from Greek thrix (hair), temnein (to cut), and mania (madness). After a stressful life event, the patient had developed both psychogenic dysphonia and the compulsive habit to remove the hair of her scalp, eyebrows, and axillary and pubic areas by shaving. Trichotemnomania is a distinct obsessive-compulsive disorder that should not be confused with trichotillomania. The condition should be taken into account when a supposed alopecia areata looks somewhat unusual.     

A clinical study of childhood alopecia areata in Singapore

Alopecia areata (AA) is a common cause of nonscarring alopecia. The aim of this epidemiologic study is to review the clinical characteristics and treatment of childhood alopecia areata in a mixed ethnic population. The study population consisted of a total of 392 children seen over a 4-year period with AA diagnosed before the age of 16 years. The female:male ratio was 1:1.4. There were 309 Chinese (78.8%), 51 Malays (13.0%), and 32 Indians (8.2%). The mean age at the time of diagnosis was 11.2 years. The majority of patients (71.7%) had alopecia of less than 6-months duration and 6% had previous episodes of AA. Females appeared to have more severe involvement. A familial history of AA was observed in 33 patients (8.4%). Associated atopy was found in 26.6% of patients and in 32.3% of their first-degree relatives. Other associations such as vitiligo or Down syndrome were rare. For limited AA, topical and/or intralesional corticosteroid was the first-line treatment used and squaric acid dibutyl ester was the choice of treatment for patients with extensive involvement. The profile of the poor respondents to therapy included young age of onset, past history of AA, Down syndrome, and extensive involvement.     

Epitopes, avidity and IgG subclasses of tyrosine hydroxylase autoantibodies in vitiligo and alopecia areata patients

Background We previously detected antibodies against tyrosine hydroxylase (TH) in 23% of patients with nonsegmental vitiligo and in 19% of patients with alopecia areata (AA). Objectives To identify TH epitopes recognized by TH antibodies in patients with vitiligo and AA. Methods Recombinant plasmids containing defined fragments of TH cDNA were constructed. The cloned TH cDNA fragments were subsequently translated in vitro to produce a series of [³⁵S]‐labelled TH protein fragments which were then used in radioimmunoassays to analyse the immunoreactivity of sera from 18 TH antibody‐positive patients with vitiligo and so initially define TH epitope domains. Further localization of TH epitopes was investigated by antibody absorption experiments using synthetic TH peptides and nonradiolabelled, in vitro‐expressed TH protein fragments. Antibody binding to identified epitopes was confirmed in TH peptide enzyme‐linked immunosorbent assays. Results Analysis of the results obtained indicated the presence of two major antibody‐binding sites on TH between amino acids 1 and 14 (epitope 1–14) and between amino acids 61 and 80 (epitope 61–80). Of 18 patients with vitiligo and six with AA, 17 (94%) and five (83%), respectively, had antibodies against epitope 1–14. In addition, 11/18 (61%) vitiligo and 2/6 (33%) AA patient sera displayed immunoreactivity against epitope 61–80. Conclusions Two major binding sites for human TH antibodies are located at the N‐terminus of the protein. The humoral immune response to TH in vitiligo and AA is heterogeneous in nature in that patients may have antibodies to more than one TH epitope. TH antibodies from patients with vitiligo or AA can recognize identical epitopes.     

TREATMENT OF ALOPECIA AREATA WITH DIPHENCYPRONE

Forty-five patients with extensive alopecia areata were treated by local application of diphencyprone. Only eleven had satisfactory regrowth of hair. Six had moderate regrowth, and of the remaining 28 some showed regrowth of vellus hair and others had no response. The side effects of the treatment consisted of intense allergic or irritant reactions, febrile reactions, anaphylactic reaction with fainting, and vitiligo. In twelve patients progressive desensitisation was observed. As the effectiveness of this treatment is low and side effects are common and sometimes severe, we conclude that diphencyprone has no advantage in the treatment of alopecia areata.     

Immune‐related alopecia (areata and universalis) in cancer patients receiving immune checkpoint inhibitors

Cytotoxic T‐lymphocyte‐associated protein‐4, programmed cell death protein and programmed cell death protein ligand 1 monoclonal antibodies (immune checkpoint inhibitors), are used to treat various malignancies. Their mechanism of action involves the inhibition of negative regulators of immune activation, resulting in immune‐related adverse events (irAEs) including endocrinopathies, pneumonitis, colitis, hepatitis and dermatological events. Dermatological irAEs include maculopapular rash, pruritus, vitiligo, blistering disorders, mucocutaneous lichenoid eruptions, rosacea and the exacerbation of psoriasis. Alopecia secondary to immune checkpoint inhibitors has been reported in 1·0–2·0% of treated patients. Our objective is to characterize for the first time the clinicopathology of patients with alopecia areata (AA) secondary to immune checkpoint inhibitors, including the first report of anti‐PD‐L1 therapy‐induced AA, and review of the literature. Four cases of patients who developed partial or complete alopecia during treatment with immune checkpoint inhibitors for underlying cancer were identified from our clinics. Methods include the review of the history and clinicopathologic features. Three patients (75%) had AA and one had universalis. Two patients had a resolution after topical, oral or intralesional therapies and one had a resolution after immunotherapy was discontinued; all regrown hair exhibited poliosis. One of the four patients had coincident onychodystrophy. This report describes a series of four patients who developed partial or complete alopecia (i.e. areata and universalis) during treatment with immune checkpoint inhibitor therapies for cancer. The recognition and management of hair‐related irAEs are important for pretherapy counselling and interventions that contribute to maintaining optimal health‐related quality of life in patients.     

Multiple courses of pulse corticosteroid therapy for alopecia areata

Various systemic corticosteroid therapies are used for alopecia areata (AA). Pulse therapy using methylprednisolone is a treatment approach for AA. The efficacy of multiple courses of pulse therapy for various severities of AA was evaluated. AA patients with less than 50% hair loss, less than or equal to 6 months after AA onset, needed 1.9 courses of pulse therapy for vellus hair to develop. On the other hand, AA patients with more than 50% hair loss, less than 6 months after AA onset, needed more courses of pulse therapy for vellus hair to develop. Regardless of the disease duration, AA patients with less than 50% hair loss showed a good response rate (100%) after both a short period and a long period after therapy. After receiving multiple courses of pulse therapy, the AA patients with more than 50% hair loss also showed improvement with limited adverse reactions.     

PULSED ADMINISTRATION OF CORTICOSTEROIDS IN THE TREATMENT OF ALOPECIA AREATA

Background. Widespread alopecia areata (AA) is difficult to treat and modalities such as topical and systemic steroids, topical sensitizers (e.g., squaric acid dibutylester and diphencyprone), psoralen-ultraviolet A (PUVA) therapy, minoxidil, and immunomodulators have been tried. Methods. Patients with widespread alopecia (> 40% scalp involvement), including alopecia totalis (AT) and universalis (AU), were treated with 300 mg oral prednisolone pulses at 4-week intervals, for a minimum of 4 doses or until cosmetically acceptable hair growth was obtained. Response to therapy was monitored by serial photographs and patients were examined monthly for side effects of steroids. A 1000 mg oral prednisolone pulse was administered to five patients with alopecia totalis/universalis and to three failures of the 300 mg-pulse treatment. Results. Thirty-two patients (24 men, 8 women) with a mean age of 29 years were recruited. They had alopecia for a mean period of 2.8 years. Twenty-seven patients (21 alopecia areata, 5 alopecia universalis, 1 alopecia totalis) received 300 mg pulse therapy and eight patients received 1000 mg prednisolone pulses. Fourteen (58.3%) patients (13 AA, 1 AT) out of 24 evaluated treated with 300 mg pulse therapy showed complete or cosmetically acceptable hair growth. Response was evident on average after 2.4 months and was cosmetically acceptable at 4 months. Three (AA, AT, AU-one each) out of seven patients assessed for the 1000-mg pulse had cosmetically acceptable hair growth at 6–9 month. Conclusions. An oral monthly pulse of prednisolone 300 mg is effective, safe, and can be administered on an outpatient basis. It is recommended as one of the modalities for the treatment of widespread alopecia areata.     

Vitiligo and alopecia areata: apples and oranges?

Vitiligo and alopecia areata are common autoimmune diseases of the skin. Vitiligo is caused by the destruction of melanocytes and results in the appearance of white patches on any part of the body, while alopecia areata is characterized by patchy hair loss primarily on the scalp, but may also involve other areas as well. At first glance, the two diseases appear to be quite different, targeting different cell types and managed using different treatment approaches. However, the immune cell populations and cytokines that drive each disease are similar, they are closely associated within patients and their family members, and vitiligo and alopecia areata have common genetic risk factors, suggesting that they share a similar pathogenesis. Like apples and oranges, vitiligo and alopecia areata have some obvious differences, but similarities abound. Recognizing both similarities and differences will promote research into the pathogenesis of each disease, as well as the development of new treatments.     

Clinical evolution of alopecia areata with a male androgenetic alopecia pattern to sisaipho

We report the case of a 16-year-old boy who developed an advanced alopecia areata (AA) type male androgenetic alopecia (MAGA). In 6 months he lost his frontal hair line and showed a sisaipho pattern of alopecia. It probably represents a rare evolution of AA in a wave-like form.