Alopecia syphilitica, a simulator of alopecia areata: histopathology and differential diagnosis

Alopecia syphilitica (AS) may be "moth-eaten" or diffuse, clinically, and be confused with alopecia areata (AA) or other alopecias. The English language literature contains scant information regarding the histopathology of AS, and the resemblance between AS and AA has not been given adequate recognition. We report the histopathological findings of AS from nine patients with secondary syphilis and acute hair loss. The alopecia was moth-eaten in four patients and diffuse, but slightly moth-eaten, in five. Microscopically, the dermoepidermal interface was not involved. The numbers of hair follicles were diminished, with increased numbers of catagens and telogens. Lymphocytic infiltration was present around the hair bulbs and fibrous tracts in eight cases. Plasma cells were present in four biopsies. Other less common findings included lymphocytes in the isthmus, parabulbal lymphoid aggregates, and granulomatous infiltrate in the upper dermis. The findings, save for the follicular changes, resembled those of macular/maculopapular syphilides outside the scalp. With the follicular changes, the overall patterns resembled AA closely. The modified Steiner stain did not reveal spirochetes in any of our cases and failed to differentiate between AS and AA. Comparing the AS cases to 13 cases of AA, we found only a few differentiating features. The presence of peribulbal eosinophils strongly suggests AA. Without peribulbal eosinophils, the presence of plasma cells, abundant lymphocytes in the isthmus, or parabulbal lymphoid aggregates suggests AS.