Follicular skin diseases
Hair problems case challenge 2
The next patient with hair loss is a young man presenting with bald areas on his chin that have appeared within the last six weeks. He denies symptoms, telling you he’s had a couple of pimples as well (which explains the scabs). No other area is affected.
Which of the following descriptions of hair loss are most suitable?
*! Localised non-scarring alopecia
* Anagen effluvium
* Localised cicatricial alopecia
* Pattern alopecia
Explanation: This is localised non-scarring alopecia. In this case, anagen hairs may be lost, but he does not have the generalised process anagen effluvium (which may be caused by chemotherapy, for example). Cicatricial means scarring but none is present. In males, pattern alopecia refers to androgenetic alopecia.
The most likely diagnosis is:
*! Alopecia areata
* Pseudosycosis barbae
* Tinea barbae
Explanation: Trichotillomania, or hair loss due to self-manipulation, mainly affects children and adolescents and rarely causes complete baldness. Pseudosycosis barbae is shaving rash, a form of irritant folliculitis affecting the beard area. Tinea barbae (dermatophyte fungus infection) may cause pustules, but characteristically there is scaling within moth-eaten areas of hair loss. The correct diagnosis is alopecia areata.
The natural history of alopecia areata is unpredictable. In a first episode of localised disease, the chance of complete regrowth is approximately what percent:
Short answer: In a first episode of localised disease, the chance of complete regrowth is approximately 80%. However, about half will relapse with hair loss in the original or a new site.
Which of the following treatments would you recommend?
* A brief course of oral prednisone
* Short-contact dithranol
*! Mid-potency topical steroid gel
* Potent steroid in an ointment base
Explanation: As the prognosis is good, and there is only poor evidence that any treatment has an effect on outcome, it is acceptable to provide an explanation and no specific treatment. However, most patients and doctors prefer to actively manage the disorder and all the listed treatments are used for alopecia areata.
Explanation: However, this patient has very limited alopecia areata and it would not normally be appropriate to use systemic steroids because of high risk-benefit ratio. Even when applied “short-contact” i.e. for 10 to 30 minutes, dithranol may irritate and stain, clearly undesirable on facial skin. Although a potent topical steroid in an ointment base may have greater anti-inflammatory effect than a less potent product, it is also likely to result in folliculitis or periorificial dermatitis when applied to the chin. The correct choice is therefore mid-potency topical steroid gel.
The patient is satisfied with your explanation and prescription.
He comes to see you again six months later. The beard area appears normal, but now he has two bald areas in his scalp.
This time, he sees a dermatologist who treats the affected areas with intralesional triamcinolone acetonide injections. Which of the following doses is appropriate?
* 5ml 0.1mg/ml
*! 1ml 10mg/ml
* 0.1ml 40mg/ml
* 1ml 40mg/ml
Explanation: Triamcinolone acetonide standard vials contain 1ml of 10mg or 40mg. The stronger preparation frequently causes subcutaneous atrophy. Most dermatologists inject 0.1ml of 10mg/ml at 1-cm intervals, with a maximum of 20mg on a single occasion. However, sometimes this is diluted with normal saline to 5mg/ml.
Refer to your textbook or the emedicine dermatology article on alopecia areata.
Which of the following statements support the contention that alopecia areata is an autoimmune disease?
# A positive family history is elicited in 10-20% subjects
# Decreased levels of the neuropeptide calcitonin gene-related peptide
#! Antibodies to anagen phase hair follicles are present in 90% affected patients
#! Association with thyroid diseases and vitiligo
Explanation: Antibodies to anagen phase hair follicles are present in 90% affected patients and alopecia areata is associated with an increased incidence of thyroid diseases and vitiligo in patients and their relatives. Decreased levels of the neuropeptide calcitonin gene-related peptide support a relationship to perifollicular nerves. A positive family history supports autoimmune conditions but could also be found in disorders due to infection and genetic mutation.
Patients with severe alopecia areata are generally advised that there is no reliable treatment.
Which of the following therapies have evidence to support their use in alopecia areata?
# Topical cyclosporin
#! Diphencyprone topical immunotherapy
# Oral minoxidil
#! Topical methoxsalen
Explanation: Oral but not topical cyclosporin has been effective for alopecia areata, perhaps because of immunosuppression, perhaps because hypertrichosis is a side effect. It is rarely used because of the potential risks and side effects and recurrence of hair loss when it is discontinued. Immunotherapy with diphencyprone probably has the highest response rate but results in undesirable contact dermatitis of patient, spouse and health professionals. It is not available in New Zealand. Topical minoxidil 5% is a safe and well-tolerated treatment and may be effective in up to 50% of patients with moderate alopecia areata. Oral and topical methoxsalen photochemotherapy is sometimes helpful but there are high relapse rates with continued treatment or when it is discontinued.