Figure 9.1
Focal non-scarring alopecia of the scalp
Trichotillomania—This term describes self-induced hair loss either from direct pulling, twirling, or other manipulation, and can be performed either consciously or unconsciously by the patient. Often a manifestation of anxiety or obsessive-compulsive disorder, trichotillomania is typically focal, areas are not completely devoid of hair, and residual hairs are broken and of different lengths.
Telogen effluvium—Telogen effluvium refers to the sudden diffuse shedding that occurs, often following severe stress or a systemic insult such as major illness, childbirth, or surgery. Hair loss is generally non-focal.
Androgenetic alopecia—Also known as male or female pattern baldness, a combination of hormones and genetics play a causative role in androgenetic alopecia. In men, gradual thinning occurs typically over the vertex, bitemporal, and frontal scalp, whereas in women thinning begins over the top of scalp and partline, preserving the frontal hairline.
Syphilis—Classically described as “moth eaten,” patchy hair loss can be a clinical manifestation of secondary syphilis. A careful review of systems, screening for risk factors, and confirmatory blood work can aid in the diagnosis if suspected.
Further Workup
A TSH is performed and found to be within normal limits. The diagnosis of alopecia areata is made by clinical history and examination; however, a scalp punch biopsy (sent for horizontal and vertical sectioning) could give confirmation, if needed, and would typically show inflammation around the base of the follicle in a “swarm of bees” configuration.
Diagnosis
Alopecia areata
Conventional Treatment Options
Intralesional steroid injections: Typically the mainstay of therapy for alopecia areata, this treatment involves injecting the scalp (at the level of the reticular dermis) with dilute triamcinolone acetonide, typically in the strengths of 2.5–5 mg/cc mixed in normal saline (placed in depots of 0.1 cc each, spaced apart by approximately 1 cm, to cover the whole affected area). The maximum amount to be injected over the whole scalp in a single session should not exceed 3 cc of 5 mg/cc strength. Injections should be repeated at intervals every 4–6 weeks. If the steroid is placed too deep, i.e., within the subcutaneous fat, there is a higher likelihood of cutaneous atrophy.
Topical steroids: High-potency (class 1) topical steroids applied to affected areas twice daily for 4–6 weeks can be an initial treatment option for pediatric patients, those with a needle aversion, or those in whom hair appears to have already started to regrow. Caution must be exercised to avoid cutaneous atrophy, although the scalp is typically more resilient to topical steroid use.
Topical squaric acid: Squaric acid dibutylester and diphencyprone are topical contact sensitizers that are applied to the scalp in varying concentrations in different regimens, in order to induce and maintain an allergic contact dermatitis of affected areas of the scalp, as a form of immunotherapy. Response rates can vary from 17 to 100 %, depending on the duration and extent of disease.Related posts:
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