A single question can make the diagnosis.

Alopecia areata is the only condition that can cause complete hair loss in 3 months without symptoms or signs.

What looks like alopecia areata is not always alopecia areata.

The differential diagnosis of a strongly positive and painless hair pull test includes alopecia areata and loose anagen syndrome. A hair mount examined with low power light microscopy easily clarifies the diagnosis.

Health-Related Quality of Life (HRQoL) in alopecia areata patients-a secondary analysis of the National Alopecia Areata Registry Data.

Alopecia areata (AA) is a nonscarring and recurrent disease characterized by hair loss that may significantly affect patient health-related quality of life (HRQoL). Given the lack of reliable and accurate reporting of HRQoL status in patients with AA, we analyzed data from 532 AA patients from the National Alopecia Areata Registry whose registry record included HRQoL assessments using three validated instruments: Skindex-16, brief version of the Fear of Negative Evaluation Scale, and Dermatology Life Quality Index. The mean HRQoL scores were compared with previously reported HRQoL levels from healthy controls and patients with other skin diseases. Two-step cluster analysis of Skindex-16 scales divided patients into two groups: 481 (57%) with good HRQoL and 361 (43%) with poor HRQoL. Multivariate logistic regression modeling revealed a set of risk factors for poor HRQoL: age <50 years (odds ratio (OR) 3.99, 95% confidence interval (CI) 1.66-9.58), female gender (OR 2.74, 95% CI 1.73-4.34), hair loss 25-99% (OR 2.47, 95% CI 1.12-5.45), family stress (OR 1.8, 95% CI 1.13-2.86), and job change (OR 2.01, 95% CI 1.02-3.94). The current analysis provides an overview of the HRQoL status of AA patients and may guide patient care in the future.

Bone mineral density in patients with alopecia areata treated with long-term intralesional corticosteroids.

BACKGROUND: Intralesional corticosteroid injections are a common treatment for patchy alopecia areata, the most prevalent subtype of this autoimmune hair disorder. To date, no studies have examined the potential adverse effects of this therapy on bone mineral density (BMD). METHODS: In this retrospective, cross-sectional case series, 18 patients with patchy alopecia areata treated at 4- to 8-week intervals with intralesional triamcinolone acetonide for at least 20 months were evaluated for BMD using dual-energy x-ray absorptiometry (DXA). Follow-up DXA measurements were obtained in those with abnormal findings. RESULTS: Nine out of 18 patients (50%) had abnormal DXA results. Patients with the following risk factors were more likely to have abnormal BMD: age older than 50 years, body mass index less than 18.5 kg/m2, lack of weight-bearing exercise, smoking history, postmenopausal status, past stress fracture, family history of osteopenia or osteoporosis, and a cumulative intralesional triamcinolone acetonide dose of greater than 500 mg. CONCLUSION: Patients with patchy alopecia areata who receive chronic intralesional triamcinolone acetonide therapy should be counseled on preventive measures for osteoporosis and monitored for effects on BMD.

Abnormal inner root sheath of the hair follicle in the loose anagen hair syndrome: an ultrastructural study.

BACKGROUND: Loose anagen hair syndrome (LAHS) is a disorder in which the hair pulls out easily and painlessly from the scalp. It first manifests in early childhood when the main concern of parents is that the sparse hair does not grow. The hair density and length improve with age, but the looseness persists into adulthood. OBJECTIVE: Light and electron microscopic studies of hair follicles were performed to better define the microscopic changes seen in LAHS. METHODS: Biopsy specimens were obtained from 4 patients, 3 children and 1 adult. The hair follicles were studied by light and electron microscopy. RESULTS: The most conspicuous structural changes were found in the inner root sheath complex of the anagen follicle. With light microscopy, the keratinized Henle cell layer showed a tortuous and irregular swelling. Irregular keratinization of the cuticle cells of the inner root sheath and a swollen appearance of Huxley cells were also found. With electron microscopy, the major pathological changes consisted of intercellular edema in the prekeratinized Huxley cell zone and dyskeratosis of Henle cells and cuticle cells of the inner root sheath. LIMITATIONS: The studies were done on a small number of patients. CONCLUSIONS: Structural abnormalities of the inner root sheath appear to disturb its normal supportive and anchoring function and result in a loose attachment of the hair shaft to the anagen follicle.

The spectrum of hair loss in patients with mycosis fungoides and Sézary syndrome.

BACKGROUND: Alopecia can be a manifestation of mycosis fungoides (MF) and Sézary syndrome (SS), but the prevalence is unknown. OBJECTIVE: We sought to describe the clinicopathologic presentation and molecular features of alopecia in patients with MF/SS. METHODS: A retrospective chart review of a prospectively collected MF/SS database was used to identify patients with alopecia. The National Alopecia Areata Registry was used to identify patients with self-reported cutaneous T-cell lymphoma. RESULTS: Among 1550 patients with MF/SS, 38 patients with patchy, total-scalp, or universal alopecia were identified. Thirteen of 38 (34%) had patchy alopecia clinically identical to alopecia areata. Scalp biopsy specimens were available in 5 of the 13 patients. Specimens from 4 patients had atypical T lymphocytes within the follicular epithelium or epidermis, and that from two patients had a histology of follicular mucinosis. The remaining 25 of 38 (66%) patients with MF/SS included 20 with alopecia within discreet patch/plaque or follicular lesions of MF and 5 with total-body hair loss, which presented only in those with generalized erythroderma and SS. LIMITATIONS: This was a retrospective study done at one cancer center. Biopsy specimens of alopecia were not available for every patient. CONCLUSIONS: Alopecia was observed in 2.5% of patients with MF/SS, with alopecia areata-like patchy loss in 34% and alopecia within MF lesions in 66%.

The "Fringe Sign" - A useful clinical finding in traction alopecia of the marginal hair line.

INTRODUCTION: Traction alopecia is hair loss caused by prolonged or repetitive tension on the hair. Diagnostic challenges are encountered when the clinical suspicion is not high and when a history of traction is remote or not obtained. We have made the observation that the presence of retained hairs along the frontal and/or temporal rim, which we termed the "fringe sign," is a finding seen in both early and late traction alopecia, and may be a useful clinical marker of the condition. METHODS: This was a retrospective single-center review to determine the frequency of the fringe sign in patients with traction alopecia. RESULTS: Over a 3.5-year period the diagnosis of traction alopecia was made in 41 women. Twelve of the 41 patients were Hispanic (29%). Thirty-five (85%) of all women and 100 percent of women who had traction involving the marginal hairline had the fringe sign. Fourteen biopsies (58%) were available for review. Histopathologic findings included retained sebaceous glands (100%), an increase in vellus-sized hairs (50%), a decrease in terminal hairs (100%), fibrotic fibrous tracts (100%), and sparse lymphocytic inflammation (57%). CONCLUSIONS: The fringe sign is a sensitive and specific clinical feature of traction alopecia when it involves the marginal hairline.

Hydroxychloroquine and lichen planopilaris: efficacy and introduction of Lichen Planopilaris Activity Index scoring system.

BACKGROUND: Lichen planopilaris (LPP) and its variant frontal fibrosing alopecia (FFA) are primary lymphocytic cicatricial alopecias for which there is no evidence-based therapy. OBJECTIVE: We assessed the efficacy of hydroxychloroquine in active LPP and FFA using the LPP Activity Index (LPPAI), a numeric score that allows quantification of the symptoms and signs of the condition for statistical comparison. In addition, we determined with the LPPAI if any improvement (reduction) in the numeric score pretreatment and posttreatment reached statistical significance. METHODS: This was a retrospective, single-center chart review of 40 adult patients with LPP, FFA, or both who were treated with hydroxychloroquine for up to 12 months from 2004 to 2007 at the University of California, San Francisco Hair Center. Symptoms, signs, activity, and spreading were scored at each visit in the standardized cicatricial alopecia flow chart. A numeric score was assigned to these markers of disease activity and a numeric score was calculated at each visit. RESULTS: There was significant reduction (P < .001) in the LPPAI at both 6 and 12 months. After 6 months, 69% had improved (reduced) symptoms and signs. At 12 months, 83% had improvement (reduction) in symptoms and signs. LIMITATIONS: Retrospective analysis and uncontrolled study are limitations. CONCLUSIONS: Hydroxychloroquine is effective in decreasing symptoms and signs in LPP and FFA as shown by significant reduction in the LPPAI in 69% and 83% of patients after 6 and 12 months of treatment, respectively.

Efficacy and safety of mycophenolate mofetil for lichen planopilaris.

BACKGROUND: Lichen planopilaris (LPP) is a chronic inflammatory disorder that causes permanent scalp hair loss and significant patient discomfort. OBJECTIVES: We sought to determine the efficacy and safety of mycophenolate mofetil (MMF) for treatment of LPP in patients who had failed prior topical, intralesional, or oral anti-inflammatory medications such as hydroxychloroquine or cyclosporine. METHODS: We conducted a retrospective chart review of 16 adult patients with LPP treated with at least 6 months of MMF in an open-label, single-center study from 2003 to 2007. Subjective and objective end points were quantified using the LPP Activity Index (LPPAI) and scores before and after treatment were assessed using a paired t test. Adverse events were monitored. RESULTS: Patients who completed treatment with MMF had significantly decreased signs and symptoms of active LPP despite having failed multiple prior therapies (P < .005). Five of 12 patients were complete responders (LPPAI score decreased>85%), 5 of 12 patients were partial responders (LPPAI score decreased 25%-85%), and two of 12 patients were treatment failures (LPPAI score decreased<25%). Four patients withdrew from the trial because of adverse events. LIMITATIONS: Retrospective analysis and small sample size were limitations. CONCLUSIONS: MMF was effective at reducing the signs and symptoms of active LPP in 83% of patients (10 of 12) who had failed multiple prior treatments after at least 6 months of treatment.

Tinea capitis mimicking cicatricial alopecia: what host and dermatophyte factors lead to this unusual clinical presentation?

Tinea capitis is the most common dermatophyte infection in children. The clinical presentation varies from subtle asymptomatic scaling to inflammatory suppurative nodules and draining tracks. Both chronic and acute inflammatory infections may damage the hair follicle leading to secondary cicatricial alopecia. In rare instances, the initial presentation can mimic a primary cicatricial alopecia. We present three cases of tinea capitis in children masquerading as cicatricial alopecia and discuss the possible host immune and fungal antigenic factors that may influence the course of disease and its clinical presentation. An understanding of the clinical morphology of tinea capitis in the context of both host and fungal factors may improve treatment strategies and direct future paradigms of therapy.

Subcutaneous efalizumab is not effective in the treatment of alopecia areata.

BACKGROUND: Alopecia areata (AA) is a T-cell-mediated autoimmune disease. Efalizumab is a T-cell-targeted therapy approved for the treatment of psoriasis. OBJECTIVE: To assess the efficacy and safety of efalizumab in the treatment of moderate-to-severe AA. METHODS: Sixty-two patients were enrolled into this phase II, placebo-controlled trial. The trial consisted of three 12-week periods-a double-blind treatment period, an open-label efalizumab treatment period, and a safety follow-up. RESULTS: There were no statistical differences between treatment groups in percent hair regrowth, quality-of-life measures, or changes in biologic markers of disease severity after 12 or 24 weeks. In both groups, there was an approximately 8% response rate for hair regrowth (at 12 weeks). Efalizumab was well tolerated. LIMITATIONS: Numbers were too small for certain analyses. CONCLUSION: A 3- to 6-month trial of efalizumab was not effective in promoting hair regrowth in this small cohort of patients with moderate-to-severe AA.

Trichotillomania.

Patients with trichotillomania often first present to dermatologists, as patients may be unaware of or deny hair pulling and seek an etiology for their hair loss. It therefore becomes the job of the dermatologist to correctly diagnose trichotillomania as well as offer treatment options. There appear to be three groups characterized by age of onset: preschool-age children, preadolescents to young adults, and adults. Young children often have a self-limited course of hair pulling. Adults frequently have psychiatric conditions associated with their trichotillomania. Preadolescents to young adults may benefit the most from active intervention, such as increasing awareness of hair pulling behaviors and behavior modification training. The approach of a patient by age of onset is helpful in guiding a dermatologist towards effective treatment options.

Structural and molecular hair abnormalities in trichothiodystrophy.

We examined hair from 15 patients with trichothiodystrophy (TTD), a rare inherited disorder with brittle, cystine-deficient hair. They had a wide variety of phenotypes, from brittle hair only to severe intellectual impairment and developmental delay. Polarizing light microscopic examination showed alternating light and dark (tiger tail) bands under polarizing microscopy. Confocal microscopy captured structural features of breaks in intact TTD hairs. The autofluorescent appearance was regular and smooth in normal donors and markedly irregular in sections of TTD hairs possibly reflecting abnormalities in melanin distribution. Scanning electron microscopy revealed numerous surface irregularities. All TTD hair samples had reduced sulfur content. We observed an inverse correlation (R(val)=0.9) between sulfur content and percent of hairs with shaft abnormalities (trichoschisis, trichorrhexis nodosa, or ribbon/twist). There was no association between clinical disease severity and percent of abnormal hairs. Raman spectra of hairs from TTD patients and normal donors revealed a larger contribution of energetically less favored disulfide conformers in TTD hairs. Our data indicate that the brittleness of the TTD hair is dependent upon abnormalities at several levels of organization. These changes make TTD hairs excessively prone to breakage and weathering.

Changes in hair weight in men with androgenetic alopecia after treatment with finasteride (1 mg daily): three- and 4-year results.

BACKGROUND: We previously reported the effects of finasteride on scalp hair weight and count over a 2-year period in men with androgenetic alopecia (AGA). OBJECTIVE: Our purpose was to evaluate the effects of finasteride on hair weight and count over 4 years in men with AGA. METHODS: Men with AGA were randomized to receive finasteride (1 mg/d) or placebo for 192 weeks. Results of the second (weeks 96-144) and third (weeks 144-192) extension periods are reported. RESULTS: Finasteride increased hair weight at 144 and 192 weeks (week 192: finasteride, 21.6% increase from baseline; placebo, 24.5% decrease from baseline; net increase in hair weight for finasteride vs placebo = 46.0%, P < .001). Hair count also increased with finasteride at 144 and 192 weeks (week 192: finasteride, 7.2% increase from baseline; placebo, 13.0% decrease from baseline; net increase in hair count for finasteride vs placebo = 20.3%, P < .05). Finasteride was generally well tolerated. LIMITATIONS: Because this study was extended from its original 48-week duration to nearly 4 years, the sample size available for analysis decreased with time. CONCLUSION: Long-term finasteride treatment led to sustained improvement in hair weight compared with placebo. Hair weight increased to a larger extent than hair count, implying that factors other than the number of hairs, such as increased growth rate (length) and thickness of hairs, contribute to the beneficial effects of finasteride in treated men.