Case Report Access this article online Website: www.ijtrichology.com DOI: 10.4103/0974-7753.122970 Quick Response Code:
Annular Alopecia Areata: Report of Two Cases Manish Bansal, Kajal Manchanda, SS Pandey Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India ABSTRACT Alopecia areata (AA) is an auto‑immune disorder characterized by the appearance of non‑scarring bald patches affecting the hair bearing areas of the body. Scalp is the most common site of involvement. AA can affect any age group. The usual pattern of the hair loss is oval or round. We hereby, report two cases of annular and circinate pattern of AA due to its unusual morphology.
Address for correspondence: Dr. Manish Bansal, Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi ‑ 221 005, Uttar Pradesh, India. E‑mail: manishderma@ gmail.com
Key words: Alopecia areata, annular, scalp
INTRODUCTION
A
lopecia areata (AA) is a chronic autoimmune disease that involves hair follicles and sometimes the nails. It involves any hair bearing area of the body, but scalp is involved in most of the cases. It is the most common form of non‑scarring alopecia. It is thought to be an organ specific autoimmune disorder with a genetic predisposition.[1] AA is also associated with other auto‑immune disorders such as vitiligo, thyroid abnormalities and diabetes and are commonly reported together.[2] Alopecia of the scalp shows a great variety of shape and extent varying from a single round patch to that involving large surface area termed as alopecia totalis. Few authors have reported different patterns of AA over scalp including linear pattern and rectangular pattern.[3,4] However, annular pattern of AA has never been reported in English literature. We hereby, report two cases of AA presenting in an unusual annular pattern. CASE REPORTS
Case 1 This was a case report of a 25‑year‑old male patient who presented with the chief complaints of asymptomatic International Journal of Trichology / Apr-Jun 2013 / Vol-5 / Issue-2
loss of hair at multiple sites over the scalp for 2 month. Hair loss was annular in pattern as it was more obvious at the periphery compared with the center of the patch. There was no history of similar illness in family members and also no history of drug intake and trauma. On examination, there were multiple well‑defined annular patches of non‑scarring alopecia of size ranging from 2 cm × 3 cm to 4 cm × 4 cm present mainly at parietal and occipital region of scalp [Figure 1a]. The area was smooth with no associated skin changes. Systemic examination was within the normal limits. Potassium hydroxide (KOH) examination of hair showed no fungal elements. Fungal culture with Sabouraud’s media at 4 weeks revealed no growth. Histopathological examination from the hairless region in scalp showed a few vellus follicles in mid dermis with a sparse perifollicular lymphocytic infiltrate [Figure 1b]. The dermis and subcutis also showed several follicular stellae representing former follicular papillae. The total number of follicles was substantially reduced with no terminal follicles. On the basis of clinical examination and histopathology, the diagnosis of annular AA was made. Patient was given intralesional injections of trimacinolone acetonide (5 mg/ml) every 4 weeks and showed remarkable improvement in the 91
Bansal, et al.: Annular alopecia areata
lesions after 3 months (3 intralesional injections) of follow‑up [Figure 1c]. Case 2 A 27‑year‑old male patient presented with the chief complaints of asymptomatic loss of hair from the scalp for the past 3 months. The hair loss started as a small patch and gradually increased in size assuming an annular pattern. There was no history of similar illness in family, no history of drug intake and no history suggestive of systemic illness. On examination, a well‑defined area of non‑scarring alopecia in an annular pattern was present at the occipital region of the scalp [Figure 2]. KOH examination did not reveal any fungal hyphae. Histopathological examination of a tissue taken from the affected area confirmed the diagnosis of AA. The patient improved markedly in 5 months with the intralesional triamcolone acetonide injections (5 mg/ml) every 4 weeks.
DISCUSSION
AA is a chronic organ specific disease which affects the hair follicle and occasionally nails. The prevalence of AA has been reported to be 0.2% of the population at a time and 1.7% of the population experience an episode of AA in their life time.[1] The exact etiopathogenesis is unknown and is thought to be mediated by autoreactive T‑cells against hair follicle.[1] The histopathological features vary depending upon the stage of the disease. The earliest and the most important feature in the acute stage is peribulbar lymphocytic infiltrate, which may extend into the epithelium and hair matrix. In the later stages, inflammation may be diminished or absent.[5] AA has been reported to be associated with various autoimmune diseases such as myxedema and pernicious anemia, atopy, psychological stress and certain malignancies.[4] The onset of AA may be at any age, with a peak in first 3
Figure 1a: Pre‑treatment image of case I showing multiple areas of non‑scarring alopecia in an annular pattern
Figure 1b: Perifollicular lymphocytic infiltrates with few vellus follicles (H and E, ×40)
Figure 1c: Post‑treatment image of case I showing marked improvement after 3 months
Figure 2: Clinical image of case II showing well‑defined area of non‑scarring alopecia in an annular pattern over the occipital region
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International Journal of Trichology / Apr-Jun 2013 / Vol-5 / Issue-2
Bansal, et al.: Annular alopecia areata
decades of life and is seen equally in males and females.[1] The characteristic initial lesion is a circumscribed, bald smooth patch with short easily extractable broken hair known as exclamation mark hair at the periphery of the patch. It can also progress to alopecia totalis involving whole scalp and alopecia universalis involving hair over other body parts. Nail shows fine stippled pitting of the nail plate, but some cases also show trachyonychia or onychomadesis.[1] As there are no randomized trials, so treatment recommendations are based mainly on case series and clinical experience.[1] Counseling of patient on the nature of disease is essential. Topical corticosteroids are widely used to treat AA sometimes under occlusion.[6] Other treatment options include intralesional hydrocortisone acetate (25 mg/ml) and triamcinolone acetonide (5-10 mg/ ml) and oral corticosteroid therapy. Contact immunotherapy with dinitrochlorobenzene, squaric acid di butylester and diphenylcyclopropenone has been recommended for larger areas with variable results.[7,8] Photochemotherapy, topical minoxidil application and use of dithranol have also been tried for treatment of AA.[1]
presented cases represent a unique annular pattern not described before. We want to conclude that AA may present in any morphological pattern although the nature of the treatment and the response remains the same.
Certain unique patterns of hair loss in AA have been described in the literature recently including linear alopecia, which was described to be a variant of biopsy proven lupus profundus and rectangular pattern AA which was found to be associated with malignancies including diffuse large B cell lymphoma, alveolar soft part sarcoma and cavernous sinus arteriovenous fistula with embolization.[3,4] The above
8.
International Journal of Trichology / Apr-Jun 2013 / Vol-5 / Issue-2
REFERENCES 1.
2. 3. 4. 5. 6.
7.
Paus R, Olsen AE, Messenger GA. Hair growth disorders. In: Fitzpatrick TB, Wolff K, Goldsmith AL, Gilchrest AB, Paller SA, Leffell JD, editors. Dermtology in General Medicine. 7th ed. New york, NY: Mc‑Graw‑Hill; 2008. p. 753‑77. Thomas EA, Kadyan RS. Alopecia areata and autoimmunity: A clinical study. Indian J Dermatol 2008;53:70‑4. Rhee CH, Kim SM, Kim MH, Cinn YW, Ihm CW. Two cases of linear alopecia on the occipital scalp. Ann Dermatol 2009;21:159‑63. Shin J, Jang HS, Cho SB. Rectangular‑patterned occipital Alopecia Areata: A report of three cases. Int J Trichology 2012;4:164‑6. Stefanato CM. Histopathology of alopecia: A clinicopathological approach to diagnosis. Histopathology 2010;56:24‑38. Tosti A, Piraccini BM, Pazzaglia M, Vincenzi C. Clobetasol propionate 0.05% under occlusion in the treatment of alopecia totalis/universalis. J Am Acad Dermatol 2003;49:96‑8. Rokhsar CK, Shupack JL, Vafai JJ, Washenik K. Efficacy of topical sensitizers in the treatment of Alopecia Areata. J Am Acad Dermatol 1998;39:751‑61. Singh G, Okade R, Naik C, Dayanand CD. Diphenylcyclopropenone immunotherapy in ophiasis. Indian J Dermatol Venereol Leprol 2007;73:432‑3. How to cite this article: Bansal M, Manchanda K, Pandey SS. Annular alopecia areata: Report of two cases. Int J Trichol 2013;5:91-3. Source of Support: Nil, Conflict of Interest: None declared.
93
Copyright of International Journal of Trichology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Annular Alopecia Areata: Report of Two Cases Manish Bansal, Kajal Manchanda, SS Pandey Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India ABSTRACT Alopecia areata (AA) is an auto‑immune disorder characterized by the appearance of non‑scarring bald patches affecting the hair bearing areas of the body. Scalp is the most common site of involvement. AA can affect any age group. The usual pattern of the hair loss is oval or round. We hereby, report two cases of annular and circinate pattern of AA due to its unusual morphology.
Address for correspondence: Dr. Manish Bansal, Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi ‑ 221 005, Uttar Pradesh, India. E‑mail: manishderma@ gmail.com
Key words: Alopecia areata, annular, scalp
INTRODUCTION
A
lopecia areata (AA) is a chronic autoimmune disease that involves hair follicles and sometimes the nails. It involves any hair bearing area of the body, but scalp is involved in most of the cases. It is the most common form of non‑scarring alopecia. It is thought to be an organ specific autoimmune disorder with a genetic predisposition.[1] AA is also associated with other auto‑immune disorders such as vitiligo, thyroid abnormalities and diabetes and are commonly reported together.[2] Alopecia of the scalp shows a great variety of shape and extent varying from a single round patch to that involving large surface area termed as alopecia totalis. Few authors have reported different patterns of AA over scalp including linear pattern and rectangular pattern.[3,4] However, annular pattern of AA has never been reported in English literature. We hereby, report two cases of AA presenting in an unusual annular pattern. CASE REPORTS
Case 1 This was a case report of a 25‑year‑old male patient who presented with the chief complaints of asymptomatic International Journal of Trichology / Apr-Jun 2013 / Vol-5 / Issue-2
loss of hair at multiple sites over the scalp for 2 month. Hair loss was annular in pattern as it was more obvious at the periphery compared with the center of the patch. There was no history of similar illness in family members and also no history of drug intake and trauma. On examination, there were multiple well‑defined annular patches of non‑scarring alopecia of size ranging from 2 cm × 3 cm to 4 cm × 4 cm present mainly at parietal and occipital region of scalp [Figure 1a]. The area was smooth with no associated skin changes. Systemic examination was within the normal limits. Potassium hydroxide (KOH) examination of hair showed no fungal elements. Fungal culture with Sabouraud’s media at 4 weeks revealed no growth. Histopathological examination from the hairless region in scalp showed a few vellus follicles in mid dermis with a sparse perifollicular lymphocytic infiltrate [Figure 1b]. The dermis and subcutis also showed several follicular stellae representing former follicular papillae. The total number of follicles was substantially reduced with no terminal follicles. On the basis of clinical examination and histopathology, the diagnosis of annular AA was made. Patient was given intralesional injections of trimacinolone acetonide (5 mg/ml) every 4 weeks and showed remarkable improvement in the 91
Bansal, et al.: Annular alopecia areata
lesions after 3 months (3 intralesional injections) of follow‑up [Figure 1c]. Case 2 A 27‑year‑old male patient presented with the chief complaints of asymptomatic loss of hair from the scalp for the past 3 months. The hair loss started as a small patch and gradually increased in size assuming an annular pattern. There was no history of similar illness in family, no history of drug intake and no history suggestive of systemic illness. On examination, a well‑defined area of non‑scarring alopecia in an annular pattern was present at the occipital region of the scalp [Figure 2]. KOH examination did not reveal any fungal hyphae. Histopathological examination of a tissue taken from the affected area confirmed the diagnosis of AA. The patient improved markedly in 5 months with the intralesional triamcolone acetonide injections (5 mg/ml) every 4 weeks.
DISCUSSION
AA is a chronic organ specific disease which affects the hair follicle and occasionally nails. The prevalence of AA has been reported to be 0.2% of the population at a time and 1.7% of the population experience an episode of AA in their life time.[1] The exact etiopathogenesis is unknown and is thought to be mediated by autoreactive T‑cells against hair follicle.[1] The histopathological features vary depending upon the stage of the disease. The earliest and the most important feature in the acute stage is peribulbar lymphocytic infiltrate, which may extend into the epithelium and hair matrix. In the later stages, inflammation may be diminished or absent.[5] AA has been reported to be associated with various autoimmune diseases such as myxedema and pernicious anemia, atopy, psychological stress and certain malignancies.[4] The onset of AA may be at any age, with a peak in first 3
Figure 1a: Pre‑treatment image of case I showing multiple areas of non‑scarring alopecia in an annular pattern
Figure 1b: Perifollicular lymphocytic infiltrates with few vellus follicles (H and E, ×40)
Figure 1c: Post‑treatment image of case I showing marked improvement after 3 months
Figure 2: Clinical image of case II showing well‑defined area of non‑scarring alopecia in an annular pattern over the occipital region
92
International Journal of Trichology / Apr-Jun 2013 / Vol-5 / Issue-2
Bansal, et al.: Annular alopecia areata
decades of life and is seen equally in males and females.[1] The characteristic initial lesion is a circumscribed, bald smooth patch with short easily extractable broken hair known as exclamation mark hair at the periphery of the patch. It can also progress to alopecia totalis involving whole scalp and alopecia universalis involving hair over other body parts. Nail shows fine stippled pitting of the nail plate, but some cases also show trachyonychia or onychomadesis.[1] As there are no randomized trials, so treatment recommendations are based mainly on case series and clinical experience.[1] Counseling of patient on the nature of disease is essential. Topical corticosteroids are widely used to treat AA sometimes under occlusion.[6] Other treatment options include intralesional hydrocortisone acetate (25 mg/ml) and triamcinolone acetonide (5-10 mg/ ml) and oral corticosteroid therapy. Contact immunotherapy with dinitrochlorobenzene, squaric acid di butylester and diphenylcyclopropenone has been recommended for larger areas with variable results.[7,8] Photochemotherapy, topical minoxidil application and use of dithranol have also been tried for treatment of AA.[1]
presented cases represent a unique annular pattern not described before. We want to conclude that AA may present in any morphological pattern although the nature of the treatment and the response remains the same.
Certain unique patterns of hair loss in AA have been described in the literature recently including linear alopecia, which was described to be a variant of biopsy proven lupus profundus and rectangular pattern AA which was found to be associated with malignancies including diffuse large B cell lymphoma, alveolar soft part sarcoma and cavernous sinus arteriovenous fistula with embolization.[3,4] The above
8.
International Journal of Trichology / Apr-Jun 2013 / Vol-5 / Issue-2
REFERENCES 1.
2. 3. 4. 5. 6.
7.
Paus R, Olsen AE, Messenger GA. Hair growth disorders. In: Fitzpatrick TB, Wolff K, Goldsmith AL, Gilchrest AB, Paller SA, Leffell JD, editors. Dermtology in General Medicine. 7th ed. New york, NY: Mc‑Graw‑Hill; 2008. p. 753‑77. Thomas EA, Kadyan RS. Alopecia areata and autoimmunity: A clinical study. Indian J Dermatol 2008;53:70‑4. Rhee CH, Kim SM, Kim MH, Cinn YW, Ihm CW. Two cases of linear alopecia on the occipital scalp. Ann Dermatol 2009;21:159‑63. Shin J, Jang HS, Cho SB. Rectangular‑patterned occipital Alopecia Areata: A report of three cases. Int J Trichology 2012;4:164‑6. Stefanato CM. Histopathology of alopecia: A clinicopathological approach to diagnosis. Histopathology 2010;56:24‑38. Tosti A, Piraccini BM, Pazzaglia M, Vincenzi C. Clobetasol propionate 0.05% under occlusion in the treatment of alopecia totalis/universalis. J Am Acad Dermatol 2003;49:96‑8. Rokhsar CK, Shupack JL, Vafai JJ, Washenik K. Efficacy of topical sensitizers in the treatment of Alopecia Areata. J Am Acad Dermatol 1998;39:751‑61. Singh G, Okade R, Naik C, Dayanand CD. Diphenylcyclopropenone immunotherapy in ophiasis. Indian J Dermatol Venereol Leprol 2007;73:432‑3. How to cite this article: Bansal M, Manchanda K, Pandey SS. Annular alopecia areata: Report of two cases. Int J Trichol 2013;5:91-3. Source of Support: Nil, Conflict of Interest: None declared.
93
Copyright of International Journal of Trichology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
