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3 Benoit T, Bacelieri R, Morrell DS, Metcalf J. Viralassociated trichodysplasia of immunosuppression: report of a pediatric patient with response to oral valganciclovir. Arch Dermatol 2010; 146: 871–874. 4 Schwieger-Briel A, Balma-Mena A, Ngan B, et al. Trichodysplasia spinulosa – a rare complication in immunosuppressed patients. Pediatr Dermatol 2010; 27: 509–513.

Woolly hair nevus: neonatal alopecia can be an initial manifestation

Dear Editor, Woolly hair nevus is a rare, nonhereditary condition characterized by tightly curled hair in restricted areas of the scalp. Woolly hair nevus first appears at birth or when the scalp hair begins to grow.1 Here we report a case of woolly hair nevus in which a patch of hair loss at birth was the initial manifestation. A 12-day-old Japanese boy presented with a patch of scalp showing hair loss since birth. Examination found an area measuring about 4 cm in diameter showing hair loss on the right occipital region (Fig. 1a). The alopecic patch did not show complete hair loss but rather demonstrated sparse thin hair. There were no broken hairs and exclamation point hairs, and a hair pull test was negative at the periphery of the patch. The patient was otherwise in good health. There was no family history of hair disease. We could not establish a diagnosis and decided to take a wait-and-see approach. One year later, when the baby was brought back to our hospital, there were many short curly hairs growing in the alopecic patch. These hairs were smaller in diameter and lighter in color than the surrounding scalp hair (Fig. 1b). On the left side of the nape of the neck, there was a light brown, slightly elevated pigmented lesion (Fig. 1c). Based on the clinical appearance, we finally diagnosed the lesion as woolly hair nevus. Woolly hair nevus is a rare condition associated with unruly, curly hair in limited to well-demarcated areas of the scalp. The woolly hair is generally a different color and a smaller diameter hair shaft than the normal hair. About 50% of woolly hair nevi are associated with an ipsilateral pigmented, or epidermal nevus, usually on the neck or arm. Woolly hair nevus is usually apparent at birth or when the hair starts to grow. In our case, woolly hair nevus was not apparent at birth; instead, the patient exhibited a patch of hair loss resembling alopecia areata. This alopecic patch did not show complete hair loss but rather showed some short thin hair, although there was no apparent woolly hair. However, when the patient returned to our hospital one year after birth, woolly hair had become obvious. We International Journal of Dermatology 2013, 52, 1567–1624

5 van der Meijden E, Janssens RW, Lauber C, et al. Discovery of a new human polyomavirus associated with trichodysplasia spinulosa in an immunocompromised patient. PLoS Pathog 2010; 6: e1001024. 6 Matthews MR, Wang RC, Reddick RL, et al. Viralassociated trichodysplasia spinulosa: a case with electron microscopic and molecular detection of the trichodysplasia spinulosa-associated human polyomavirus. J Cutan Pathol 2011; 38: 420–431.

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Figure 1 (a) A patch of hair loss in the right occipital region. (b) Woolly hair nevus was apparent 1 year later. (c) A lightbrown, slightly elevated pigmented lesion on left side of the nape of the neck ª 2013 The International Society of Dermatology

Correspondence

think that the reason the woolly hair presented as only short thin hair at birth is that it grew at a slower rate than the normal hair, as previously indicated.2 Our case demonstrated, for the first time, that neonatal alopecia could be the initial sign of woolly hair nevus. There are certain diseases that could show patches of hair loss in neonate, including alopecia areata, triangular alopecia, aplasia cutis, congenital nevi, post-traumatic alopecia due to uterine pressure during labor, or occipital alopecia of the newborn.3 We propose that woolly hair nevus should be included in the differential diagnosis of neonatal alopecia. It should also be remembered that neonatal alopecia can be a sign of complex syndromes such as Adams–Oliver syndrome, Hallermann–Streiff syndrome, or trisomy 13.4 Furthermore, woolly hair nevus can be associated with abnormalities of other organs.5,6 Careful consideration of the differential diagnosis in neonatal alopecia is an important role of the dermatologist. Kazutoshi Murao, MD, PhD Yoshiaki Kubo, MD, PhD Seiji Arase, MD, PhD Department of Dermatology, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan

Photodynamic therapy for necrobiosis lipoidica is an unpredictable option: three cases with different results

Editor, Photodynamic therapy (PDT) is suitable for the treatment of actinic keratoses, superficial and selected nodular basal cell carcinomas, and Bowen’s disease.1 Off-label indications are progressively increasing and include, in addition to neoplasias, infectious and inflammatory cutaneous diseases. We report our experience with three patients with histologically confirmed diagnoses of necrobiosis lipoidica (NL) on their shins treated with PDT. They had previously been treated with repeated courses of high-potency topical corticosteroids for four weeks twice per day without improvement. Patient 1 (female, aged 60 years, 12-month diagnosis of NL) and Patient 3 (female, aged 28 years, 4-month diagnosis of NL) had diabetes mellitus, whereas Patient 2 (female, aged 35 years, 24-month diagnosis of NL) was otherwise healthy. All patients were treated with methylaminolevulinic (MAL) acid cream (Metvix; Galderma International, Paris, France) under occlusion for three hours, followed by irradiation with red light (630 nm, 37 J/cm2, 7.5 min) using a light-emitting diode source (Aktilite; PhotoCure ASA, Oslo, Norway). The intervals between sessions ranged from 1 to 3 months. The number of sessions ª 2013 The International Society of Dermatology

Kazutoshi Murao, MD, PhD 3-15-18 Kuramoto-cho Tokushima City Tokushima 770-8503 Japan E-mail: [email protected] Conflicts of interest: None.

References 1 Reda AM, Rogers RS, Peters MS. Woolly hair nevus. J Am Acad Dermatol 1990; 22: 377–380. 2 Goldin HM, Bronson DM, Fretzin DF. Woolly-hair nevus: a case report and study by scanning electron microscopy. Pediatr Dermatol 1984; 2: 41–44. 3 De Viragh PA, Giannadda B, Levy ML. Congenital alopecia areata. Dermatology 1997; 195: 96–98. 4 Bardazzi F, Neri I, Raone B, et al. Congenital alopecia areata: another case. Dermatology 1999; 199: 369. 5 Tay YK, Weston WL, Ganong CA, et al. Epidermal nevus syndrome: association with central precocious puberty and woolly hair nevus. J Am Acad Dermatol 1996; 35: 839–842. 6 Al-Harmozi SA, Mahmoud SF, Ejeckam GC. Woolly hair nevus syndrome. J Am Acad Dermatol 1992; 27: 259–260.

depended on the response (two sessions in Patient 1, one session in Patient 2, three sessions in Patient 3). Necrobiosis lipoidica plaques were evaluated before treatment, at one week after each session, and three months after the last session by two independent observers. In Patient 1, the plaques showed no changes. Likewise, Patient 2 was classified as a non-responder; she demonstrated initial worsening at the evaluation performed seven days after PDT as a result of transient PDT-associated adverse events, but three months later the appearance of the NL plaques was similar to that seen prior to PDT (Fig. 1). Patient three experienced great improvement after the second session (Fig. 2). Pain during irradiation was the most common side effect. Necrobiosis lipoidica is a disorder that involves the degeneration of collagen with a granulomatous response, thickening of blood vessel walls, and fat deposition.2 Its pathogenesis is unknown, and diabetic microangiopathy may play a role.2,3 In NL, plaques range in color from red– brown to dark purple or yellow. Ulcerations and telangiectasias may occur.3 The legs are commonly involved, but other localizations have been described.4 In general, NL plaques are anesthetic. However, in some cases they may be painful, itchy, or evolve into infected ulcerations.5 Several therapeutic approaches with limited success have been International Journal of Dermatology 2013, 52, 1567–1624

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Woolly hair nevus: neonatal alopecia can be an initial manifestation.

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