Alopecia Areata

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Topical corticosteroids and topical anthralin may be helpful and are fairly safe treatments for alopecia areata. Intralesional corticosteroids and psoralens with ultraviolet light have been used. Generally the adverse effects of systemic corti-costeroids do not warrant their use. Appropriate referrals for hairpieces and informing the patient of the existence of the National Alopecia Areata Foundation (P.O. Box 150760, San Rafael, CA 94915-0760; telephone: 415-456-4644) for education information and local support group information are often helpful in this frequently very stress-producing disorder that lacks an effective treatment.

TRICHOTILLOMANIA

1. Selective serotonin reuptake inhibitors may be effective.

2. Clomipramine (Anafranil) has been reported effective for some patients with trichotillomania. Scarring (Cicatricial) Alopecia

As skin disorders that can lead to a scarring hair loss one should include discoid lupus erythematosus, scleroderma, lichen planus (lichen planopilaris), fungal infections, and prolonged inflammatory tinea. Metastatic carcinoma and trauma of various types can cause scarring hair loss. A skin biopsy and a fungal culture are indicated to help establish the diagnosis in cases of scarring alopecia ( Fig 27.16).

One particular type of trauma from the use of hot combs may cause scarring hair loss, but 10 African-American women recently diagnosed with "hot comb" alopecia may instead have an idiopathic follicular degeneration syndrome characterized by premature desquamation of the inner root sheath (Sperling and Sau, 1992).

Headington suggests (Headington, Dermatol Clin 1996) that the follicular degeneration syndrome may not be a true clinicopathologic entity and that various hair care practices including chemical straightening as well as hot combs and hair styles involving tight traction perhaps lead to a scarring alopecia. Perhaps the more nebulous term scarring vertex alopecia in African Americans is a more appropriate umbrella under which to place "hot comb" alopecia and "follicular degeneration syndrome" for now.

Another "new" scarring hair loss reported in Australia termed postmenopausal frontal fibrosing alopecia may in fact be a frontal variant of lichen planopilaris (Kossard, 1997). This was described as progressive, asymptomatic, marginal scarring hair loss extending to temporal and parietal areas in menopausal women.

Lichen planopilaris usually presents as a patchy, scarring hair loss that is progressive and may be associated with lesions of lichen planus elsewhere on the skin. Early lesions of lichen planopilaris show lichenoid changes, but late lesions of lichen planopilaris may just show scarring and be fairly nondiagnostic. Antimalarials may show modest effectiveness; topical and intralesional steroids may be ineffective.

Folliculitis decalvans is a chronic folliculitis of unclear cause. It is characterized by recurrent, progressive pustules that gradually extend and destroy the hair follicle. Bacterial cultures may reveal Staphylococcus aureus but usually reveal nonpathogenic organisms. Fungal cultures should be done to exclude a scarring type of tinea capitis. Favus of the scalp caused by Trichophyton schoenleinii may mimic this disease. Therapy with oral antibiotics is occasionally effective.

Pseudopelade of Brocq (alopecia cicatrisata) is a scarring alopecia of unknown cause that presents with skin-colored areas of permanent hair loss without a clinically evident folliculitis. It may be a separate entity or the end stage of another skin disorder such as lichen planopilaris. There is no effective treatment.

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