ABSTRACT: INTRODUCTION Hair loss is an uncommon manifestation of secondary syphilis. Its clinical manifestations include diffuse effluvium or patchy 'moth-eaten' pattern of alopecia. Although syphilitic alopecia is non-scarring hair loss often associated with other mucocutaneous lesions of secondary syphilis, it might well be the only presenting symptom of syphilis. Secondary syphilis was diagnosed in ten homosexual men who attended the City Institute for Skin and Venereal Diseases in Belgrade from January to October 2010, among them three patients were HIV positive. Syphilitic alopecia was detected in two of these three patients, both HIV positive receiving antiretroviral therapy and with the 'moth-eaten' pattern of hair loss, presented herein. CASE REPORTS Case 1. A 33-year-old homosexual man was referred to the City Institute for Skin and Venereal Diseases, complaining of reddish patches involving the penile shaft and scrotum, which had appeared two weeks before. Examination revealed a few red papulosquamous lesions with flat surfaces on the penis and scrotum and non-tender bilateral regional lymphadenopathy with no other skin lesions. Further examination also revealed a mucous patch on the tongue and patches of 'moth-eaten' alopecia in the parieto-occipital scalp regions (Fig. 1). These areas of alopecia were free from other cutaneous lesions and the hair pull test was negative. The patient had several sexual experiences with different partners during the previous six months, and he practiced unprotected receptive anal intercourse. However, he denied any previous anogenital or other skin lesions. Serologic test results included positive nontreponemal reaction; the Venereal Disease Research Laboratory (VDRL) test titer was 1:64, with specific Treponema pallidum Hemagglutination Assay (TPHA) test being positive as well. Five months before, HIV infection was detected and the patient was receiving treatment with abacavir, lamivudine and efeviranz. At that time, his CD-4 lymphocyte count was 185 per mm3. The patient was treated with 3 consecutive doses of penicillin G benzathine, 2.4 million units intramuscularly at 1-week intervals (total 7.2 million units). He experienced dramatic hair regrowth within 3 months of treatment, VDRL titer declined (1:8) and CD-4 T lymphocyte count was 362 cells/mm3. Case 2. A 30-year-old homosexual man presented to our Institute complaining of genital ulcers. Examination revealed erosions on the prepuce, non-tender bilateral regional lymphadenopathy and the 'moth-eaten' pattern of alopecia. Genital lesions appeared one month before, and had already been treated by a dermatologist with topical antibiotic cream, but the lesions remained unchanged. This patient also had several sexual partners during the previous six months, and he practiced unprotected insertive oral intercourse. Nontreponemal VDRL test titer was 1:256, with positive TPHA test. The patient was detected as being HIV positive one year before and was receiving lamivudine, zidovudine and efeviranz. His CD-4 lymphocyte count was 295 per mm3. The patient was treated with penicillin G benzathine (total 7.2 million units). All syphilitic lesions resolved within 3 months after treatment, VDRL test titer declined to 1:64 and CD-4 level was 863 cells/mm3. The patient refused to be photographed. DISCUSSION Alopecia syphilitica is not a common feature of secondary syphilis. The prevalence of syphilitic alopecia ranges from 2.9% (1) to 3.9% (2), with the highest reported rate of 11% (3). In these studies, the HIV status of syphilitic patients was not specified, since they originate from the initial era of the HIV pandemic. The course of syphilis in an HIV-infected patient may differ from the natural history of the disease (4). In the case series of secondary syphilis among homosexual men in our Institute from January to October 2010, seven (70%) patients presented with rash on the trunk, one with syphilitic hepatitis (5) and two with alopecia (20%), both HIV infected. Similarly, in one Brazilian study, 15 of 24 HIV infected patients with syphilis had secondary syphilis and 3 (20%) patients presented with patchy alopecia (6). Moreover, the HIV infection rate is high in patients with syphilis. Studies conducted in the United States revealed that the median HIV seroprevalence in men and women infected with syphilis was 15.7%, and seroprevalence among men who have sex with men and injecting drug users ranged from 64.3% to 90% and 22.5% to 70.6%, respectively (7). These facts along with the current data raise the question whether the prevalence of alopecia syphilitica differ between HIV negative and HIV positive patients, nevertheless, it could not be deducted herein because of small number of patients. The pathogenesis of alopecia syphilitica has not been completely elucidated. In the study by Nam-Cha et al., Treponema pallidum was detected in the hair follicle in syphilitic alopecia, suggesting that alopecia may be caused directly by spirochetes (8). There are two types of secondary syphilitic alopecia: uncommon 'symptomatic' type where hair loss is associated with an actual secondary lesion on the scalp, and 'essential' alopecia without visible syphilitic scalp lesions (9). Essential syphilitic alopecia could be present in a diffuse pattern with generalized thinning of the hair, as localized pattern called 'moth-eaten' alopecia, or as a combination of both. Of these, the 'moth-eaten' pattern is most frequent (10). Even though syphilitic alopecia predominantly affects scalp, hair loss can involve any body area including eyebrows, chest and legs (11). Clinically, the 'moth-eaten' pattern of alopecia may mimic trichotillomania and traction alopecia. The chief clinical and histologic differential diagnosis includes alopecia areata because both alopecias are inflammatory and non-scarring types and are mediated by a peribulbar lymphocytic infiltrate (12). On the other hand, clinical conditions that mimic diffuse syphilitic alopecia include telogen effluvium and androgenic alopecia (13). The treatment of choice for secondary syphilis is a single dose of penicillin G benzathine, 2.4 million units intramuscularly, however, our HIV positive patients were treated with 3 consecutive doses at 1-week intervals (total 7.2 million units). Alopecia usually resolves within three months of treatment (11), as described in our patients. Syphilitic alopecia should not be overlooked in patients with localized non-scarring hair loss. Complete examination of the skin and mucous membranes to detect the lesions of secondary syphilis as well as serologic tests for syphilis are mandatory to confirm the diagnosis in patients with localized non-scarring hair loss.
Acta dermatovenerologica Croatica : ADC. 04/2012; 20(1):48-50.