Alopecic Plaques in a Cook

Full text

Actas
Dermosifiliogr.
2016;107(4):339---340
CASE
FOR
DIAGNOSIS
Alopecic
Plaques
in
a
Cook夽
Placas
alopécicas
en
una
cocinera
Medical
History
A
26-year-old
woman
with
no
relevant
medical
history
con-
sulted
because
the
hair
in
some
areas
of
her
scalp
had
been
gradually
falling
out
for
the
previous
2
years
and
the
rate
of
hair
loss
had
increased
in
recent
months.
She
was
diagnosed
with
alopecia
areata
(AA).
Treatment
with
mometasone
and
vitamins
produced
no
improvement.
The
patient
had
long,
wavy
hair,
which
she
wore
loose
on
the
day
she
came
to
our
clinic.
For
the
previous
4
years,
she
had
been
using
a
tight
elastic
headband
and
styling
gel
because,
as
a
cook,
she
was
required
to
wear
her
hair
up
at
work
(Fig.
1).
Physical
Examination
Physical
examination
revealed
2
symmetrical
ovoid
plaques
of
alopecia
with
diminished
capillary
density
in
the
temporal
regions,
measuring
12
×
6
cm
and
10
×
8
cm,
with
a
positive
hair-pull
test
at
the
borders
and
hair
casts
(Fig.
2).
There
was
also
a
small,
poorly
defined
frontal
plaque
with
diminished
Figure
1
夽Please
cite
this
article
as:
Ézsöl-Lendvai
Z,
I˜
niguez-de
Onzo˜
no
L,
Pérez-García
L.
Placas
alopécicas
en
una
cocinera.
Actas
Dermosi-
filiogr.
2016;107:340---341.
Figure
2
Figure
3
Hematoxylin-eosin,
original
magnification
×100.
capillary
density,
measuring
3
×
2
cm.
Trichoscopy
revealed
empty
follicular
orifices
and
areas
without
follicular
orifices.
Black
dots,
hyperkeratosis,
and
perifollicular
erythema
were
not
observed.
It
was
observed
that
the
elastic
headband
causes
traction
in
the
areas
in
which
alopecia
was
present.
Additional
Tests
Biochemistry
profile,
complete
blood
count,
ferrokinetics,
and
thyroid-stimulating
hormone
were
normal.
Histopathology
Analysis
of
transversal
and
longitudinal
sections
revealed
fibrous
tracts
of
follicular
regression
with
clumped
melanin.
Direct
immunofluorescence
was
negative
(Fig.
3).
What
Is
Your
Diagnosis?
1578-2190/©
2015
AEDV.
Published
by
Elsevier
España,
S.L.U.
All
rights
reserved.

340
CASE
FOR
DIAGNOSIS
Diagnosis
Partially
scarring
traction
alopecia
(TA)
secondary
to
long-
term
use
of
an
elastic
headband
during
work.
Clinical
Course
We
recommended
that
the
patient
stop
using
the
headband
and
prescribed
clobetasol
and
minoxidil.
Repopulation
was
not
initially
achieved.
However,
20
weeks
after
advising
the
patient
to
stop
using
the
headband,
partial
repopulation
of
the
3
plaques----especially
the
frontal
one----was
observed,
although
patchy
areas
without
follicular
orifices
persisted.
Comment
TA
is
a
mechanically
induced
type
of
alopecia.
The
most
widely
recognized
cause
of
TA
is
prolonged
and/or
repeated
tension
on
the
hair
over
a
long
period
of
time,
caused
by
various
types
of
hairstyles----tight
braids,
ponytails,
buns,
extensions,
and
hair
straightening---- o r
by
traumatic
manip-
ulation.
TA
is
characterized
by
elongated
or
linear
plaques
of
alopecia,
usually
in
the
temporoparietal
and/or
frontal
region
of
the
scalp,
the
areas
where
tension
is
greatest.1 --- 4
Hair
casts
observed
by
trichoscopy
indicate
active
trac-
tion,
but
are
not
always
present.4No
other
specific
trichoscopic
signs
are
known.
Trichomalacia
and
accumula-
tions
of
pigment
(incontinentia
pigmenti)
are
suggestive,
but
not
specific,
histopathologic
findings.
Characteristically,
the
number
of
terminal
hair
follicles
is
reduced
and
no
inflam-
matory
infiltrate
is
present.
In
advanced
stages,
terminal
hair
follicles
can
be
replaced
by
fibrosis.2
TA
is
relatively
common
in
African
American
women,
and
very
tight
African-style
braids
(cornrows)
are
the
most
com-
mon
cause
of
the
condition.5TA
is
rare
in
white
women
because
of
the
different
racial
characteristics
of
their
hair
and,
especially,
because
of
their
different
hairstyling
habits.
In
white
women,
TA
is
associated,
very
rarely,
with
wearing
ponytails
or
tight
buns
regularly
for
years.1,4
If
the
hairstyle
responsible
for
the
condition
is
not
evident
at
the
time
of
consultation,
the
physician
may
erroneously
diagnose
AA
because
both
conditions
are
characterized
by
similar
plaques
and
because
there
are
generally
no
clinical
manifestations
of
inflammation.3,4 The
differential
diagnosis
also
includes
lichen
planopilaris
and
other
mechan-
ical
alopecias
(trichotillomania
and
friction
alopecia).
TA
can
occur
in
2
phases.
In
the
initial
phase,
it
can
be
reversed
if
the
patient
strictly
avoids
all
traction
and
manip-
ulation
(the
only
effective
treatment).
If
the
cause
persists,
permanent
follicular
destruction
occurs
and
the
condition
progresses
to
irreversible
scarring
alopecia,
also
known
as
end-stage
TA
or
follicular
degeneration
syndrome.1 --- 7
The
time
needed
for
scarring
TA
to
develop
is
unknown.
It
is
therefore
essential
to
assess
the
possibility
of
TA
in
patients
with
temporoparietal
or
temporofrontal
plaques
of
alopecia
by
asking
the
patient
specifically
about
his
or
her
hairstyling
and
manipulation
habits.3,4
Occupational
cases
of
TA
caused
by
uniforms----such
as
nurses’
caps
or
nuns’
coifs----were
more
common
years
ago.1
Nowadays,
the
cause
of
TA
is
usually
cosmetic,
namely,
traction-inducing
hairstyles.
The
cause
in
our
patient----the
use
of
an
elastic
headband
at
work----suggests
occupational
TA.
References
1.
Puig
L.
Alopecias
por
tracción
y
fricción.
In:
Camacho
FM,
Tosti
A,
editors.
Montagna
Tricología.
Enfermedades
del
folículo
pilosebáceo.
Tercera
edición
Madrid:
Grupo
Aula
Médica;
2013.
p.
869---78.
2.
Bernárdez
C,
Molina-Ruiz
AM,
Requena
L.
Histopatología
de
las
alopecias.
Parte
I:
alopecias
no
cicatriciales.
Actas
Dermosifiliogr.
2015;106:158---67.
3.
Goldberg
LJ.
Cicatricial
marginal
alopecia:
Is
it
all
traction?
Br
J
Dermatol.
2009;160:62---8.
4.
Tosti
A,
Miteva
M,
Torres
F,
Vincenzi
C,
Romanelli
P.
Hair
casts
are
a
dermoscopic
clue
for
the
diagnosis
of
traction
alopecia.
Br
J
Dermatol.
2010;163:1353---5.
5.
Rucker
Wright
D,
Gathers
R,
Kapke
A,
Johnson
D,
Joseph
CL.
Hair
care
practices
and
their
association
with
scalp
and
hair
disorders
in
African
American
girls.
J
Am
Acad
Dermatol.
2011;64:253---62.
Z.
Ézsöl-Lendvai,a,∗L.
I˜
niguez-de
Onzo˜
no,b
L.
Pérez-Garcíaa
aServicio
de
Dermatología,
Complejo
Hospitalario
Universitario
de
Albacete,
Albacete,
Spain
bServicio
de
Anatomía
Patológica,
Complejo
Hospitalario
Universitario
de
Albacete,
Albacete,
Spain
∗Corresponding
author.
E-mail
address:
ezsolsofia@yahoo.it
(Z.
Ézsöl-Lendvai).