87: Alopecia Areata

Question 1

What is alopecia areata and how does it present clinically?

Answer 1

Alopecia areata is a nonscarring hair disorder that can affect both genders and all age groups, with a higher incidence in younger individuals. Clinically, it presents with well-demarcated round or oval bald spots on the scalp or other parts of the body.

Question 2

What are the characteristic hallmarks of alopecia areata?

Answer 2

The characteristic hallmarks of alopecia areata include: 1. Black dots (cadaver hairs, point noir): Hair that breaks off by the time it reaches the skin surface. 2. Exclamation point hairs: Hairs with a blunt distal end that taper proximally, appearing when broken hairs are pushed out of the follicle.

Question 3

What is the etiology and pathogenesis of alopecia areata?

Answer 3

Alopecia areata is considered a chronic, organ-specific autoimmune disease. Key points include: - Autoactive, cytotoxic CD8 T cells affect hair follicles and nails, driven by an interferon gamma immune response. - IFN γ and induced chemokines are main drivers of disease pathogenesis. - NK cells may play a regulatory role in the condition.

Question 4

What diagnostic features are used to identify alopecia areata?

Answer 4

The diagnosis of alopecia areata is supported by: 1. Clinical features leading to diagnosis. 2. Positive family history. 3. Presence of associated diseases (e.g., thyroid disease). 4. Dermatoscopic evaluation showing: - Follicular ostia - Exclamation point hair - Cadaver hair (black dots in follicular ostia) - Yellow dots 5. Biopsy for sudden diffuse AA showing generalized miniaturization and immune infiltrate around hair bulbs.

Question 5

What is the significance of stress perception in alopecia areata?

Answer 5

Stress perception may influence the onset and exacerbation of alopecia areata, indicating a potential link between psychological factors and the autoimmune response in this condition.

Question 6

A 10-year-old child presents with well-demarcated round bald spots on the scalp. What is the most likely diagnosis, and what clinical features would confirm it?

Answer 6

The most likely diagnosis is alopecia areata. Clinical features include black dots (cadaver hairs), exclamation point hairs, and possibly nail changes like pitting or sandpaper nails. Dermatoscopic evaluation may show follicular ostia, cadaver hairs, and yellow dots.

Question 7

A patient with alopecia areata has a family history of autoimmune diseases. What is the likely etiology and pathogenesis of their condition?

Answer 7

Alopecia areata is a chronic, organ-specific autoimmune disease. Cytotoxic CD8 T cells attack hair follicles, driven by an interferon-gamma immune response. A positive family history is common, occurring in 10-42% of cases.

Question 8

A patient with alopecia areata reports sudden whitening of their hair. What is this phenomenon called, and what causes it?

Answer 8

This phenomenon is called canities subita. It occurs because white hairs are spared by the disease, creating the illusion of sudden whitening.

Question 9

A patient presents with alopecia areata and thyroid disease. What other associated disorders should be considered?

Answer 9

Other associated disorders include vitiligo, atopic dermatitis, psoriasis, cataracts, Cronkhite-Canada syndrome, and Down syndrome.

Question 10

A biopsy of a patient with alopecia areata shows a ‘swarm of bees’ pattern. What does this indicate?

Answer 10

The ‘swarm of bees’ pattern indicates peribulbar immune infiltrate (CD8, CD4, NK cells) centered around the hair bulb, which is characteristic of the acute phase of alopecia areata.

Question 11

A patient with alopecia areata has a positive family history and reports stress as a trigger. How do these factors influence the condition?

Answer 11

A positive family history indicates a hereditary component, and stress perception can influence the onset and exacerbation of alopecia areata.

Question 12

A patient with alopecia areata has black dots visible on dermatoscopic evaluation. What do these black dots represent?

Answer 12

Black dots represent cadaver hairs or residual hair shafts visible in follicular ostia.

Question 13

A patient with alopecia areata has exclamation point hairs. What do these hairs indicate?

Answer 13

Exclamation point hairs have a blunt distal end and taper proximally, indicating broken hairs being pushed out of the follicle.

Question 14

A patient with alopecia areata has yellow dots on dermatoscopic evaluation. What do these dots signify?

Answer 14

Yellow dots signify follicular ostia filled with keratin and sebum, which are characteristic of alopecia areata.

Question 15

How does the presence of associated diseases influence the diagnosis of Alopecia Areata?

Answer 15

The presence of associated diseases, such as thyroid disease, can support the diagnosis of Alopecia Areata (AA). A positive family history and clinical features are also critical in diagnosing AA. Dermatoscopic evaluation can reveal: 1. Follicular ostia 2. Exclamation point hairs 3. Cadaver hair (residual hair shafts visible as black dots in follicular ostia) 4. Yellow dots.

Question 16

What role do CD8+ NKG2D T cells play in the pathogenesis of Alopecia Areata?

Answer 16

CD8+ NKG2D (natural killer group 2 member D positive) T cells are involved in the inflammatory infiltrate in Alopecia Areata (AA). They contribute to the autoimmune response affecting hair follicles.

Question 17

What is the significance of stress perception in the onset and exacerbation of Alopecia Areata?

Answer 17

Stress perception may influence both the onset and exacerbation of Alopecia Areata (AA). Individuals with a high perception of stress may experience a higher incidence of AA, particularly in early onset cases.

Question 18

In what scenarios should Alopecia Areata be included in the differential diagnosis (DDx)?

Answer 18

Alopecia Areata (AA) should be included in the differential diagnosis (DDx) whenever there are high percentages of telogen hairs or miniaturized hairs present, even in the absence of peribulbar inflammation.

Question 19

What are the complications associated with alopecia areata?

Answer 19

• Relapsing course - Progression to alopecia totalis or universalis - Increased incidence of sunburns and skin cancers, nasopharyngeal and ophthalmologic inflammation - Diminished sense of personal well-being and self-esteem, leading to severe depressive mood and withdrawal from social situations.

Question 20

What is the prognosis for patients with alopecia areata?

Answer 20

• Variable course of disease with irregular relapsing course: 40% relapse within the 1st year - Larger percentage relapses within 5 years - 25% experience a solitary episode - Spontaneous regrowth of hair is common but often followed by repeated episodes of hair loss.

Question 21

What are the treatment options available for alopecia areata?

Answer 21

• There is no single therapy that can alter the natural course of the disease; all treatments are palliative. A. Conservative Management B. Topical Corticosteroids: Superpotent (Class I) corticosteroids C. Intralesional Corticosteroids: Triamcinolone acetonide D. Platelet Rich Plasma: Superior to low dose triamcinolone acetonide E. Systemic Corticosteroids: Prednisone 20 to 40 mg F. Topical Minoxidil 5% solution G. Prostaglandin Analogs.

Question 22

A patient with alopecia areata has a relapsing course. What is the likelihood of relapse within the first year and within five years?

Answer 22

40% of patients relapse within the first year, and a larger percentage relapse within five years.

Question 23

A patient with alopecia areata has nail changes and childhood onset. What is the prognosis?

Answer 23

The prognosis is poor due to the presence of nail changes and childhood onset, which are associated with a chronic relapsing course.

Question 24

A patient with alopecia areata is treated with intralesional corticosteroids. What is the expected timeline for response, and what are the potential side effects?

Answer 24

Response is typically seen after 4 to 8 weeks. Side effects include atrophy of subcutaneous fat.

Question 25

A patient with alopecia areata is considering systemic corticosteroids. What are the risks and limitations of this treatment?

Answer 25

Systemic corticosteroids do not alter the long-term prognosis and frequently result in relapse after discontinuation. Adverse effects include striae, acne, obesity, cataracts, and hypertension.

Question 26

A patient with alopecia areata totalis is prescribed topical minoxidil. What is the expected efficacy of this treatment?

Answer 26

Topical minoxidil has little efficacy in treating alopecia areata totalis and universalis.

Question 27

A patient with alopecia areata has a solitary episode of hair loss. What is the likelihood of spontaneous regrowth?

Answer 27

Spontaneous regrowth of hair is common, with 60% of patients experiencing partial regrowth within one year.

Question 28

A patient with alopecia areata has occipital involvement. How does this affect the prognosis?

Answer 28

Occipital involvement is associated with a poor prognosis.

Question 29

A patient with alopecia areata is treated with platelet-rich plasma (PRP). How does PRP compare to other treatments?

Answer 29

In a double-blind trial, PRP was found to be superior to low-dose triamcinolone acetonide and placebo injections.

Question 30

A patient with alopecia areata is treated with prostaglandin analogs. What areas are these treatments most effective for?

Answer 30

Prostaglandin analogs like latanoprost and bimatoprost are effective for treating alopecia areata of the eyelashes and eyebrows.

Question 31

A patient with alopecia areata is diagnosed with telogen effluvium. How can this condition be differentiated from alopecia areata?

Answer 31

Telogen effluvium is characterized by diffuse hair shedding without the well-demarcated bald spots seen in alopecia areata.

Question 32

A patient with alopecia areata is diagnosed with trichotillomania. How can this condition be differentiated from alopecia areata?

Answer 32

Trichotillomania involves irregularly shaped patches of hair loss with broken hairs of varying lengths, unlike the well-demarcated bald spots of alopecia areata.

Question 33

A patient with alopecia areata is diagnosed with tinea capitis. How can this condition be differentiated from alopecia areata?

Answer 33

Tinea capitis often presents with scaling, inflammation, and broken hairs, which are not typical of alopecia areata.

Question 34

A patient with alopecia areata is diagnosed with androgenetic alopecia. How can this condition be differentiated from alopecia areata?

Answer 34

Androgenetic alopecia involves gradual thinning and miniaturization of hair, typically in a patterned distribution, unlike the patchy hair loss of alopecia areata.

Question 35

A patient with alopecia areata is diagnosed with secondary syphilis. How can this condition be differentiated from alopecia areata?

Answer 35

Secondary syphilis may present with a 'moth-eaten' appearance of hair loss, which is distinct from the well-demarcated patches of alopecia areata.

Question 36

A patient with alopecia areata is diagnosed with early scarring alopecia. How can this condition be differentiated from alopecia areata?

Answer 36

Early scarring alopecia involves permanent destruction of hair follicles, leading to scarring, which is not seen in alopecia areata.

Question 37

A patient with alopecia areata is diagnosed with anagen effluvium. How can this condition be differentiated from alopecia areata?

Answer 37

Anagen effluvium involves rapid hair loss due to disruption of the anagen phase, often caused by chemotherapy, unlike the autoimmune etiology of alopecia areata.

Question 38

A patient with alopecia areata is diagnosed with temporal triangular alopecia. How can this condition be differentiated from alopecia areata?

Answer 38

Temporal triangular alopecia is a congenital condition with hair loss confined to the temporal region, unlike the autoimmune and variable presentation of alopecia areata.

Question 39

What are the potential complications associated with alopecia areata, particularly regarding its progression and psychological impact?

Answer 39

- Relapsing course: Progression to alopecia totalis or universalis is common, especially in younger patients with hair loss from trunk and extremities. - Increased incidence of: Sunburns, skin cancers, nasopharyngeal and ophthalmologic inflammation. - Psychological effects: Diminished sense of personal well-being, leading to severe depressive mood and withdrawal from social situations.

Question 40

What factors contribute to a poor prognosis in patients with alopecia areata?

Answer 40

1. Occipital involvement and/or hairline 2. Chronic relapsing course 3. Presence of nail changes 4. Childhood onset.

Question 41

What are the treatment options available for alopecia areata, and what is the general effectiveness of these treatments?

Answer 41

- No single therapy can alter the natural course of the disease; all treatments are palliative. - Topical Corticosteroids: Superpotent (Class I) and potent (Class II) corticosteroids with minoxidil. - Intralesional Corticosteroids: Triamcinolone acetonide or Hexacetonide, with a response seen after 4 to 8 weeks.

Question 42

What is the general effectiveness of treatments for alopecia areata?

Answer 42

No single therapy can alter the natural course of the disease; all treatments are palliative.

Question 43

What are the types of corticosteroids used in alopecia areata treatment?

Answer 43

Topical Corticosteroids: Superpotent (Class I) and potent (Class II) corticosteroids with minoxidil. ## Footnote Intralesional Corticosteroids: Triamcinolone acetonide or Hexacetonide, with a response seen after 4 to 8 weeks.

Question 44

What is the role of Platelet Rich Plasma in alopecia areata treatment?

Answer 44

Platelet Rich Plasma has been shown to be superior to low dose triamcinolone acetonide in trials.

Question 45

Why are systemic corticosteroids not recommended for alopecia areata?

Answer 45

Systemic Corticosteroids are not recommended as routine treatment due to lack of long-term prognosis alteration.

Question 46

What is the efficacy of topical minoxidil 5% in alopecia areata?

Answer 46

Topical Minoxidil 5% is used in combination with corticosteroids, but has little efficacy in AA totalis and universalis.

Question 47

What are the prostaglandin analogs used for in alopecia areata?

Answer 47

Prostaglandin Analogs, such as Latanoprost and Bimatoprost, are used for the treatment of AA of eyelashes and eyebrows.

Question 48

What is the mechanism of action (MOA) of Diphenylcyclopropenone (DPCP) in alopecia areata?

Answer 48

The MOA of DPCP involves a decrease in the peribulbar CD4/CD8 lymphocyte ratio and a shift of T lymphocytes from the perifollicular area to the interfollicular area and dermis.

Question 49

What are the side effects associated with the use of Anthralin in alopecia areata treatment?

Answer 49

Side effects of Anthralin include irritation, scaling, folliculitis, regional lymphadenopathy, and brown discoloration of the skin.

Question 50

What is the desired effect of using DPCP in alopecia areata treatment?

Answer 50

The desired effect of using DPCP is the creation of contact dermatitis.

Question 51

What are the advantages and disadvantages of using cyclosporine for alopecia areata?

Answer 51

Advantages: Effective in some cases. Disadvantages: High recurrence rate and side effect profile, including elevation of serum transaminases, headaches, and myalgia, render it impractical as a treatment for alopecia areata.

Question 52

What is the role of Janus Kinase inhibitors in the treatment of alopecia areata?

Answer 52

Janus Kinase inhibitors, such as Baricitinib and Tofacitinib, play a significant role in maintaining autoreactive CD8+ infiltrate in alopecia areata and can lead to full regrowth of scalp hair in widespread cases.

Question 53

What is the relapse rate associated with photo(chemo)therapy for alopecia areata?

Answer 53

Photo(chemo)therapy has a very high relapse rate in the treatment of alopecia areata.

Question 54

What is the mechanism of action of Anthralin in alopecia areata treatment?

Answer 54

Anthralin has a nonspecific immunomodulating effect (anti-Langerhans cell).

Question 55

What are the adverse effects of topical immunotherapy with DPCP?

Answer 55

Adverse effects include lymphadenopathy, severe contact eczema, and discoloration of the skin.

Question 56

What are the limitations of phototherapy in alopecia areata?

Answer 56

Phototherapy has a very high relapse rate and is therefore not a long-term solution.

Question 57

What are the potential side effects of cyclosporine in alopecia areata treatment?

Answer 57

Side effects include elevation of serum transaminases and cholesterol levels, headaches, dysesthesia, fatigue, diarrhea, gingival hyperplasia, flushing, and myalgia.

Question 58

What is the mechanism of action of UVB phototherapy in alopecia areata?

Answer 58

UVB phototherapy affects T-cell function and antigen presentation, inhibiting the local immunologic attack against hair follicles by depleting Langerhans cells.

Question 59

What is the expected outcome of treatment with baricitinib for alopecia areata?

Answer 59

Baricitinib, a Janus kinase inhibitor, can lead to full regrowth of scalp hair in widespread cases of alopecia areata.

Question 60

What is the expected outcome of treatment with tofacitinib citrate for alopecia areata?

Answer 60

Tofacitinib citrate, a Janus kinase inhibitor, can lead to full regrowth of scalp hair in widespread cases of alopecia areata.

Question 61

What is the expected outcome of treatment with ruxolitinib for alopecia areata?

Answer 61

Ruxolitinib, a Janus kinase inhibitor, can lead to full regrowth of scalp hair in widespread cases of alopecia areata.

Question 62

What precautions should be taken when using anthralin for alopecia areata?

Answer 62

Precautions include avoiding application near the eyebrows and beard, using cool or lukewarm water for rinsing, and being cautious of potential irritation to the eyes.

Question 63

What is the significance of Janus Kinase inhibitors in the treatment of alopecia areata?

Answer 63

Janus Kinase inhibitors, such as Baricitinib and Tofacitinib, play a significant role in maintaining autoreactive CD8+ infiltrate in alopecia areata and have shown potential for full regrowth of scalp hair in widespread cases.

Question 64

What is the initial treatment for alopecia areata in patients under age 10?

Answer 64

The initial treatment for alopecia areata in patients under age 10 includes topical corticosteroids (mometasone) with or without topical 5% minoxidil.

Question 65

How does the treatment approach differ for patients over age 10 with less than 50% scalp involvement?

Answer 65

For patients over age 10 with less than 50% scalp involvement, the treatment approach includes topical corticosteroids with or without intralesional corticosteroids and topical 5% minoxidil.

Question 66

What treatment options are available for patients over age 10 with greater than 50% scalp involvement?

Answer 66

For patients over age 10 with greater than 50% scalp involvement, treatment options include JAK inhibitors with or without intralesional corticosteroids and scalp prosthesis.

Question 67

What is the next step if a patient responds successfully to topical immunotherapy (DPCP)?

Answer 67

If a patient responds successfully to topical immunotherapy (DPCP), the next step is to continue DPCP as needed.

Question 68

What should be done if there is no successful response to JAK inhibitor therapy in patients over age 10?

Answer 68

If there is no successful response to JAK inhibitor therapy in patients over age 10, the next step is to continue JAK inhibitor therapy with or without intralesional corticosteroids and consider topical immunotherapy.

Question 69

What treatment options are available for patients with alopecia areata under age 10 with less than 50% scalp involvement?

Answer 69

For patients under age 10 with less than 50% scalp involvement, the treatment options include: 1. Topical corticosteroids (mometasone) 2. Topical 5% minoxidil (optional) 3. Intralesional corticosteroids (optional)

Question 70

What is the next step if a patient over age 10 with greater than 50% scalp involvement does not respond to JAK inhibitor therapy?

Answer 70

If a patient over age 10 with greater than 50% scalp involvement does not respond to JAK inhibitor therapy, the next step is to consider: 1. Topical immunotherapy 2. Scalp prosthesis (if needed)

Question 71

What is the role of topical immunotherapy (DPCP) in the treatment of alopecia areata for patients over age 10 with less than 50% scalp involvement?

Answer 71

Topical immunotherapy (DPCP) is used for patients over age 10 with less than 50% scalp involvement as follows: - If there is a successful response to topical immunotherapy, it should be continued as needed. - If there is no successful response, the treatment may progress to SADBE (squaric acid dibutylester) as needed.