alopecia
A clinicopathologic study of scarring alopecia due to lichen planus: comparison with scarring alopecia in discoid lupus erythematosus and pseudopelade.

Annessi G, Lombardo G, Gobello T, Puddu P.

Department of Dermatology and Laboratory of Dermatopathology, Istituto Dermopatico dell Immacolata, IRCCS, Rome, Italy.

The clinicohistologic findings in 68 patients with lichen planus scarring alopecia (LP) were compared with those of 25 patients with discoid lupus erythematosus of the scalp (DLE) and 25 with pseudopelade (PP). The combination of diffuse scaling, erythema, telangiectases, and mottled hyperpigmentation within areas of scarring alopecia was a distinctive feature of DLE, whereas the clinical picture of PP was indistinguishable from that seen in 29 patients with LP. In most patients with LP, the histologic changes involved only the follicles and the perifollicular dermis. Less frequently, the inflammatory process extended to the epidermis and the papillary dermis. In all cases, histopathologic features allowed LP to be distinguished from DLE regardless of the stage of the disease. The finding of a bandlike fibrotic thickening of the papillary dermis accompanied by fibrotic tracts at sites of destroyed follicles appeared to be a hallmark of "burnt out" lesions of LP. This histologic clue may be helpful in achieving a specific diagnosis of LP in cases that fulfill the clinical criteria for PP.

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alopecia
Quantitative and ultrastructural analysis of inflammatory infiltrates in male pattern alopecia.

Sueki H, Stoudemayer T, Kligman AM, Murphy GF.

Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, USA.

In order to determine whether lymphocytic inflammation around the lower infundibula in male pattern alopecia is incidental or a general phenomenon, we performed morphometric and ultrastructural analysis of inflammatory infiltrates in the transitional zones of the vertex and occipital hairy scalps of 19 patients with male pattern alopecia. Six normal subjects served as controls. The number of inflammatory infiltrates around the follicular infundibula of the alopecic vertices and non-alopecic occiputs of male pattern alopecia patients was significantly greater than the corresponding control value. The number of mast cells in the widened fibrous tracts in the vertices of male pattern alopecia patients was significantly greater than those in the adventitial fibrotic sheaths of control subjects and the non-alopecic occiputs of male pattern alopecia patients. These data support the idea that the inflammatory process may be, at least in part, responsible for the development of male pattern alopecia.

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alopecia
The predictive value of symptoms in diagnosing childhood tinea capitis.

Hubbard TW.

Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, Norfolk, USA.

OBJECTIVE: To determine which sign, symptom, or combination thereof best predicts cultures positive for fungi in children with possible tinea capitis. DESIGN: Convenience survey. SETTING: Urban hospital-based general pediatric practice. PATIENTS: Results were obtained on 100 consecutive children presenting with at least 1 sign or symptom (scalp pruritus, scaling, diffuse or circumscribed alopecia, or occipital adenopathy). INTERVENTION: All enrolled children had samples for scalp cultures taken. Demographic information and clinical findings were verified by the author. MAIN OUTCOME MEASURE: Whether detected clinical findings can predict the outcome of fungal cultures. RESULTS: Cultures positive for fungi were found in 68 children. There was a significant relationship (Fisher exact test; P<.001) between the number of signs and symptoms and a culture positive for fungi. Positive likelihood ratios were 7.5, 3.3, 1.4, and 1.1 for the presence of adenopathy, alopecia, pruritus, and scaling, respectively, for children with cultures positive for fungi. All children (n = 55) who presented with both adenopathy and alopecia and 60 of 62 children who presented with both adenopathy and scaling had cultures positive for fungi. No cultures positive for fungi were found in children without adenopathy and scaling; only 1 of 68 children without adenopathy and alopecia had a culture positive for fungi. CONCLUSIONS: In children who are suspected of having tinea capitis, there is a high likelihood of cultures positive for fungi in those with adenopathy. A fungal infection is rarely the cause when neither adenopathy nor alopecia is present. Attention to signs and symptoms in children with suspected tinea capitis can result in better diagnostic and treatment precision.

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alopecia
Scarring alopecia in neonates as a consequence of hypoxaemia-hypoperfusion.

Gershan LA, Esterly NB.

Department of Pediatrics, Medical College of Wisconsin, Milwaukee.

Scarring alopecia is relatively uncommon in infants and children and rarely discussed in the paediatric literature. It does not appear to have been previously documented as a consequence of compromised oxygenation and blood supply in the neonatal population or as a complication of extracorporeal membrane oxygenation (ECMO) treatment. During a six month period, we observed five patients who presented to our neonatal intensive care unit with pressure ulcers that eventuated in scarring alopecia. The patients were all > or = 2500 g at birth, had some disruption of the cardiac circulation, were hypoxaemic and acidotic, and required vasopressor treatment. Institution of a positioning schedule and use of a thermostable Spenco gel pad during the subsequent six month period eliminated the presence of pressure ulceration and scarring alopecia in this at-risk population. Although scarring alopecia is a permanent condition, skin changes preceding its development in this setting are recognisable and follow a predictable pattern and time course, and should therefore allow for intervention at an earlier stage. Neonatal ECMO patients, as well as those who suffer hypoxaemia-hypoperfusion, but do not require circulatory bypass, appear to be at increased risk for development of the pressure ulcers that precede scarring alopecia. Paediatricians should consider this possibility and seek the appropriate historical information when confronted with a case of scarring alopecia after the neonatal period.

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alopecia
Of hairless mice and men: the genetic basis of congenital alopecia universalis/congenital atrichia.

Bale SJ.

Genetic Studies Section, LSB, National Institute of Arthritis & Musculoskeletal & Skin Disease, National Institutes of Health, Bethesda, Maryland 20892-2757, USA.

BACKGROUND: Mouse models of human diseases help identify gene defects. OBJECTIVE: The methods of homozygosity mapping and mouse/human homology to identify genes are reviewed. The genotype/phenotype correlation in two clinical entities with mutations in the human hairless gene are discussed. METHODS: The example of the hairless mouse's contribution to our knowledge of hereditary alopecia is used, and the utility of consanguineous families for genetic studies is highlighted. RESULTS: Mutations in the human homolog of the mouse hairless gene lead to congenital alopecia universalis and atrichia with papules. CONCLUSION: A mouse model of congenital alopecia has led to understanding the molecular basis of at least one type of severe human alopecia.

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alopecia
Antibodies against hair follicles are associated with alopecia totalis in autoimmune polyendocrine syndrome type I.

Hedstrand H, Perheentupa J, Ekwall O, Gustafsson J, Michaelsson G, Husebye E, Rorsman F, Kampe O.

Department of Medical Sciences, University Hospital, Uppsala, Sweden. hakan.hedstrand mediciin.uu.se

In the autosomal recessively inherited autoimmune polyendocrine syndrome type I (APS I) patients have autoantibodies directed against several endocrine and nonendocrine organs. Alopecia areata is present in about one-third of the patients and usually in the more severe forms, alopecia universalis or totalis. Sera from 39 patients with APS I, diluted 1:150, were used in indirect immunofluorescence staining of cryo-sections from normal human scalp. Two hair follicle staining patterns were observed. A cytoplasmic staining of the differentiating matrix, cuticle, and cortex keratinocytes in the anagen hair follicle was seen in five (13%) APS I sera. All these five patients had alopecia totalis, representing 63% of the eight patients with alopecia totalis (p < 0.0001). Furthermore, four (10%) of the APS I sera stained the nuclei of the melanocytes in the hair follicle. Two of these patients had vitiligo. None of 20 healthy control sera stained the keratinocyte cells or the melanocyte nuclei. These data show that many patients with APS I have high-titer autoantibodies directed against the anagen matrix, cuticle, and cortex keratinocytes and a melanocyte nuclear antigen, and also that the hair follicle keratinocyte staining is associated with alopecia, especially alopecia totalis. This study emphasizes the role of the differentiating anagen keratinocytes as an important structure in the autoimmune etiology of alopecia, both in APS I and at least in a subgroup of patients with alopecia areata unrelated to APS I.

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