His & Hers Hair Loss

A 29-year-old woman and her 40-year-old husband present together for evaluation of similar problems: One month ago, they both experienced sudden hair loss—the wife in two spots on her scalp, the husband in his beard. In both cases, the hair came out suddenly, without any symptoms. Neither has had this problem before. Both patients are otherwise healthy, but they admit to being under a great deal of stress in the weeks prior to onset of the condition.

Before consulting dermatology, they were seen in an urgent care clinic, where they were diagnosed with “ringworm.” Twice-daily application of nystatin cream was prescribed—to no good effect.

EXAMINATION
On each side of the woman’s parietal scalp is a round, completely hairless patch with exceptionally well-defined margins. The sites are otherwise unremarkable, free of redness, edema, or scaling. Each lesion measures about 3.5 cm in diameter. No lymph nodes are palpable in the adjacent neck.

On the man’s left jawline is a solitary, round, 4-cm, hairless patch. It is also free of edema, erythema, or epidermal disturbance of any kind. There are no palpable lymph nodes in the drainage area.

What is the diagnosis?

 

DISCUSSION
Sudden, asymptomatic, complete, well-marginated hair loss in any hair-bearing area is likely to be alopecia areata (AA). AA is an autoimmune process in which hair follicles are immobilized and unable to grow new hair until the process stops, which usually happens within weeks to months.

Because stress and AA have a suspected correlation, the patients’ histories of recent stress corroborate the diagnosis. Other features that bolster this impression are the lack of epidermal disturbance (eg, scaling, redness, edema) or palpable nodes in the area. The unusual factor in this case was the simultaneous appearance of the condition in husband and wife—for which I have no good explanation.

There are many items in the differential for localized hair loss, including discoid lupus, lichen planopilaris, and tinea capitis. However, these almost always manifest with frank inflammation characterized by epidermal disturbance.

Treatments such as intralesional steroid injection can promote modest hair growth but are generally ineffective for long-term recovery; unless the procedure is repeated, the hair will continue to fall out. These patients were offered treatment but declined, and they recovered in a short period of time.

TAKE-HOME LEARNING POINTS
• Alopecia areata (AA) typically displays as acute, asymptomatic, complete hair loss in one or more hair-bearing locations, usually in a round, well-defined configuration.
• AA is an autoimmune process that immobilizes hair follicles, causing them to fall out and not be replaced until the process ceases. This can take months, and the condition does not respond well to treatment.
• AA can affect the scalp, beard, brows, or even genital hair.
• The differential for localized hair loss includes tinea capitis, discoid lupus, lichen planopilaris, and lues; however, these all involve disruption of the overlying skin with scaling, redness, or edema.

A 29-year-old woman and her 40-year-old husband present together for evaluation of similar problems: One month ago, they both experienced sudden hair loss—the wife in two spots on her scalp, the husband in his beard. In both cases, the hair came out suddenly, without any symptoms. Neither has had this problem before. Both patients are otherwise healthy, but they admit to being under a great deal of stress in the weeks prior to onset of the condition.

Before consulting dermatology, they were seen in an urgent care clinic, where they were diagnosed with “ringworm.” Twice-daily application of nystatin cream was prescribed—to no good effect.

EXAMINATION
On each side of the woman’s parietal scalp is a round, completely hairless patch with exceptionally well-defined margins. The sites are otherwise unremarkable, free of redness, edema, or scaling. Each lesion measures about 3.5 cm in diameter. No lymph nodes are palpable in the adjacent neck.

On the man’s left jawline is a solitary, round, 4-cm, hairless patch. It is also free of edema, erythema, or epidermal disturbance of any kind. There are no palpable lymph nodes in the drainage area.

What is the diagnosis?

 

DISCUSSION
Sudden, asymptomatic, complete, well-marginated hair loss in any hair-bearing area is likely to be alopecia areata (AA). AA is an autoimmune process in which hair follicles are immobilized and unable to grow new hair until the process stops, which usually happens within weeks to months.

Because stress and AA have a suspected correlation, the patients’ histories of recent stress corroborate the diagnosis. Other features that bolster this impression are the lack of epidermal disturbance (eg, scaling, redness, edema) or palpable nodes in the area. The unusual factor in this case was the simultaneous appearance of the condition in husband and wife—for which I have no good explanation.

There are many items in the differential for localized hair loss, including discoid lupus, lichen planopilaris, and tinea capitis. However, these almost always manifest with frank inflammation characterized by epidermal disturbance.

Treatments such as intralesional steroid injection can promote modest hair growth but are generally ineffective for long-term recovery; unless the procedure is repeated, the hair will continue to fall out. These patients were offered treatment but declined, and they recovered in a short period of time.

TAKE-HOME LEARNING POINTS
• Alopecia areata (AA) typically displays as acute, asymptomatic, complete hair loss in one or more hair-bearing locations, usually in a round, well-defined configuration.
• AA is an autoimmune process that immobilizes hair follicles, causing them to fall out and not be replaced until the process ceases. This can take months, and the condition does not respond well to treatment.
• AA can affect the scalp, beard, brows, or even genital hair.
• The differential for localized hair loss includes tinea capitis, discoid lupus, lichen planopilaris, and lues; however, these all involve disruption of the overlying skin with scaling, redness, or edema.

A 29-year-old woman and her 40-year-old husband present together for evaluation of similar problems: One month ago, they both experienced sudden hair loss—the wife in two spots on her scalp, the husband in his beard. In both cases, the hair came out suddenly, without any symptoms. Neither has had this problem before. Both patients are otherwise healthy, but they admit to being under a great deal of stress in the weeks prior to onset of the condition.

Before consulting dermatology, they were seen in an urgent care clinic, where they were diagnosed with “ringworm.” Twice-daily application of nystatin cream was prescribed—to no good effect.

EXAMINATION
On each side of the woman’s parietal scalp is a round, completely hairless patch with exceptionally well-defined margins. The sites are otherwise unremarkable, free of redness, edema, or scaling. Each lesion measures about 3.5 cm in diameter. No lymph nodes are palpable in the adjacent neck.

On the man’s left jawline is a solitary, round, 4-cm, hairless patch. It is also free of edema, erythema, or epidermal disturbance of any kind. There are no palpable lymph nodes in the drainage area.

What is the diagnosis?

 

DISCUSSION
Sudden, asymptomatic, complete, well-marginated hair loss in any hair-bearing area is likely to be alopecia areata (AA). AA is an autoimmune process in which hair follicles are immobilized and unable to grow new hair until the process stops, which usually happens within weeks to months.

Because stress and AA have a suspected correlation, the patients’ histories of recent stress corroborate the diagnosis. Other features that bolster this impression are the lack of epidermal disturbance (eg, scaling, redness, edema) or palpable nodes in the area. The unusual factor in this case was the simultaneous appearance of the condition in husband and wife—for which I have no good explanation.

There are many items in the differential for localized hair loss, including discoid lupus, lichen planopilaris, and tinea capitis. However, these almost always manifest with frank inflammation characterized by epidermal disturbance.

Treatments such as intralesional steroid injection can promote modest hair growth but are generally ineffective for long-term recovery; unless the procedure is repeated, the hair will continue to fall out. These patients were offered treatment but declined, and they recovered in a short period of time.

TAKE-HOME LEARNING POINTS
• Alopecia areata (AA) typically displays as acute, asymptomatic, complete hair loss in one or more hair-bearing locations, usually in a round, well-defined configuration.
• AA is an autoimmune process that immobilizes hair follicles, causing them to fall out and not be replaced until the process ceases. This can take months, and the condition does not respond well to treatment.
• AA can affect the scalp, beard, brows, or even genital hair.
• The differential for localized hair loss includes tinea capitis, discoid lupus, lichen planopilaris, and lues; however, these all involve disruption of the overlying skin with scaling, redness, or edema.