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Baldness evokes a variety of responses from both sexes. Alopecia is the medical term for hair loss. Not all hair loss is permanent and certainly not all forms are hereditary.

Alopecia Areata
Androgenetic alopecia (Common baldness, Pattern baldness)
Scarring Alopecia (Pseudopelade)
Telogen and anagen effluvium


Disease Associations  
Laboratory/Radiologic/Other Diagnostic Testing  
Gross Appearance and Clinical Variants  
Histopathological Features and Variants  
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Differential Diagnosis  
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Association of reversible alopecia with occupational topical exposure to common borax-containing solutions

William S. Beckett, etal.

J Am Acad Dermatol 2001;44:599-602 Abstract quote

Boron is widely used in industrial materials, most frequently as the salt borax. Systemic exposure (eg, ingestion) to boron in boric acid been associated with reversible toxic alopecia among other manifestations. There is scant clinical literature on alopecia caused by topical exposure to boron.

We observed a series of 3 patients in 2 workplaces who suffered reversible alopecia from cutaneous boron exposure. The scalp alopecia was global in 1 patient and patchy in 2 patients. Alopecia was completely reversed by elimination or reduction of exposure to boron-containing materials in all 3 patients.

We conclude that occupational topical exposure to boron in solutions may cause reversible alopecia.

The diagnosis and treatment of iron deficiency and its potential relationship to hair loss.

Trost LB, Bergfeld WF, Calogeras E.

Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.

J Am Acad Dermatol. 2006 May;54(5):824-44. Abstract quote  

Iron deficiency is the world's most common nutritional deficiency and is associated with developmental delay, impaired behavior, diminished intellectual performance, and decreased resistance to infection. In premenopausal women, the most common causes of iron deficiency anemia are menstrual blood loss and pregnancy. In men and postmenopausal women, the most common causes of iron deficiency anemia are gastrointestinal blood loss and malabsorption.

Hemoglobin concentration can be used to screen for iron deficiency, whereas serum ferritin concentration can be used to confirm iron deficiency. However, the serum ferritin concentration may be elevated in patients with infectious, inflammatory, and neoplastic conditions. Other tests may be needed, such as erythrocyte zinc protoporphyrin concentration, transferrin concentration, serum iron concentration, and transferrin saturation.

The cause of iron deficiency must be identified. If the patient is male, postmenopausal female, or has risk factors for blood loss, then the patient should be evaluated for sources of blood loss, especially gastrointestinal (eg, colon cancer). Several studies have examined the relationship between iron deficiency and hair loss. Almost all have addressed women exclusively and have focused on noncicatricial hair loss. Some suggest that iron deficiency may be related to alopecia areata, androgenetic alopecia, telogen effluvium, and diffuse hair loss, while others do not.

Currently, there is insufficient evidence to recommend universal screening for iron deficiency in patients with hair loss. In addition, there is insufficient evidence to recommend giving iron supplementation therapy to patients with hair loss and iron deficiency in the absence of iron deficiency anemia. The decision to do either should be based on clinical judgment. It is our practice at the Cleveland Clinic Foundation to screen male and female patients with both cicatricial and noncicatricial hair loss for iron deficiency. Although this practice is not evidence based per se, we believe that treatment for hair loss is enhanced when iron deficiency, with or without anemia, is treated. Iron deficiency anemia should be treated.

Treating iron deficiency without anemia is controversial. Treatment of nutritional iron deficiency anemia includes adequate dietary intake and oral iron supplementation. Excessive iron supplementation can cause iron overload and should be avoided, especially in high-risk patients such as those with hereditary hemochromatosis. Patients who do not respond to iron replacement therapy should undergo additional testing to identify other underlying causes of iron deficiency anemia.



Nomenclature proposal for the zones and landmarks of the balding scalp.

Beehner ML.

10 Railroad Place, Saratoga Springs, NY 12866, USA.

Dermatol Surg 2001 Apr;27(4):375-80 Abstract quote

BACKGROUND: Up until now there has existed no precise, agreed-upon terminology for referring to the areas of the balding scalp.

OBJECTIVE: A standardized nomenclature system for the areas of the balding scalp is proposed so that physicians and other paraprofessionals can have a common, precise language for communicating with each other.

METHODS: The following, in its initial form, was proposed to the surgical hair restoration community in the Hair Transplant Forum International in 1998. This final proposal includes feedback and input from those physicians.

RESULTS: The balding scalp is divided into three major areas: the frontal region, the midscalp, and the vertex. Additional "subregions" are also defined, and long-standing landmarks of the scalp and its borders are reviewed. A new landmark, the "vertex transition point," is proposed, to designate that point in the posterior midscalp where the plane begins to change from horizontal to vertical.

CONCLUSION: It is hoped that a universal nomenclature system for the scalp will facilitate communication between hair surgeons, other medical specialties, nonsurgical hair replacement personnel, and hair stylists.


Approach to the adult female patient with diffuse nonscarring alopecia.

Chartier MB, Hoss DM, Grant-Kels JM.

Department of Dermatology, University of Connecticut Health Center.

J Am Acad Dermatol 2002 Dec;47(6):809-18 Abstract quote

Alopecias are traditionally categorized by the presence or absence of scarring and by a diffuse or localized pattern. A common clinical conundrum is that of a woman presenting with the chief complaint of diffuse, nonscarring hair loss.

We review the 4 main diagnostic possibilities for this clinical scenario: (1) female pattern hair loss (androgenetic alopecia), (2) acute and chronic telogen effluvium, (3) diffuse alopecia areata, and (4) loose anagen syndrome. We also outline our approach to the individual patient, emphasizing the pertinent history, physical examination, and appropriate diagnostic testing.

This approach usually allows the clinician to make a definitive diagnosis or limited differential diagnosis and to offer the patient therapeutic options. (J Am Acad Dermatol 2002;47:809-18.) Learning objective: At the completion of this learning activity, participants should be familiar with the diagnostic possibilities in evaluating diffuse, nonscarring hair loss in women.


Transverse sections for diagnosis of alopecia?

Boer A, Hoene K.

From Dermatologikum Hamburg, Hamburg, Germany.
Am J Dermatopathol. 2005 Aug;27(4):348-52. Abstract quote  

Several authors have claimed usage of sections cut horizontally as being preferable to conventional cuts in vertical direction in the diagnosis of alopecias.

In this article, we address in critical fashion, all statements that have been made in the literature that seem to favor sections cut horizontally in contrast to sections cut conventionally (ie, vertically) in coming to a diagnosis of diseases of the scalp. Our assessment reveals that the idea of horizontal sections being advantageous compared with sections cut vertically is based largely on the assumption that counting of follicles is the key to a diagnosis with specificity of diseases of the scalp. But a quantitative approach to diagnosis of alopecias is flawed; it does not allow differential diagnosis of common alopecias to be made with certainty.

A qualitative approach, however, based on reliable and repeatable criteria applied in sections cut vertically, allows in most instances a diagnosis to be rendered precisely.
A comparison of vertical versus transverse sections in the evaluation of alopecia biopsy specimens.

Elston DM, Ferringer T, Dalton S, Fillman E, Tyler W.

Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania 17821, USA.
J Am Acad Dermatol. 2005 Aug;53(2):267-72. Abstract quote  

BACKGROUND: Both vertical and transverse sections are used in the histologic interpretation of alopecia biopsy specimens. Although a combination of the two may be optimal, the pathologist is frequently only provided with a single specimen. Even though the trend in recent years has been toward transverse sections in this setting, we are not aware of any published data directly comparing the two methods.

METHODS: One hundred two consecutive archived hair biopsy accessions that demonstrated comparable vertical and transverse sections were examined twice, each time in a random order. The pathologist's interpretation based only on the vertical sections and an interpretation based only on the transverse sections were compared with the original biopsy report, which had been based on the combination of vertical and transverse sections.

RESULTS: In 76 cases, all 3 diagnoses were concordant (ie, the diagnosis made with vertical sections alone, the diagnosis made with transverse sections alone, and the original diagnosis were all in agreement). In 2 cases, neither the diagnosis made with vertical sections alone nor the diagnosis made with transverse sections alone were in full agreement with the original diagnosis. In 20 cases, only the diagnosis made with vertical sections was concordant with the original diagnosis. In 4 cases, only the diagnosis made with transverse sections alone was concordant with the original diagnosis.

LIMITATIONS: Our practice is heavily weighted toward scarring alopecia, and the results of our study may not be applicable to practices weighted toward other forms of alopecia. Because the cases had been signed out over a period of several years, the nomenclature for some entities changed. For the purposes of our study, we counted the diagnoses of follicular degeneration syndrome and idiopathic pseudopelade to be subtypes of (and concordant with) a diagnosis of central centrifugal cicatricial alopecia. In some cases, a definitive diagnosis was not possible at the time of the original diagnosis, but rather the pathologist had provided a histologic description and a differential diagnosis. For purposes of this study, an interpretation was considered to be concordant with the original descriptive diagnosis if all of the important histologic features were identified that had been described in the original report. Sampling error could have contributed to discordant diagnoses, but would be expected to affect both vertical and transverse samples in a random manner.

CONCLUSION: The combination of vertical and transverse sections is superior to either alone. Although transverse sections have revolutionized the evaluation of alopecia, in this study, the diagnosis made with vertical sections alone had a higher concordance rate with the combination than did transverse sections alone. As there are advantages and disadvantages inherent in either method, when only a single biopsy specimen is submitted, it may be sectioned either vertically or transversely, at the discretion of the pathologist. With either method, serial step sections should be obtained to reduce the risk of missing important histologic findings.
The reliability of horizontally sectioned scalp biopsies in the diagnosis of chronic diffuse telogen hair loss in women.

Sinclair R, Jolley D, Mallari R, Magee J.

Skin and Cancer Foundation, University of Melbourne, Monash University, St Vincent's Hospital, Alfred Hospital, Melbourne, Victoria, Australia.
J Am Acad Dermatol. 2004 Aug;51(2):189-99. Abstract quote  

BACKGROUND: Chronic diffuse telogen hair loss is common in women. Paired 4-mm punch biopsy from the vertex scalp for horizontal and vertical sectioning is commonly used to distinguish between chronic telogen effluvium (CTE) and female pattern hair loss (FPHL). FPHL is now the favored term for androgenetic alopecia in women.

OBJECTIVE AND METHODS: To evaluate the reliability of a single horizontally sectioned scalp biopsy in the diagnosis of FPHL, 207 women presenting with chronic diffuse hair loss had three 4-mm punch biopsy specimens taken from immediately adjacent skin on the mid scalp, and all 3 biopsy specimens were sectioned horizontally. Findings were compared with 305 women who underwent two biopsies, with one sectioned horizontally and the other vertically. The terminal to vellus-like hair ratio (T:V) at the mid-isthmus level was used to diagnose FPHL (T:V <4:1), CTE (T:V >8:1), or indeterminate hair loss (T:V=5:1, 6:1, or 7:1). To correlate the histologic diagnosis with the clinical severity, a mid-scalp clinical grading scale was developed.

RESULTS: Among the 305 women who had a single horizontal scalp biopsy, 181 (59%) were diagnosed as having FPHL, 54 (18%) having CTE, and 70 (23%) having indeterminate hair loss. Six hundred twenty-one horizontal biopsy specimens were assessed from 207 patients. On the basis of consensus over 3 biopsies, 159 (77%) were diagnosed as having FPHL, 44 (21%) having CTE, and the remaining 4 women (2%) as having indeterminate hair loss. Among these 207 women, 114 were assessed clinically as having stage 1 or 2 hair loss. Sixty-nine (60%) were diagnosed as having FPHL on the basis of triple biopsy, 42 (37%) having CTE, and 2 having indeterminate hair loss. Ninety-three were graded as having stage 3, 4, or 5 hair loss. FPHL was diagnosed in 90 women (97%), CTE in 2, and indeterminate hair loss in one. By using each single biopsy as the criterion for diagnosis, 398 (61%) were classified as FPHL, 99 (16%) as CTE, and 124 (20%) as indeterminate. In 493 biopsies (79%), the single biopsy conclusion was identical to the 3 biopsy conclusions. Where disagreement was seen (21%), most were classified as indeterminate, rather than as a wrong diagnosis (3.3%).

CONCLUSION: Application of these diagnostic criteria achieved accurate diagnostic definition in 98% of women with triple horizontal biopsies versus 79% with single horizontal biopsy. Ninety-seven percent of women with a mid-scalp clinical grade of 3, 4, or 5 were given a diagnosis of FPHL on triple biopsy. Scalp biopsy for diagnosis should be reserved for women with a mid-scalp clinical grade of 1 or 2.

Vertical and transverse sections of alopecia biopsy specimens: combining the two to maximize diagnostic yield.

Elston DM, McCollough ML, Angeloni VL.

Dermatology Service, Brooke Army Medical Center, Fort Sam Houston, Texas.

J Am Acad Dermatol 1995 Mar;32(3):454-7 Abstract quote

BACKGROUND: Traditional vertical sections of scalp biopsy specimens contain few hair follicles. For this reason transverse sections of scalp biopsy specimens have been advocated. Both methods have advantages and disadvantages. We have developed a simple method that we believe offers the best of both methods.

OBJECTIVE: Our purpose was to assess the impact of combining vertical and transverse sections of scalp biopsy specimens.

METHODS: Two 4 mm punch biopsies are performed. One specimen is bisected vertically: half for hematoxylin-eosin (H-E) staining, half for direct immunofluorescence. The second specimen is bisected transversely and submitted for H-E. The three pieces of tissue for H-E staining are embedded in a single cassette.

RESULTS: Because a biopsy specimen for direct immunofluorescence is commonly obtained in cases of alopecia, our method does not add a surgical procedure. All three pieces of tissue for H-E staining are embedded in a single paraffin block. Therefore the cost of histologic interpretation is not increased. Our diagnostic yield improved. Transverse sections were superior in cases of lupus erythematosus and lichen planopilaris with focal follicular involvement. Features of the follicular degeneration syndrome were also best demonstrated in transverse sections. Interface changes, lupus panniculitis, miniaturized hairs, and trichomalacia were better demonstrated in vertical sections.

CONCLUSION: Our method exploits the advantages of both vertical and transverse sections and improves diagnostic yield without increasing cost.

Hair counts from scalp biopsy specimens in Asians

Hyun-Jeong Lee, MD
Seog-Jun Ha, MD
Joo-Han Lee, MD
Jin-Wou Kim, MD
Hyung-Ok Kim, MD
David A. Whiting, MD

Seoul, Korea, and Dallas, Texas

J Am Acad Dermatol 2002;46:218-21 Abstract quote

Background: Differences in hair density have been described according to the ethnic background in whites and blacks. Asians are known to have fewer hairs than whites.

Objective: We performed this study to assess the normal values of hair counts in scalp biopsy specimens from Koreans.

Methods: A total of 35 subjects with clinically normal occipital scalps (13 patients with androgenetic alopecia, 20 with patchy alopecia areata, and 2 healthy volunteers) were included. Horizontal sections of 4-mm punch biopsy specimens from clinically normal occipital scalps were examined at various levels from the papillary dermis to the subcutis, and follicular counts of terminal/vellus hairs and anagen/telogen hairs were obtained.

Results: The numbers of total hairs, terminal and vellus hairs, and terminal anagen hairs were significantly lower (P < .05) in Koreans compared with the published data of whites and blacks. Percent ratio of terminal anagen and telogen hairs were similar to whites and blacks. Follicular density was significantly lower (P < .05) in Koreans than in whites and blacks. In Koreans, female subjects had a significantly higher number of terminal hairs than male subjects (P < .05).

Conclusion: Hair density is significantly lower in Koreans than in whites or blacks. Slight sexual difference exists in follicular counts in Koreans. Our data could be used as a guideline for determining normalcy in interpreting horizontal sections of scalp biopsy specimens from Asians.


Clinical and pathologic correlations in genetically distinct forms of atrichia.

Zlotogorski A, Hochberg Z, Mirmirani P, Metzker A, Ben-Amitai D, Martinez-Mir A, Panteleyev AA, Christiano AM.

Departments of Dermatology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel.
Arch Dermatol. 2003 Dec;139(12):1591-6. Abstract quote  

BACKGROUND: The genetic basis of 2 distinct forms of atrichia with papules has recently been defined at the molecular level. In atrichia with papular lesions (APL; Online Mendelian Inheritance in Man [OMIM] 209500), mutations in the hairless gene on chromosome 8p21 have recently been identified. Atrichia with papules also occurs in the clinical setting of vitamin D-dependent rickets type IIA (VDDR IIA; OMIM 277440), resulting from mutations in the vitamin D receptor gene on chromosome 12q12-q14. Despite the distinct genetic basis for both forms of atrichia, the clinical findings are strikingly similar and exhibit classic pathognomonic features unique to this phenotype. We sought to document the clinical and molecular features of APL and VDDR IIA.

OBSERVATIONS: Molecular analysis of the hairless and vitamin D receptor genes was performed on genomic DNA from probands and family members from 3 families with APL and 2 with VDDR IIA. We present a clinical and histologic comparison of atrichia in patients with APL and VDDR IIA and highlight the genetically heterogeneous basis of atrichia by identification of pathogenetic mutations.

CONCLUSIONS: Increased awareness of these diseases will allow early diagnosis and potential therapeutic intervention for the rickets in VDDR IIA and avoidance of treatment of the atrichia in both APL and VDDR IIA. Their phenotype similarities suggest the possibility of a functional relationship between HR and VDR.

Familial focal alopecia. A new disorder of hair growth clinically resembling pseudopelade.

Headington JT, Astle N.

Arch Dermatol 1987 Feb;123(2):234-7 Abstract quote

A 14-year-old girl was evaluated for patchy hair loss present from early childhood. Her mother was found to have a similar condition.

When studied in transverse section, biopsy specimens from both women showed marked anagen-telogen transformation that circumstantially appears to be irreversible. Preservation of telogen epithelium with absence of inflammation and scarring readily separate focal familial alopecia from the pseudopelade state and from localized alopecia areata.

To our knowledge, this is the first description of a new familial disorder causing focal alopecia.

Frontal fibrosing alopecia in postmenopausal women.

Tosti A, Piraccini BM, Iorizzo M, Misciali C.

Department of Dermatology, University of Bologna, Italy.
J Am Acad Dermatol. 2005 Jan;52(1):55-60. Abstract quote

BACKGROUND: Frontal fibrosing alopecia is a variety of cicatricial alopecia characterized by a band of frontal/frontoparietal hair recession and marked decrease or a complete loss of the eyebrows, typically observed in women who are postmenopausal.

OBJECTIVE: The purpose of this study was to report clinical and histopathologic findings and results of treatment in a group of women affected by the disease.

METHOD: A total of 14 women with alopecia of the frontal hairline were evaluated from June 2000 through July 2003 in our outpatient consultation for hair disorders.

RESULTS: Clinical examination revealed a band of symmetric recession of the frontoparietal hairline extending to the preauricular areas associated with loss of follicular orifices, mild skin atrophy, and perifollicular erythema at the scalp margin. In all, 9 patients also had partial or total loss of the eyebrows. The histologic features of the scalp specimens were similar in all our patients with a reduction of the number of hair follicles, and a high number of intermediate and velluslike follicles. Intemediate and velluslike follicles were more commonly affected than terminal follicles by the lymphocytic inflammatory infiltrate and perifollicular fibrosis.

CONCLUSION: Frontal fibrosing alopecia is a cicatricial alopecia that follows destruction of hair follicles by an inflammatory lymphocytic infiltrate that is localized around the upper portion of the hair follicle. It differs from lichen planopilaris because the lymphocytic infiltrate and fibrosis affect selectively the intermediate and the velluslike follicles of the frontal margin and eyebrows. The reason for this selective involvement is still unknown. Frontal fibrosing alopecia may represent a variety of lichen planopilaris with selective involvement of certain androgen-dependent areas. The affected follicles may have typical biologic markers that could explain the clinical and histologic features found in the disease. It is interesting to note that some of the patients treated with finasteride (2.5 mg/d) showed an arrest in the progression of the disease. Even if there is no proof for a hormonal basis of the disease, the effectiveness of finasteride in some patients may indicate that androgens might be partially responsible of the pathogenesis of the disease.
Postmenopausal frontal fibrosing alopecia: a frontal variant of lichen planopilaris.

Kossard S, Lee MS, Wilkinson B.

Skin and Cancer Foundation Australia, NSW, Australia.

J Am Acad Dermatol. 1997 Jan;36(1):59-66. Abstract quote

BACKGROUND: Lichen planopilaris usually produces multifocal areas of scarring alopecia. Recently, a condition in postmenopausal women characterized by progressive frontal hairline recession associated with scarring has been described.

OBJECTIVE: Our purpose was to study the clinical and histopathologic features and results of treatment in a group of women with the frontal variant of lichen planopilaris and to compare the immunohistochemical profile of scalp biopsy specimens from this subset with that found in the multifocal variant of lichen planopilaris.

METHOD: The clinical data as well as the histopathologic findings in 16 women with frontal fibrosing alopecia were collated. The immunohistochemical profile of six scalp biopsy specimens from the frontal hairline were compared with six specimens from women with multifocal lichen planopilaris.

RESULTS: In addition to the progressive frontal fibrosing alopecia in all 16 women, total loss or a marked decrease of the eyebrows was observed in 13. No evidence of lichen planus was observed at other sites. In one patient multifocal areas of lichen planopilaris developed in the scalp. The frontal fibrosing alopecia was slowly progressive but has stabilized in five patients. Biopsy specimens from the frontal hairline showed histologic changes identical to lichen planopilaris. Immunophenotyping failed to reveal any significant differences between the frontal and multifocal variants. No effective treatments emerged although oral steroids and antimalarials may temporarily slow the course. Hormone replacement therapy did not appear to influence the course of the alopecia.

CONCLUSION: Progressive frontal fibrosing alopecia is a clinically distinct variant of lichen planopilaris that affects in particular elderly women and frequently involves the eyebrows. The basis for this lichenoid tissue reaction targeting frontal scalp follicles and eyebrows is unknown.
Histopathology of hypotrichosis with juvenile macular dystrophy.

Bergman R, Sapir M, Sprecher E.

Department of Dermatology, Rambam Medical Center and the Bruce Rappaport Faculty of Medicine, Haifa, Israel.
Am J Dermatopathol. 2004 Jun;26(3):205-9. Abstract quote  

Hypotrichosis with juvenile macular dystrophy (HJMD) (MIM 601553) is a rare disorder characterized by the paucity of hair and progressive macular degeneration leading to blindness. We have recently shown that mutations in the CDH3 gene encoding P-cadherin are the proximal cause of HJMD.

The present study was performed to establish the histopathology of this disorder. 4 mm punch scalp biopsies from 6 HJMD patients aged 9 to 21 years were studied. All patients had a homozygous missense mutation resulting in a single amino acid substitution at position 503 of P-cadherin amino acid sequence (R503H). The total number of hair follicles varied between 6 and 14 per histologic section. More catagen-telogen hair follicles were observed in five cases, and an increased ratio of vellus hair follicles to terminal hair follicles was observed in two cases. There were no signs of inflammation or scarring.

Thus, the most frequent histologic abnormality in HJMD resembles chronic telogen effluvium. This suggests that absence of functional P-cadherin interferes with normal hair cycle.
Lipedematous scalp and lipedematous alopecia: a clinical and histologic analysis of 3 cases.

Martin JM, Monteagudo C, Montesinos E, Guijarro J, Llombart B, Jorda E.

Department of Dermatology, Hospital Clinico Universitario de Valencia, Spain.
J Am Acad Dermatol. 2005 Jan;52(1):152-6. Abstract quote

BACKGROUND: Lipedematous alopecia and lipedematous scalp are two similar unusual conditions mostly affecting healthy black women.

OBJECTIVE: The purpose of our study was to report three cases of this condition with emphasis on clinical and histologic findings, and to review the literature on the subject.

METHODS: The study includes clinical, echographic, and histologic findings of 3 patients, complemented with a literature review.

RESULTS: Two cases of lipedematous alopecia and one of lipedematous scalp in 3 white women had echographic confirmation of an increased subcutaneous layer. The presence of ectatic lymphatic vessels in the two cases with hair loss was particularly emphasized.

CONCLUSIONS: Our findings suggest a lessened role of racial factors, but confirms the sex implications in these related conditions, and stress the potential significance of lymphangiectatic vessels in the development of alopecia in these patients.

Lipedematous alopecia: a clinicopathologic, histologic and ultrastructural study

Kevaghn P.Fair1, Keith A.Knoell2, James W.Patterson1,2, Rebecca J.Rudd2 and Kenneth E.Greer2

1Department of Pathology, 2Department of Dermatology, University of Virginia Health Science Center, Charlottesville, Virginia, USA

J Cutan Pathol 2000;27 (1), 49-53 Abstract quote

Lipedematous alopecia is a rare condition of unknown etiology characterized by a thick, boggy scalp with varying degrees of hair loss that occurs in adult black females, with no clearly associated medical or physiologic conditions. The fundamental pathologic finding consists of an approximate doubling in scalp thickness resulting from expansion of the subcutaneous fat layer in the absence of adipose tissue hypertrophy or hyperplasia.

Observations by light and electron microscopy detailed in this report suggest that this alteration principally manifests by localized edema with disruption and degeneration of adipose tissue. Some diminution in the number of follicles as well as focal bulb atrophy is noted. Aberrant mucin deposition such as that seen in myxedema or other cutaneous mucinoses is not a feature.

The histologic findings bear some resemblance to those seen in lipedema of the legs, a relatively common but infrequently diagnosed condition.

We present a case of lipedematous alopecia with emphasis on histologic and ultrastructural features. The etiology is unknown.


Clinical and histologic findings in temporal triangular alopecia.

Trakimas C, Sperling LC, Skelton HG

3rd, Smith KJ, Buker JL. Dermatology Service, Walter Reed Army Medical Center, Washington, DC 20307.

J Am Acad Dermatol 1994 Aug;31(2 Pt 1):205-9 Abstract quote

BACKGROUND: Temporal triangular alopecia (TTA; also called "congenital triangular alopecia") is a common disorder that is assumed to be congenital. Little is known about its histologic features.

OBJECTIVE: Our purpose was to describe four new cases, review the literature, and present histologic features based on vertical and transverse sectioning. METHODS: The history, clinical features, and histologic findings of four patients with TTA are described and the relevant literature reviewed.

RESULTS: Lesions of TTA are seldom congenital, and most are best described as lancet-shaped. The "bald spot" contains normal numbers of hairs, although virtually all are vellus or indeterminate follicles.

CONCLUSION: Most cases of TTA appear to develop during the first few years of life, and the designation "congenital" is a misnomer. The appearance of alopecia can be best explained as a focal zone of hair miniaturization leading to vellus hair formation.

Temporal triangular alopecia acquired in adulthood.

Trakimas CA, Sperling LC.

Dermatology Service, Walter Reed Army Medical Center, Washington, DC, USA.

J Am Acad Dermatol 1999 May;40(5 Pt 2):842-4 Abstract quote

Temporal triangular alopecia is a relatively common, nonscarring form of alopecia. Sometimes congenital, the vast majority of lesions appear during the first 6 years of life and remain stable thereafter.

We report a case of temporal triangular alopecia arising during adulthood.


Trichotillomania. Presentation, etiology, diagnosis and therapy.

Walsh KH, McDougle CJ.

Indiana University School of Medicine, Indianapolis, Indiana, USA.

Am J Clin Dermatol 2001;2(5):327-33 Abstract quote

Trichotillomania (TTM) is an impulse disorder, in which patients chronically pull hair from the scalp and/or other sites. Very early onset of hair pulling in children under the age of 6 may be more benign and self-limiting than the more common syndrome of late childhood onset hair pulling. While far more women and adolescent girls appear for treatment, survey studies suggest chronic hair pulling also occurs in males.

Diagnosis may be complicated by patient and family denial or ignorance of the hair pulling; accurate scalp examination and biopsy can be critical. Classic scalp biopsies for TTM feature trichomalacia, pigment clumps, peribulbar hemorrhage and hair canal pigment casts, and lack lymphocytic infiltrates seen in alopecia areata.

Treatment is difficult: the tricyclic antidepressant clomipramine is the most promising agent, although many patients find it difficult to tolerate at adequate dosages, and treatment response may not be maintained over the long term. More benign medications have not demonstrated efficacy in controlled studies. Augmentation with topical preparations or psychotropic medications may be helpful for patients experiencing limited efficacy or relapse. Specialized psychotherapy, known as habit reversal training, is highly recommended; however, the treatment is intensive and highly specialized. Skilled therapists are difficult to locate.

The combined utilization of clinical and histological findings in the diagnosis of trichotillomania.

Bergfeld W, Mulinari-Brenner F, McCarron K, Embi C.

Departments of Dermatology and Pathology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA.

J Cutan Pathol 2002 Apr;29(4):207-214 Abstract quote

BACKGROUND:: Trichotillomania (TM) is a chronic disorder in which patients traumatically remove their own hair in a bizarre pattern. TM histopathological findings are not well defined.

METHODS:: Twenty-eight scalp biopsies of TM were reviewed. Multiple vertical sections and special stains were used to evaluate the specimens. Twenty-six patients (24 female, 2 male) were in the cohort, 2 patients had 2 sets of biopsies.

RESULTS: Age range was 13^78 years (mean 41 years), most of them presented with chronic TM. Specific histological findings included trichomalacia (57%) and pigmented casts (46%). Non-specific histological findings included: follicular plugging (96%), decreased number of follicles (96%), reversed anagen:telogen ratio (86%), decreased number of sebaceous glands (68%), melanoderma (68%), increased number of fibrous tracts (64%) and vellus hairs (57%), superficial dermal inflammation (57%), evidence of hemorrhage (18%) and presence of hair granulomas (18%).

CONCLUSIONS: Even though TM is often a disease of the young people, middle aged and elderly patients with TM have more often a biopsy to confirm the diagnosis. This paper suggests diagnostic criteria for TM. Specific histological findings and clinical suspicion of TM were considered major criteria, while the non-specific histological findings were considered minor diagnostic criteria for TM.



Elastic tissue in scars and alopecia.

Elston DM, McCollough ML, Warschaw KE, Bergfeld WF.

Department of Dermatology, Wilford Hall Air Force and Brooke Army Medical Centers, Fort Sam Houston, Texas 78234-6200, USA.

J Cutan Pathol 2000 Mar;27(3):147-52 Abstract quote

A recent report suggests that elastic fibers appear in scars in a time-dependent fashion. This observation prompted our investigation, because we have found elastic tissue stains helpful in determining the pattern of scarring in cases of permanent alopecia.

We carried out this investigation to determine if the Verhoeff-Van Gieson (VVG) elastic stain can reliably differentiate scarred from non-scarred dermis and to test our hypothesis that elastic stained sections are helpful in distinguishing lichen planopilaris (LPP) from lupus erythematosus (LE), central progressive alopecia in black females ("follicular degeneration syndrome" and "hot comb alopecia" are other terms used to describe this condition) and classic ivory white idiopathic pseudopelade.

We studied histological sections from surgical scars of known duration, stained with the VVG elastic stain and VVG-stained sections of scalp biopsies from patients with established lesions of permanent alopecia. In most cases, both vertical and transverse sections were examined. In every case, the VVG stain clearly differentiated scar from the normal surrounding dermis. Distinct patterns of elastic tissue allowed for correct classification in most of the well-established cases of permanent alopecia studied.

We determined that the Verhoeff-Van Gieson stain is an excellent stain to evaluate the pattern of scarring in cases of permanent alopecia and elastic tissue stains may be helpful in the histological evaluation of alopecia.



Scarring alopecia and the dermatopathologist.

Sperling LC.

Department of Dermatology, Uniformed Services University, Bethesda, Maryland 20814, USA.

J Cutan Pathol 2001 Aug;28(7):333-42 Abstract quote

BACKGROUND: The evaluation of patients with cicatricial alopecia is particularly challenging, and dermatopathologists receive little training in the interpretation of scalp biopsy specimens. Accurate interpretation of specimens from patients with hair disease requires both qualitative (morphology of follicles, inflammation, fibrosis, etc.) and quantitative (size, number, follicular phase) information. Much of this data can only be obtained from transverse sections. In most cases, good clinical/pathologic correlation is required, and so clinicians should be expected to provide demographic information as well as a brief description of the pattern of hair loss and a clinical differential diagnosis.

RESULTS: The criteria used to classify the various forms of cicatricial alopecia are relatively imprecise, and so classification is controversial and in a state of evolution. There are five fairly distinctive forms of cicatricial alopecia: 1) chronic, cutaneous lupus erythematosus (discoid LE); 2) lichen planopilaris; 3) dissecting cellulitis (perifolliculitis abscedens et suffodiens); 4) acne keloidalis; and 5) central, centrifugal scarring alopecia (follicular degeneration syndrome, folliculitis decalvans, pseudopelade). Not all patients with cicatricial alopecia can be confidently assigned to one of these five entities, and "cicatricial alopecia, unclassified" would be an appropriate label for such cases.

CONCLUSION: The histologic features of five forms of cicatricial alopecia are reviewed. Dermatopathologists can utilize a "checklist" to catalog the diagnostic features of scalp biopsy specimens. In many, but not all, cases the information thus acquired will "match" the clinical and histologic characteristics of a form of cicatricial alopecia. However, because of histologic and clinical overlap between the forms of cicatricial alopecia, a definitive diagnosis cannot always be rendered.

Main Category Dermal Histologic Pattern Additional Clues Disease
  Normal number of follicles Some follicles thinned and positioned higher in dermis than normal, in time, all follicles vellus Androgenic alopecia
    Most follicles normal, few follicles in catagen or telogen Telogen effluvium
    Trichomalacia Trichotillomania
  Decreased number of follicles Thickened collagen bundles in widened fibrous tracts Traction alopecia
  Lymphocytes predominate Around base of follicles Alopecia areata
    Around infundibula mostly-wedge shaped hypergranulosis of infundibula Lichen planopilaris
    Around infundibula mostly-smudge appearance of dermoepidermal junction beneath epidermis thinned focally DLE
    Nodules of lymphocytes and plasma cells at junction of dermis and subcutaneous fat, and at junction of septa and lobules Scleroderma
  Neutrophils predominate Signs of infectious cause and identifiable-bacteria Folliculitis decalvans
    Signs of infectious cause and identifiable-fungal Tinea capitis
Majocchi's granuloma
    Signs of infectious cause and identifiable-viral Zoster/Varicella/Herpes simplex
    Sinus tracts Dissecting cellulitis
    Ulcers Burns
    Necrosis of epidermal and adnexal epithelium Radiodermatitis, acute
  Histiocytes and plasma cells predominate   Syphilis, secondary
  Little or no infiltrate of inflammatory cells Discrete whorls of thin collagen bundles in deep reticular dermis Alopecia areata, late
    Fibroplasia along thinned follicles, infundibular hypergranulosis Lichen planopilaris, late
    Thickened basement membrane, thinned epidermis DLE, late
    Thickened crowded bundles of collagen parallel to skin surface in reticular dermis Scleroderma, late
    Coarse bundles of collagen and prominent venules parallel to skin surface Burn, late
    Sclerosis throughout dermis, abnormal fibrocytes, thrombosed vessels often Radiation dermatitis, late


A comparative clinical and histologic study of hair transplantation using Er:YAG, Er:YAG/CO2, and standard punch techniques.

Sadick NS, Shea CR, Nicholson J, Gat M, Lunievski S, Prieto VG.

Department of Dermatology, Weill Medical College of Cornell University, New York, New York, USA.

Dermatol Surg 2001 Sep;27(9):807-12 Abstract quote

BACKGROUND: This study compares the effects of Er:YAG laser alone, Er:YAG/CO2 laser at 5 W (low power), Er:YAG/CO2 at 10 W (high power), and standard punch techniques in 10 men with androgenetic alopecia.

OBJECTIVE: To study the clinical and histologic features of hair transplantation with recipient graft defects created by a new hybrid Er:YAG and CO2 laser.

METHODS: Ten male patients (mean age 34 y) with Norwood IV-VI androgenetic alopecia had hair replacement surgery with the recipient sites divided into four quadrants comparing cold stell, erbium, combined erbium low-power CO2, and combined erbium high-power CO2 technologies. Hair growth, intraoperative procedure, lateral thermal damage, and patient satisfaction were compared, utilizing each of the four stated technologies.

RESULTS: The addition of CO2 laser at both low and high power settings resulted in improved hemostasis when compared with standard punch or Er:YAG laser alone. The mean hair counts were similar for the Er:YAG laser, Er:YAG/CO2 (5 W) laser, and standard punch at both 3 and 6 months after treatment. Lateral thermal damage was not significantly increased by the addition of low-power CO2 to Er:YAG. The addition of high-power CO2 (10 W) laser resulted in slightly lower mean hair counts at 3 months, but significantly decreased at 6 months (P =.05). Also, high-power CO2 laser caused significantly increased lateral damage. There were no detectable differences in hsp70 expression among the groups.

CONCLUSION: The addition of 5 W CO2 laser to Er:YAG laser results in better hemostasis than Er:YAG laser alone, while not significantly diminishing mean hair counts or inducing increased lateral thermal damage.


A new strategy for modulating chemotherapy-induced alopecia, using PTH/PTHrP receptor agonist and antagonist.

Peters EM, Foitzik K, Paus R, Ray S, Holick MF.

Department of Medicine, Boston University Medical Center, MA 02118, USA.

J Invest Dermatol 2001 Aug;117(2):173-8 Abstract quote

Parathyroid hormone (PTH) related peptide (PTHrP) and the PTH/PTHrP receptor (PTH/PTHrP-R) show prominent cutaneous expression, where this signaling system may exert important paracrine and/or autocrine functions, such as in hair growth control. Chemotherapy-induced alopecia - one of the fundamental unsolved problems of clinical oncology - is driven in part by defined abnormalities in hair follicle cycling.

We have therefore explored the therapeutic potential of a PTH/PTHrP-R agonist and two PTH/PTHrP-R antagonists in a mouse model of cyclophosphamide-induced alopecia. Intraperitoneal administration of the agonist PTH(1-34) or the antagonists PTH(7-34) and PTHrP(7-34) significantly altered the follicular response to cyclophosphamide in vivo. PTH(7-34) and PTHrP(7-34) shifted it towards a mild form of "dystrophic anagen", associated with a significant reduction in apoptotic (TUNEL+) hair bulb cells, thus mitigating the degree of follicle damage and retarding the onset of cyclophosphamide-induced alopecia. PTH(1-34), in contrast, forced hair follicles into "dystrophic catagen", associated with enhanced intrafollicular apoptosis. We had previously shown that an induced shift in the follicular damage-response towards "dystrophic catagen" mitigates cyclophosphamide-induced alopecia, whereas a shift towards "dystrophic catagen" initially enhanced the hair loss, yet subsequently promoted accelerated hair follicle recovery.

Therefore, this study in an established animal model of chemotherapy-induced alopecia, which closely mimics human chemotherapy-induced alopecia, strongly encourages the exploration of PTH/PTHrP-R agonists and antagonists as novel therapeutic agents in chemotherapy-induced alopecia.

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