A 22-year-old woman comes to the physician seeking evaluation for hair loss. She developed a small, discrete patch of hair loss a few years ago that resolved spontaneously without scarring. In the past 3 weeks, she has developed another patch that is larger than the previous one and is causing her significant anxiety. She denies pulling on her hair. There is no associated itching or burning of her scalp. The patient has no other significant medical history. Her only medication is birth control pills. She is in graduate school and is under a lot of stress from her studies.
On examination, she appears healthy and her vital signs are normal. A photograph of her scalp is shown below.

Some hairs in the margin are larger on top than at their base and are extractable with minimal traction. There is no evidence of scalp inflammation and there are no nail abnormalities.
Laboratory results are as follows:

What would be the most appropriate therapy for this patient?

Question

A 22-year-old woman comes to the physician seeking evaluation for hair loss.  She developed a small, discrete patch of hair loss a few years ago that resolved spontaneously without scarring.  In the past 3 weeks, she has developed another patch that is larger than the previous one and is causing her significant anxiety.  She denies pulling on her hair.  There is no associated itching or burning of her scalp.  The patient has no other significant medical history.  Her only medication is birth control pills.  She is in graduate school and is under a lot of stress from her studies.
On examination, she appears healthy and her vital signs are normal.  A photograph of her scalp is shown below.

Some hairs in the margin are larger on top than at their base and are extractable with minimal traction.  There is no evidence of scalp inflammation and there are no nail abnormalities.
Laboratory results are as follows:

What would be the most appropriate therapy for this patient?

Quizplus · Accepted Answer

This patient's smooth, circular patch of non-scarring hair loss is most characteristic of alopecia areata. Alopecia areata is a chronic, recurring inflammatory disorder and is associated with other autoimmune disorders (eg, thyroiditis). Diagnosis of alopecia areata is established clinically. It tends to appear as smooth, circular patches of hair loss with exclamation point hairs seen at the margins. It usually develops over a few weeks in individuals under age 30. There may be some nail involvement (eg, nail pitting). Alopecia areata does not cause permanent damage to the hair follicle. In contrast, scarring alopecia (eg, discoid lupus erythematosus refers to hair loss associated with fibrosis and scar tissue (inflammation) that eventually permanently destroys the hair follicle. discoid lupus erythematosus More than 50% of individuals with alopecia areata experience a spontaneous recovery within a year. However, relapses are also common. Sometimes, depending on the size and site of the hair loss, no treatment is indicated. Many clinicians feel that intralesional corticosteroids are safe and effective for limited areas of involvement. Topical steroids can be given if the patient refuses injections. Topical immunotherapy is usually reserved for individuals with extensive alopecia or those who have not responded well to other treatments. (Choice A) Traumatic alopecia (trichotillomania) is treated with patient education and cognitive behavioral therapy. In trichotillomania, examination shows bizarre, asymmetric, and irregular hair loss. (Choice B) Oral contraceptives do not cause hair loss. In contrast, the postpartum period is associated with some hair loss but requires no treatment. (Choice D) Oral terbinafine is an effective treatment for tinea capitis. Tinea capitis can also result in non-scarring patches of hair loss. This disorder is most commonly seen in children and is associated with erythematous, scaly patches of underlying skin. Tinea capitis (Choice E) Minoxidil is generally considered a second-line therapy that can be used alone or in combination with first-line therapy. Compared with intralesional corticosteroids and topical immunotherapy, minoxidil is less efficacious. Educational objective: Discrete, circular patches of non-inflamed and non-scarring hair loss are usually due to alopecia areata. Characteristic exclamation point hairs are seen at the margins. First-line therapy is intralesional corticosteroids. __________ References: Interventions for alopecia areata. (http://www.ncbi.nlm.nih.gov/pubmed/18425901) Alopecia areata update: part II. treatment. (http://www.ncbi.nlm.nih.gov/pubmed/20115946)

A 22-Year-Old Woman Comes to the Physician Seeking Evaluation for Hair