A 42-year-old Caucasian woman comes to the physician because of "patchy hair loss" for the past six weeks. Her other medical problems include hypothyroidism, gastroesophageal reflux disease, and bipolar disorder. She has smoked one pack of cigarettes daily for the past 15 years. She drinks 1-2 ounces of alcohol daily, and is a vegetarian. Her mother has thyroid disease, bipolar disorder and breast cancer. The patient's medications include lansoprazole, L-thyroxine and valproic acid. On physical examination, her vital signs are within normal limits. Scalp exam reveals several well-demarcated circular areas of complete hair loss. Fingernail pitting is also present. Which of the following is the most likely cause of her hair loss?

Question

A 42-year-old Caucasian woman comes to the physician because of "patchy hair loss" for the past six weeks.  Her other medical problems include hypothyroidism, gastroesophageal reflux disease, and bipolar disorder.  She has smoked one pack of cigarettes daily for the past 15 years.  She drinks 1-2 ounces of alcohol daily, and is a vegetarian.  Her mother has thyroid disease, bipolar disorder and breast cancer.  The patient's medications include lansoprazole, L-thyroxine and valproic acid.  On physical examination, her vital signs are within normal limits.  Scalp exam reveals several well-demarcated circular areas of complete hair loss.  Fingernail pitting is also present.  Which of the following is the most likely cause of her hair loss?

Quizplus · Accepted Answer

Explanation: Alopecia areata is a type of non-scarring hair loss that can affect any hair-bearing area. It is thought to be an autoimmune process that targets genetically predisposed individuals. The classic clinical description is of a well-demarcated, often round, non-scarred patch of complete hair loss. The presence of so-called "exclamation point hairs" (hairs which are tapered near the insertion into the scalp), especially at the periphery of an alopecic plaque, is considered pathognomonic of, but not necessary for, the diagnosis. Areas of involvement may be single or multiple. Nail pitting is a commonly associated finding. The affected areas of skin are typically asymptomatic, but the disease can be emotionally traumatic and socially stigmatizing. Alopecia areata is often self-limited, but may be relapsing and remitting or chronic and progressive. Patients with alopecia areata are at increased risk for other autoimmune conditions including autoimmune thyroid disease, vitiligo, and pernicious anemia. (Choice B) Certain medications may cause hair loss via a telogen or anagen effluvium. Medication-related hair loss typically manifests as diffuse non-scarring thinning, rather than as discrete bald patches. Telogen effluvium usually begins about 3 months after some precipitating event, such as an illness, stressor, or new medication. Beta-blockers, anti-coagulants, systemic retinoids, anti-convulsants, and anti-thyroid medications are frequently implicated causes of telogen effluvium. Chemotherapeutics (e.g. antimetabolites, alkylating agents, mitotic inhibitors) can cause anagen effluvium, which usually begins within 1-2 weeks of chemotherapy initiation. (Choice C) Psoriasis is a chronic inflammatory skin disorder characterized by well-demarcated erythematous plaques with silvery scale. The extensor extremities, periumbilical area, gluteal cleft, lumbosacral area, and scalp are among the areas most commonly involved. Associated hair loss is usually minimal. Nail changes are common in psoriasis and may include pitting, onycholysis, as well as thickening and yellowing of the nail plate. (Choice D)Tinea capitis is a dermatophyte infection of the scalp that affects children most commonly. Trichophyton tonsurans and Microsporum canis are the most common causes of tinea capitis in the United States. The clinical presentation varies by causative organism, but may consist of erythema, scaling, "black dot" alopecia (secondary to breakage of hairs near the scalp), pustules, or boggy plaques with posterior cervical or posterior auricular lymphadenopathy. While patchy or diffuse alopecia is common, the accompanying inflammation, scale, and lymphadenopathy are typically sufficient to distinguish tinea capitis from alopecia areata. Trichophyton tonsurans Microsporum canis (Choice E) Trichotillomania is a psychiatric impulse control disorder where hairs are plucked, twisted, or otherwise broken from the scalp. On physical examination, irregularly shaped areas of hair loss containing hairs of many different lengths are typical. Educational objective: The classic presentation of alopecia areata consists of well-demarcated, non-scarred, round patches of hair loss, which may have "exclamation point" hairs. Affected patients are more likely to have a personal or family history of other autoimmune conditions, including autoimmune thyroid disease, pernicious anemia, and vitiligo. References: Diagnosing and treating hair loss. (http://www.ncbi.nlm.nih.gov/pubmed/19678603)

A 42-Year-Old Caucasian Woman Comes to the Physician Because of "Patchy