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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 11  |  Issue : 4  |  Page : 170-172  

Overnight alopecia: A subtype of acute diffuse and total alopecia?


Cutis Academy of Cutaneous Sciences (Affiliated to Rajiv Gandhi University of Health Sciences), Bengaluru, Karnataka, India

Date of Web Publication19-Aug-2019

Correspondence Address:
Dr Rashmi Agarwal
Cutis Academy of Cutaneous Sciences, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijt.ijt_36_19

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   Abstract 


Acute diffuse and total alopecia (ADTA) is a variant of alopecia areata which lacks the typical patchy hair loss seen in classical alopecia areata and presents with an acute onset of diffuse hair loss commonly reported in young females with the duration from disease onset to diffuse hair loss ranging from 2 to 20 weeks. Although the clinical features of ADTA resemble telogen effluvium, dermoscopy can prove to be a useful tool for differentiating these two conditions and avoiding unnecessary investigations as specific dermoscopic findings of alopecia areata are invariably present along the disease course. Herein, we report a case of ADTA in a 42-year-old Indian female who presented with sudden onset of diffuse hair loss of only 1-day duration.

Keywords: Acute diffuse and total alopecia, alopecia areata, females


How to cite this article:
Chandrashekar B S, Shenoy C, Agarwal R. Overnight alopecia: A subtype of acute diffuse and total alopecia?. Int J Trichol 2019;11:170-2

How to cite this URL:
Chandrashekar B S, Shenoy C, Agarwal R. Overnight alopecia: A subtype of acute diffuse and total alopecia?. Int J Trichol [serial online] 2019 [cited 2019 Nov 20];11:170-2. Available from: http://www.ijtrichology.com/text.asp?2019/11/4/170/264717




   Introduction Top


Alopecia areata causing nonscarring alopecia affects all races and both sexes. It may be associated with autoimmune diseases such as autoimmune thyroiditis, diabetes mellitus, and vitiligo.[1],[2] Acute diffuse and total alopecia (ADTA) is a variant of alopecia areata lacking the typical patchy hair loss seen in classical alopecia areata and presents with acute onset of diffuse hair loss in young females. It has a favorable prognosis.[3] Herein, we report a case of ADTA in a 42-year-old Indian female who presented with diffuse hair loss of >80%, over the scalp of only 1-day duration.


   Case Report Top


A 42-year-old female presented to us with acute onset of diffuse hair loss from the scalp of 1-day duration [Figure 1]a. She was a known case of vitiligo vulgaris on treatment with topical tacrolimus 0.1% ointment and fluticasone ointment along with spot Narrow-band UVB (NB-UVB) phototherapy therapy for the past 8 months. She had undergone appendicectomy 1 month back and had also developed cellulitis of the left hand at the same time. Based on the clinical history and diffuse hair loss, acute telogen effluvium, female pattern hair loss, and ADTA areata were considered as the differential diagnosis in this case. Dermoscopy showed the presence of black dots, yellow dots, and short vellus hair [Figure 2]a. These findings were suggestive of alopecia areata. There were no associated nail changes and no family history of alopecia areata. Her complete blood count, liver function test, renal function test, and random blood sugar were all within normal limits. A diagnosis of ADTA presenting with overnight alopecia was made, and the patient was started on topical minoxidil lotion and clobetasol propionate 0.05% gel once daily to which she responded very well and hair growth was seen within 6 weeks [Figure 1]b. Dermoscopy showed predominance of terminal hair at the end of 12 weeks [Figure 2]b. The patient is on regular follow-up without any recurrence for the past 1 year.
Figure 1: (a) Diffuse hair loss from the scalp of a 42-year-old female patient. (b) Improvement in hair growth after 6 weeks of therapy

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Figure 2: (a) Videodermoscopy before initiation of therapy showed the presence of black dots (blue arrow), short vellus hair (red arow), and yellow dots (green arrow). (b) Videodermoscopy at the end of 6 months of therapy showing predominance of terminal hair

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   Discussion Top


Alopecia areata is a common cause of nonscarring alopecia affecting people in their second to fourth decade of life. The exact cause is not known, but autoimmunity is thought to play a key role in its pathogenesis.[4] ADTA is a variant of alopecia areata, affecting mostly young females with a favorable prognosis.[3] It lacks the typical patchy hair loss pattern seen in alopecia areata and has an extremely acute onset with duration from disease onset to diffuse hair loss ranging from 2 to 20 weeks.[1],[5] But in our case, the patient gave a history of overnight alopecia which was very striking. According to Rebora,[6] it occurs when alopecia areata affects those people with high percentages of telogen hair on the scalp. The histopathological findings of ADTA are similar to the classical forms of the disease with inflammatory infiltrate around the terminal hair bulb being the most consistent finding in acute cases.[5],[7] Sato-Kawamura et al. reported a remarkable eosinophilic infiltrate in the scalp biopsies of nine female cases of acute and diffuse hair loss which was not reported in other studies.[3]

Although the clinical features of ADTA resemble telogen effluvium, dermoscopy can prove to be a useful tool for differentiating these two conditions and avoiding unnecessary investigations as specific dermoscopic findings of alopecia areata are invariably present along the disease course. A study conducted on 300 cases of alopecia areata revealed that only 49.1% of patients with diffuse-type alopecia areata showed signs of cadaverized hair, exclamation mark hair, or broken hair and that 96.5% showed either yellow dots or short vellus hairs.[8] Similar dermoscopic findings were also reported in another study conducted on 70 patients with acute alopecia totalis.[5] Dermoscopy of ADTA does not usually reveal exclamation mark hair in the early stages but is seen in the later stages. Videodermoscopic finding in our case also revealed multiple yellow dots with short vellus hair. Absence of exclamation mark hair may be due to the acute onset of the disease process. These dermoscopic findings were specific in the diagnosis of alopecia areata, thus avoiding the need for performing a scalp biopsy.

The treatment modalities for ADTA mainly include oral and topical steroids. Choi and Ihm suggested the use of corticosteroid pulse therapy in the early stages of rapidly evolving alopecia areata is effective.[7] In a study conducted on 30 Korean patients with ADTA, 11 patients were kept under close observation without any treatment, while 19 patients were given local DPCP application. All patients experienced hair regrowth within about 6 months, without regard to the method of treatment.[1] Minoxidil has been shown to be effective as an adjuvant therapy in combination with topical or intralesional steroids.[9] In alopecia areata, minoxidil can induce hair regrowth by stimulating proliferation at the base of the bulb and differentiation above the dermal papilla, independent of its vascular influences.[10] It has been shown to have a synergistic stimulatory effect on the follicular epithelium and a suppressive effect on lymphocyte-mediated immunologic phenomenon.[9] Our patient responded to topical minoxidil and topical steroid lotion without any oral drugs within 6 weeks and was able to achieve complete regrowth over 12 weeks. She was followed up for a period of 1 year without any relapse.

We highlight this case due to the striking overnight alopecia with which the patient presented to us and to explain the importance of dermoscopic evaluation of a case of hair loss, as it can help the clinician to avoid unnecessary investigations including invasive procedures such as biopsy, and thereby aid in earlier and proper management of the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Lew BL, Shin MK, Sim WY. Acute diffuse and total alopecia: A new subtype of alopecia areata with a favorable prognosis. J Am Acad Dermatol 2009;60:85-93.  Back to cited text no. 1
    
2.
Ozcan D, Cevlik Aydoǧan F. Concurrence of alopecia areata and vitiligo at the same anatomical site. Australas J Dermatol 2012;53:e61-3.  Back to cited text no. 2
    
3.
Sato-Kawamura M, Aiba S, Tagami H. Acute diffuse and total alopecia of the female scalp. A new subtype of diffuse alopecia areata that has a favorable prognosis. Dermatology 2002;205:367-73.  Back to cited text no. 3
    
4.
Tan E, Tay YK, Goh CL, Chin Giam Y. The pattern and profile of alopecia areata in Singapore – A study of 219 Asians. Int J Dermatol 2002;41:748-53.  Back to cited text no. 4
    
5.
Tosti A, Whiting D, Iorizzo M, Pazzaglia M, Misciali C, Vincenzi C, et al. The role of scalp dermoscopy in the diagnosis of alopecia areata incognita. J Am Acad Dermatol 2008;59:64-7.  Back to cited text no. 5
    
6.
Rebora A. Alopecia areata incognita: A hypothesis. Dermatologica 1987;174:214-8.  Back to cited text no. 6
    
7.
Choi HJ, Ihm CW. Acute alopecia totalis. Acta Dermatovenerol Alp Pannonica Adriat 2006;15:27-34.  Back to cited text no. 7
    
8.
Inui S, Nakajima T, Nakagawa K, Itami S. Clinical significance of dermoscopy in alopecia areata: Analysis of 300 cases. Int J Dermatol 2008;47:688-93.  Back to cited text no. 8
    
9.
Price VH. Double-blind, placebo-controlled evaluation of topical minoxidil in extensive alopecia areata. J Am Acad Dermatol 1987;16:730-6.  Back to cited text no. 9
    
10.
Seetharam KA. Alopecia areata: An update. Indian J Dermatol Venereol Leprol 2013;79:563-75.  Back to cited text no. 10
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