International Journal of Trichology International Journal of Trichology
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 Table of Contents  
Year : 2015  |  Volume : 7  |  Issue : 4  |  Page : 184-186  

Patchy traction alopecia mimicking Areata

1 Department of Dermatology of the University Hospital from the Federal University of Mato Grosso do Sul, Campo Grande (MS), Brazil
2 Department of Dermatology of the University Hospital from the University of São Paulo, São Paulo, Brazil
3 Department of Dermatology, School of Medicine, University of São Paulo (Faculdade de Medicina), Universidade de São Paulo, São Paulo, Brazil

Date of Web Publication11-Dec-2015

Correspondence Address:
Aline Blanco Barbosa
Rua Dr. Antônio Alves Arantes, 201, Campo Grande, Mato Grosso do Sul, CEP: 79040-720
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-7753.171588

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Acute traction alopecia is a diagnostic challenge when the external factor is not suspected or admitted. We report two female patients with non-scarring patchy alopecia resulting from traction of video-electroencephalogram electrodes in which the clinical diagnosis of alopecia areata was suspected. Associated diffuse hair disorders might be implicated in these cases. The correct diagnosis of traction alopecia is important in order to avoid unnecessary treatments.

Keywords: Alopecia, desmoscopy, pathology

How to cite this article:
Barbosa AB, Donati A, Valente NS, Romiti R. Patchy traction alopecia mimicking Areata. Int J Trichol 2015;7:184-6

How to cite this URL:
Barbosa AB, Donati A, Valente NS, Romiti R. Patchy traction alopecia mimicking Areata. Int J Trichol [serial online] 2015 [cited 2023 Jan 27];7:184-6. Available from: https://www.ijtrichology.com/text.asp?2015/7/4/184/171588

   Introduction Top

Traction alopecia (TA) is a form of trauma-induced alopecia and results from continuous excessive pulling of hair shafts. Hairstyling is the most common cause of longstanding traction and usually results in alopecia of scalp margins. [1] When tension forces are not applied over the margin, for example, due to hair clips or wefts, [2],[3] an atypical pattern may result and the diagnosis can be challenging.

We present two cases of patchy TA due to video- electroencephalogram (VEEG) test. Differential diagnosis with alopecia areata (AA) and trichotillomania (TTM) are discussed.

   Case reports Top

Case 1

A 40-year-old epileptic woman complained of hair loss few days after a 12-day-long VEEG test. Lamotrigine had been started couple months before and was withdrawn after hair loss onset. The patient presented several irregularly shaped alopecic patches [Figure 1]a] with black dots, yellow dots, and vellus hairs on dermoscopy [Figure 1]b]. No exclamation mark hairs were observed. The rest of the scalp showed normal hair density with diffusely positive pull test. The clinical hypothesis of AA, TTM, or TA associated with telogen effluvium was made. Scalp biopsies showed increased telogen germinative units [Figure 1]c] and pigment casts [Figure 1]d]. No peribulbar infiltrate or miniaturized follicles were observed and AA was excluded. Spontaneous complete regrowth was observed after 6 months of follow-up [Figure 1]e and f].
Figure 1: Case 1 (a): Clinical aspect; (b): Dermoscopy - yellow dots, black dots, few vellus hairs (videodermoscopy, ×32); (c): Biopsy - no peribulbar infiltrate (H and E, ×40); (d): Vertical section - pigment cast (H and E, ×100); (e): Six-month follow-up - complete hair regrowth clinically and (f): On dermoscopy

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Case 2

A 44-year-old epileptic woman presented with hair loss few days after a 7-day-long VEEG test. Scalp examination revealed several irregular alopecic patches associated with diffuse thinning over the crown [Figure 2]a]. Dermoscopy showed black dots, yellow dots, vellus hairs and increased shaft diameter variability on the patch border [Figure 2]b]. Female pattern hair loss (FPHL) associated with patches of AA, TTM, or TA was considered as a clinical hypothesis. Histology showed increased catagen count and pigment clumps with no signs of AA. After 6 months, full recovery of the alopecic patches was observed and topical minoxidil 5% was initiated for FPHL diagnosis [Figure 2]c and d].
Figure 2: Case 2 (a): Clinical aspect - patches of alopecia (electrodes REF and F2), diffuse hair thinning; (b): Dermoscopy - black dots, yellow dots, vellus hairs. Notice hair variability (videodermoscopy, ×32); (c): Six-month follow-up - hair regrowth; (d): Dermoscopy; (e): Model - loosely braided hair, electrodes positions

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   Discussion Top

TA is usually due to traumatic hair care practices [4] and presents as bandlike hair loss of the frontal-temporal margin of the scalp, with the typical fringe sign. [1] Patchy TA due to hair pins, clips or wefts is not marginal, and presents as localized areas of noncicatricial alopecia, mimicking AA or TTM. [2],[3]

Dermoscopy of recent-onset TA differs from longstanding TA [4],[5] and shows mainly black dots and broken hairs. [6],[7] Vellus hairs and yellow dots might also be seen, [7] but exclamation mark hairs are absent. [8] Histology of recent-onset TA closely resembles TTM with increased catagen-telogen count and pigment casts within the hair canal. [9] The absence of peribulbar lymphocytic infiltrate or miniaturized hair follicles help differentiate from AA [Table 1]. [10]
Table 1: Comparative findings between longstanging traction alopecia, recent-onset traction alopecia, acute patchy alopecia areata and trichotillomania

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VEEG test is indicated in epileptic patients with infrequent convulsive episodes and includes the application of several electrodes to the scalp surface [Figure 2]e]. To our knowledge, these are the first reported cases of TA due to VEEG electrodes. We hypothesize associated hair cycle disorders, such as telogen effluvium and FPHL, might have facilitated plucking in cases 1 and 2, respectively.

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


Conflicts of interest

There are no conflicts of interest.

   References Top

Samrao A, Zedek D, Price VH, Mirmirani P. The "Fringe Sign" A Useful Clinical Finding in Traction Alopecia of the Marginal Hair Line. J Clin Exp Dermatol Res 2011;2:117.  Back to cited text no. 1
Ahdout J, Mirmirani P. Weft hair extensions causing a distinctive horseshoe pattern of traction alopecia. J Am Acad Dermatol 2012;67:e294-5.  Back to cited text no. 2
Yosefy C, Ronnen M, Edelstein D. Pseudo Alopecia Areata Caused by Skull-caps with Metal Pin Fasteners used by Orthodox Jews in Israel. Clin Dev Immunol 2003;10:193-5.  Back to cited text no. 3
Tosti A, Miteva M, Torres F, Vincenzi C, Romane P. Hair casts are a dermoscopic clue for the diagnosis of traction alopecia. Br J Dermatol 2010;163:1346-8.  Back to cited text no. 4
Köse OK, Güleç AT. Clinical evaluation of alopecias using a handheld dermatoscope. J Am Acad Dermatol 2012;67:206-14.  Back to cited text no. 5
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. 6
Shim VH, Jwa SW, Song M, Kim HS, Ko HC, Kim BS, et al. Dermoscopic approach to a small round to oval hairless patch on the scalp. Ann Dermatol 2014;26:214-20.  Back to cited text no. 7
Abraham LS, Torres FN, Azulay-Abulafia L. Dermoscopic clues to distinguish trichotillomania from patchy alopecia areata. An Bras Dermatol 2010;85:723-6.  Back to cited text no. 8
Miteva M, Romanelli P, Tosti A. Pigmented casts. Am J Dermatopathol 2014;36:58-63.  Back to cited text no. 9
Peckham SJ, Sloan SB, Elston DM. Histologic features of alopecia areata other than peribulbar lymphocytic infiltrates. J Am Acad Dermatol 2011;65:615-20.  Back to cited text no. 10


  [Figure 1], [Figure 2]

  [Table 1]

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