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International Journal of Trichology International Journal of Trichology
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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 14  |  Issue : 4  |  Page : 138-140  

Transient rectangular alopecia after endovascular embolization: A case series of four patients describing dermoscopic and histopathologic findings


1 Department of Dermatology, University Hospital of La Princesa, Madrid, Spain
2 Department of Anatomic Pathology, University Hospital of La Princesa, Madrid, Spain
3 Department of Medical Physics and Radiation Protection, University Hospital of La Princesa, Madrid, Spain
4 Department of Head of Interventional Neuroradiology, University Hospital of La Princesa, Madrid, Spain

Date of Submission16-Nov-2020
Date of Decision02-Sep-2021
Date of Acceptance14-Oct-2021
Date of Web Publication16-Jul-2022

Correspondence Address:
María Herrero-Moyano
Department of Dermatology, University Hospital of La Princesa, Calle Diego de Lóon 62, Madrid
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijt.ijt_172_20

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   Abstract 


Transient rectangular alopecia after endovascular embolization (TRAEE) is considered a specific form of radiodermatitis that is probably underreported in the literature. We present a case series of four patients from our hospital describing dermoscopic and histopathologic findings. Dermoscopic findings overlap with those of alopecia areata; therefore, TRAAE may be misdiagnosed without a precise history. Histopathology analysis of one of our cases showed different characteristics from the only report in the literature (high proportion of follicles in telogen phase). Initial reports considered that total radiation doses between 3 and 5 Gy produced TRAEE, whereas doses higher than 7Gy could trigger permanent alopecia. However, one of our patients exposed to a total dose of 7.6 Gy had complete hair regrowth.

Keywords: Alopecia, alopecia areata, pressure alopecia, radiation, trichoscopy


How to cite this article:
Herrero-Moyano M, Hernández PM, Castañon PG, Caniego Monreal JL. Transient rectangular alopecia after endovascular embolization: A case series of four patients describing dermoscopic and histopathologic findings. Int J Trichol 2022;14:138-40

How to cite this URL:
Herrero-Moyano M, Hernández PM, Castañon PG, Caniego Monreal JL. Transient rectangular alopecia after endovascular embolization: A case series of four patients describing dermoscopic and histopathologic findings. Int J Trichol [serial online] 2022 [cited 2022 Sep 27];14:138-40. Available from: https://www.ijtrichology.com/text.asp?2022/14/4/138/351241




   Introduction Top


Endovascular neuroradiology procedures are rising in the last years; however, their cutaneous adverse effects are largely unknown and probably underreported.[1] Transient rectangular alopecia after endovascular embolization (TRAEE) was first described by Huda and Peters in 1994,[2] and only small case series have been published to date.[3],[4],[5],[6]


   Cases Report Top


A 46-year-old woman presented at our department with a 1-month evolution asymptomatic alopecic patch in the right occipital area. As relevant medical history, she referred multiple sclerosis treated with interferon beta-1a. Furthermore, 17 days before appearance of the plaque, she had presented at the emergency department with an abrupt-onset severe headache. Computed tomography (CT) revealed a subarachnoid hemorrhage with a ruptured aneurysm in the anterior communicating artery (AcomA). A fluoroscopically guided embolization of the aneurysm was performed; the procedure duration was 85 min, and the total radiation dose was 7.6 Gy. One week later, she required ventriculoperitoneal shunting. During surgery, which lasted 150 min, she was in supine decubitus position with her head turned 45° to the right.

Physical examination revealed a rectangular, sharply demarcated, noncicatricial alopecic patch in the right occipital area [Figure 1]a. Trichoscopy findings included short villous hairs, broken hairs, black dots, and coiled hairs [Figure 2]a. With the diagnosis of TRAEE, she was prescribed 5% minoxidil topical solution, showing complete regrowth after 3 months.
Figure 1: Clinical image of the four patients showing sharply delineated rectangular alopecic patches. Patient 1 (a) presented one occipital patch, patient 3 (c) and 4 (d)presented one parietal patch and patient 2 (b) presented two different patches due to different consecutive fluoroscopy procedures

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Figure 2: (a) Trichoscopy image of patient number 1 showing short villous hairs (yellow arrows), broken hairs (red asterisks), black dots (yellow asterisks), and coiled hairs (red arrow), (b) histopathology image (hematoxylin and eosin, magnification ×40) of patient number 2, showing a retracted, ascending hair follicle, leaving a fibrotic tail behind. These signs are consistent with telogen follicles, which were found in higher proportion, together with a slight, patchy, perivascular, and perifollicular lymphocytic infiltrate

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After this case, we reviewed cases of postembolization alopecia seen in our dermatology department. We found three more cases between 2006 and 2016 [Table 1] and [Figure 1]b, [Figure 1]c, [Figure 1]d. Including our case, there were two women and two men with a mean age of 46 years (27–60 years). The most frequently embolized artery was the AcomA, the mean latency time was 16 days, and all cases recovered completely. In one case (Case 2), a biopsy was performed 2 months after the appearance of the patch, showing a noncicatricial alopecia with increased proportion of telogen follicles and a slight, patchy, perivascular, and perifollicular lymphocytic infiltrate [Figure 2]b.
Table 1: Characteristics of patients

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   Discussion Top


TRAEE is considered a specific form of radiodermatitis caused by an acute damage to the actively dividing matrix cells of the anagen hair follicles (anagen effluvium).[3],[4] It usually presents 2–4 weeks after the procedure, as an alopecic patch of artifact morphology that resolves spontaneously after 12–14 weeks. Its appearance depends mainly on the total duration of the fluoroscopic procedure (especially after more than 100 min) and the total radiation dose, between 3 and 5 Gy. Initial reports considered that alopecia may become permanent with doses higher than 7 Gy. However, in our case, the radiation dose was 7.6 Gy, and some other cases of hair regrowth have been reported with higher doses up to 12 Gy.[4],[7] Other factors, such as the pressure alopecia found in our patient or previous cumulative radiological procedures (i.e. CT scans), may also play a role.

Dermoscopy[8] and trichogram[9] findings overlap with those seen in alopecia areata; therefore, TRAEE may be misdiagnosed without a precise history.

In contrast with our case, the only histological analysis reported in the literature shows a high percentage of catagen follicles with no inflammatory infiltrate,[10] although differences in histology could depend, to a large extent, on the moment at which the biopsy was performed.

In summary, we present a series of four cases of TRAEE showing dermoscopy and trichoscopy findings. A correct diagnosis, essentially reached by a good anamnesis, is important to avoid unnecessary treatments and to reassure 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.

Acknowledgments

We thank Manuel Gómez Gutiérrez for editing the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Balter S, Hopewell JW, Miller DL, Wagner LK, Zelefsky MJ. Fluoroscopically guided interventional procedures: A review of radiation effects on patients' skin and hair. Radiology 2010;254:326-41.  Back to cited text no. 1
    
2.
Huda W, Peters KR. Radiation-induced temporary epilation after a neuroradiologically guided embolization procedure. Radiology 1994;193:642-4.  Back to cited text no. 2
    
3.
Tosti A, Piraccini BM, Alagna G. Temporary hair loss simulating alopecia areata after endovascular surgery of cerebral arteriovenous malformations: A report of 3 cases. Arch Dermatol 1999;135:1555-6.  Back to cited text no. 3
    
4.
Freysz M, Mertz L, Lipsker D. Temporary localized alopecia following neuroradiological procedures: 18 cases. Ann Dermatol Venereol 2014;141:15-22.  Back to cited text no. 4
    
5.
Podlipnik S, Giavedoni P, San-Román L, Ferrando J. Square alopecia: A new type of transient alopecia of the scalp following fluoroscopically endovascular embolization. Int J Trichology 2013;5:201-3.  Back to cited text no. 5
    
6.
Kaushal A, Bindra A, Singh S, Sameera V. Single sitting of cerebral endovascular procedure causing alopecia. Int J Trichology 2018;10:145-6.  Back to cited text no. 6
    
7.
Ali SY, Singh G. Radiation-induced alopecia. Int J Trichology 2010;2:118-9.  Back to cited text no. 7
    
8.
Cho S, Choi MJ, Lee JS, Zheng Z, Kim DY. Dermoscopic findings in radiation-induced alopecia after angioembolization. Dermatology 2014;229:141-5.  Back to cited text no. 8
    
9.
Seol JE, Kim DH, Park SH, Cho GJ, Kim H. Three cases of radiation-induced temporary alopecia with hair microscopic examination: “Coudability hair” might not be specific for alopecia areata. Int J Trichology 2018;10:40-3.  Back to cited text no. 9
    
10.
Bernárdez C, Alcaraz I, Molina-Ruiz AM, Requena L. Transitory rectangular alopecia after endovascular embolization: A case report and description of the histopathology findings. Actas Dermosifiliogr 2015;106:848-50.  Back to cited text no. 10
    


    Figures

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