Hair and systemic disease

Hair loss (alopecia) occurs as a manifestation of numerous systemic diseases, but usually can be categorized into one of five general groups: telogen effluvium, anagen arrest, follicular destruction, hair miniaturization, and hair shaft defects. An excess of hair also can be evidence of internal disease, and there are two general categories of increased hair density: hypertrichosis and hirsutism. The basic categories of hair disease and the systemic conditions associated with them are discussed. The history, physical examination, and histopathologic data usually are sufficient to categorize the form of hair disorder and may provide a clue to the nature of the underlying systemic disease.

Scarring alopecia and the dermatopathologist

BACKGROUND

The evaluation of patients with cicatricial alopecia is particularly challenging, and dermatopathologists receive little training in the interpretation of scalp biopsy specimens. Accurate interpretation of specimens from patients with hair disease requires both qualitative (morphology of follicles, inflammation, fibrosis, etc.) and quantitative (size, number, follicular phase) information. Much of this data can only be obtained from transverse sections. In most cases, good clinical/pathologic correlation is required, and so clinicians should be expected to provide demographic information as well as a brief description of the pattern of hair loss and a clinical differential diagnosis.

RESULTS

The criteria used to classify the various forms of cicatricial alopecia are relatively imprecise, and so classification is controversial and in a state of evolution. There are five fairly distinctive forms of cicatricial alopecia: 1) chronic, cutaneous lupus erythematosus (discoid LE); 2) lichen planopilaris; 3) dissecting cellulitis (perifolliculitis abscedens et suffodiens); 4) acne keloidalis; and 5) central, centrifugal scarring alopecia (follicular degeneration syndrome, folliculitis decalvans, pseudopelade). Not all patients with cicatricial alopecia can be confidently assigned to one of these five entities, and "cicatricial alopecia, unclassified" would be an appropriate label for such cases.

CONCLUSION

The histologic features of five forms of cicatricial alopecia are reviewed. Dermatopathologists can utilize a "checklist" to catalog the diagnostic features of scalp biopsy specimens. In many, but not all, cases the information thus acquired will "match" the clinical and histologic characteristics of a form of cicatricial alopecia. However, because of histologic and clinical overlap between the forms of cicatricial alopecia, a definitive diagnosis cannot always be rendered.

Acne keloidalis is a form of primary scarring alopecia

OBJECTIVE

To better define the pathogenesis of acne keloidalis (AK).

DESIGN

Prospective, blinded study of histologic material collected from 10 patients with clinically typical AK.

SETTING

Outpatient dermatology clinic of a military tertiary care medical center.

PATIENTS

Ten male volunteers 18 years or older with early AK lesions (1- to 4-mm firm papules on the lower occipital/nuchal region).

DATA SOURCE

Biopsy specimens from small, early lesions and from clinically uninvolved skin, studied histologically with transverse sectioning.

INTERVENTION

Three separate 4-mm punch biopsy specimens of the scalp (lesional, perilesional, and "normal" scalp) were obtained from each volunteer. The specimens were processed using transverse sectioning.

MAIN OUTCOME MEASURES

The primary variables for data analysis were the presence or absence of the following histologic features: premature loss of the inner root sheath; eccentric placement of shaft, with thinning of the outer root sheath; lamellar fibroplasia surrounding the follicle; loss of sebaceous glands; evidence of follicular destruction or scarring; inflammation; and intrafollicular or perifollicular microorganisms. The number and type of hairs were also recorded.

RESULTS

The most common findings in the 19 histologically abnormal specimens were perifollicular, chronic (lymphocytic and plasmacytic) inflammation, most intense at the level of the isthmus and lower infundibulum; lamellar fibroplasia, most marked at the level of the isthmus; complete disappearance of sebaceous glands, associated with inflamed or destroyed follicles; thinning of the follicular epithelium, most marked at the level of the isthmus; and total epithelial destruction (superficial and deep), with residual "naked" hair fragments. Even some "normal" specimens contained true follicular scars, demonstrating that normal-appearing scalp skin had previously been affected by the disease.

CONCLUSIONS

Acne keloidalis is a primary form of scarring alopecia, and many of the histologic findings closely resemble those found in certain other forms of cicatricial alopecia. Extensive subclinical disease may be present in patients with AK and can account for some of the permanent hair loss. Overgrowth of microorganisms does not appear to play an important role in the pathogenesis of the disease. There is no etiologic relationship between AK and pseudofolliculitis barbae. Therapies found to be useful in other forms of inflammatory scarring alopecia are useful in the treatment of early AK.

Hair density in African Americans

BACKGROUND

The meager data on normal hair density in humans have been gathered from a predominantly white population. Examination of scalp biopsy specimens from African Americans suggests that hair density in this group may be lower than in whites. This study was performed to quantify any differences between white and African American patients.

DESIGN

A retrospective case series of subjects who had undergone a biopsy of clinically healthy scalp skin. The 4-mm punch biopsy specimens were sectioned, and all follicles contained within the specimens were counted at various levels (suprabulbar, isthmus, and infundibulum) to arrive at the number and type of hairs present.

SETTING

Outpatient clinic in a tertiary care medical center.

PATIENTS

A consecutive sample of 22 African American and 12 white patients with clinically healthy scalp skin specimens that were studied and compared with previously reported data.

MAIN OUTCOME MEASURES

Patients' age and total number of follicles, terminal follicles, vellus follicles, terminal anagen hairs, and terminal telogen hairs.

RESULTS

Total hair density (number of follicles per 4-mm punch biopsy specimen) and total number of terminal follicles and terminal anagen hairs were significantly lower in African Americans (P<.001) than in whites and in a previously reported, predominantly white, population.

CONCLUSIONS

Hair density in African Americans is significantly lower than that in whites, which must be taken into consideration when evaluating a biopsy specimen from an African American patient. Data previously collected from white patients may not provide adequate guidance when evaluating scalp biopsy specimens from African Americans and could lead to an incorrect diagnosis.

Temporal triangular alopecia acquired in adulthood

Temporal triangular alopecia is a relatively common, nonscarring form of alopecia. Sometimes congenital, the vast majority of lesions appear during the first 6 years of life and remain stable thereafter. We report a case of temporal triangular alopecia arising during adulthood.

Hair diseases

A few common causes of hair loss account for the vast majority of cases. A well-directed history and simple physical examination is often sufficient to make a diagnosis. Laboratory testing is often unnecessary. A scalp biopsy can be useful, but only if processed and interpreted correctly. Androgenetic alopecia, alopecia areata, senescent alopecia, telogen effluvium, traction alopecia, trichotillomania, and cosmetic hair damage are common causes of non-scarring alopecia. Discoid lupus erythematosus, lichen planopilaris, and central, centrifugal scarring alopecia are the most common forms of scarring hair loss.

Transverse scalp sections: a proposed method for laboratory processing

BACKGROUND

Transverse sections of human scalp biopsy specimens can provide both qualitative and quantitative information about follicular histopathology not readily available in vertically sectioned specimens.

OBJECTIVE

We propose a method for making the processing and interpretation of such specimens easier.

METHODS

All scalp biopsy specimens obtained during the past 18 months in our institution for the evaluation of alopecia were processed for transverse sections by means of a technique employing trisection or quadrisection (rather than the standard bisection), and maintaining all sections in the same anatomic orientation (deep to superficial) in all tissue pieces on microscopic slides.

RESULTS

More than 120 transversely sectioned specimens from more than 75 patients have been processed with this technique. The typical number of slides cut per specimen decreased from between 12 and 20 to between 1 and 4, with no loss of clinical information.

CONCLUSION

This technique allows transverse sections for evaluation of alopecia to be processed in a more cost-effective manner and compares favorably with previously published techniques in providing diagnostic information.

Loose anagen hair syndrome mimicking the uncombable hair syndrome

A 7-year-old female presented with messy, difficult to manage scalp hair and mild, diffuse alopecia. Hair pull specimens, diagnostic for loose anagen hair syndrome, also showed hair shaft abnormalities described in the uncombable hair syndrome. We suggest that dysmorphic hair shafts observed on our patient account for her clinically unmanageable hair. Pertinent clinical, pathologic, and diagnostic features of both syndromes are reviewed.

Essential syphilitic alopecia revisited

There has been a resurgence of syphilis in the past decade. Uncommonly, diffuse hair loss, termed essential alopecia, is the only sign of syphilitic infection. We describe two patients with syphilis in whom the first sign of disease was alopecia and discuss the clinical and histopathologic findings of essential syphilitic alopecia.

Phialophora verrucosa: a new cause of mycetoma

A 29-year-old Thai woman had draining sinus tracts, tumefaction, and granules on the plantar aspect of the foot. Phialophora verrucosa was isolated from the lesion. P. verrucosa is a major agent of chromoblastomycosis, which is known to rarely cause subcutaneous phaeohyphomycosis. This dematiaceous fungus has not been previously reported to cause mycetoma. This case illustrates the clinical spectrum of disease of this fungus. The salient features of mycetoma and management options are presented.

Clinical and histologic findings in temporal triangular alopecia

BACKGROUND

Temporal triangular alopecia (TTA; also called "congenital triangular alopecia") is a common disorder that is assumed to be congenital. Little is known about its histologic features.

OBJECTIVE

Our purpose was to describe four new cases, review the literature, and present histologic features based on vertical and transverse sectioning.

METHODS

The history, clinical features, and histologic findings of four patients with TTA are described and the relevant literature reviewed.

RESULTS

Lesions of TTA are seldom congenital, and most are best described as lancet-shaped. The "bald spot" contains normal numbers of hairs, although virtually all are vellus or indeterminate follicles.

CONCLUSION

Most cases of TTA appear to develop during the first few years of life, and the designation "congenital" is a misnomer. The appearance of alopecia can be best explained as a focal zone of hair miniaturization leading to vellus hair formation.

Follicular degeneration syndrome in men

BACKGROUND AND DESIGN

Follicular degeneration syndrome (FDS, formerly called hot comb alopecia) has only been described in black women. The clinical and histologic features of eight black men with a scarring alopecia resembling FDS were studied.

OBSERVATIONS

All eight men had evidence of scarring alopecia, which was most prominent on the crown of the scalp. None of the men were using chemical or physical modalities to straighten or style the hair. Overall, this group of men had more evidence of active inflammation than did the previously described women with FDS. The histologic features in the men were identical to those found in women with FDS. The presence of premature desquamation of the inner root sheath and migration of the hair shaft through the outer root sheath serve as histologic markers of FDS and separate it histologically from other forms of scarring alopecia.

CONCLUSIONS

Follicular degeneration syndrome is a common form of scarring alopecia in black men, just as it is in black women. In men, there is no association between chemical or mechanical hair styling techniques (eg, the "hot comb") and onset, progression, or severity of disease. The histologic features of FDS in men are identical to those in women.

Bowen's disease of the nail bed and periungual area. A clinicopathologic analysis of seven cases

BACKGROUND

This article describes the clinical and histologic features of seven cases of Bowen's disease (BD) of the nail bed, evaluates the role of human papillomavirus in the bowenoid change, and discusses optimal therapy.

OBSERVATION

The patients presented with the clinical features of verruca vulgaris (n = 3), nail dystrophy and onycholysis (n = 2), paronychia (n = 1), and acral melanoma (n = 1). Histologically, the lesions demonstrated acanthosis, hyperkeratosis, and anaplasia, involving the full thickness of the epithelium. In four cases, human papillomavirus type 16 was demonstrated by in situ hybridization. Six lesions were treated by Mohs micrographic surgery, and one case was treated with topical 5% fluorouracil. In two cases, lesions recurred 1 and 2 years following surgery. In the case treated with topical 5% fluorouracil, residual BD was found 6 weeks after therapy. This case was then treated by Mohs surgery.

CONCLUSIONS

Bowen's disease of the nail bed and periungual area may present clinically as various inflammatory and neoplastic conditions. An important clinical finding in differentiating BD of the nail bed from verruca is the presence of scaling and onycholysis that are out of proportion to the verrucous changes. Human papillomavirus type 16 may be etiologically related to BD of the nail bed and periungual area. Mohs micrographic surgery is recommended for adequate excision and maximal preservation of normal tissue and function.

Androgen biology as a basis for the diagnosis and treatment of androgenic disorders in women. II

In the May 1993 issue of the Journal we reviewed the basic science of androgen biology in women. We now discuss the evaluation of suspected hyperandrogenism and the therapeutic modalities available.

Androgen biology as a basis for the diagnosis and treatment of androgenic disorders in women. I

Disorders of androgen excess in women are common in the practice of dermatology. The literature regarding the evaluation and treatment of women with cutaneous hyperandrogenism (acne, hirsutism, and alopecia) is vast and is contained in numerous subspecialty journals. At first glance, the basic science knowledge required to understand androgen biology appears exceedingly complex. However, an understanding of androgen physiology and a familiarity with the relevant literature are the basis of appropriate evaluations and treatment recommendations. In the first of this two-part series, we review the basic science of androgen biology and pathophysiology in women. The second part of this series will cover the evaluation of suspected hyperandrogenic women and the therapeutic modalities that are available.

The follicular degeneration syndrome in black patients. 'Hot comb alopecia' revisited and revised

BACKGROUND

The history, physical examination, and histologic findings in 10 black women with a common, distinctive form of scarring alopecia (formerly called hot comb alopecia) were retrospectively studied. A detailed history of hair care habits was obtained, and scalp biopsy specimens were examined after both vertical and transverse sectioning.

OBSERVATIONS

Poor correlation is noted between the usage of a hot comb and the onset or progression of disease. The earliest observable histologic abnormality is the premature desquamation of the inner root sheath. In severely affected follicles this is followed by a chain of histologic events leading to complete follicular degeneration.

CONCLUSIONS

The term follicular degeneration syndrome (FDS) is proposed for this clinically and histologically distinct form of scarring alopecia. Historical information is incompatible with the hypothesis that hot comb usage causes the alopecia. It remains unclear whether the use of any of a variety of hair care products and techniques plays a role in the pathogenesis of this condition. Premature desquamation of the inner root sheath serves as a histologic marker for FDS follicular degeneration syndrome, and may be an important pathogenetic factor.

Hair anatomy for the clinician

The rational evaluation of hair disorders requires familiarity with follicular anatomy. Hair structure can be easily examined by studying clipped hair shafts, entire hairs gently pulled or forcibly plucked from the scalp, and scalp biopsies (sectioned vertically or transversely). Anatomic features will be different depending on whether a given hair is in the anagen, catagen, or telogen phase. Follicle size will also vary, from the minute vellus hair to the long, thick terminal hair. Each follicle can be divided into distinct regions--bulb, suprabulbar zone, isthmus, and infundibulum. Activity growing (anagen) hairs are characterized by a hair matrix surrounding a dermal papilla; inner and outer root sheaths are present and well developed. A catagen hair can be identified by its markedly thickened vitreous layer and fibrous root sheath, which surrounds an epithelial column; above this column, the presumptive club forms. A telogen hair is distinguished by its fully keratinized club, which is surrounded by an epithelial sac. Below this lies the secondary hair germ and condensed dermal papilla, waiting for the mysterious signal that initiates a new life cycle.

Inflammatory tinea capitis (kerion) mimicking dissecting cellulitis. Occurrence in two adolescents

Tinea capitis is unusual in postpubertal individuals and is frequently misdiagnosed. In cases of inflammatory disease, prompt initiation of therapy is essential to prevent scarring and permanent hair loss. Two examples are presented to illustrate principles of evaluation and treatment.

The uncombable hair syndrome

The uncombable hair syndrome was first described by Dupre as "cheveux incoiffables." Since that time more than fifty cases have been reported. We wish to present three more cases, review the salient features of the syndrome, and describe some new observations.

The transverse anatomy of androgenic alopecia

Twenty-five biopsy specimens from the balding frontal scalp of five patients were studied. Processing included vertical and transverse (horizontal) sectioning, toluidine blue and hematoxylin and eosin staining, and fixed and frozen sectioning. Findings included decreased hair density, increased numbers of vellus hairs, and alteration of the normal follicular architecture. Transverse frozen sectioning with toluidine blue staining appeared to be a rapid and reliable tool for studying androgenic alopecia.

Scalp whorls

Abnormally placed or absent scalp whorls have been associated with abnormal brain development. Defects of bony cranial development are not associated with such patterns. Single and double parietal whorls are examples of normal scalp patterns. Frontal patterns are variable, and scalp whorls associated with a cowlick can be seen at any location along the frontal hair line. A case of triple parietal scalp whorls and a case of a right temporal scalp whorl, both associated with normal development, are described. Current theories of hair whorl development, as well as normal and abnormal scalp whorl patterns, also are discussed.

Localized cutaneous sporotrichosis

Localized sporotrichosis can present a difficult diagnostic problem. It mimics many other skin diseases, some of which are far more common. Often the skin biopsy is not helpful. The disease tends to be chronic, requiring specific therapy with potassium iodide.

Eccrine hidrocystomas

Little has been written about eccrine hidrocystomas since the condition was first described in 1893. This paper presents a "classic" case of this disorder, and reviews current knowledge about clinical and histologic features. New information concerning the etiology, histochemistry, and electron microscopy of eccrine hidrocystomas is presented, as well as the first description of an effective, safe, and rational method of treatment.

Endoscopic foreign body retrieval through a gastrostomy feeding orifice

This report concerns the removal of a dental bridge through a feeding gastrotomy orifice under direct endoscopic visualization. A 90-year-old bedridden female with a feeding gastrostomy tube, dislodged and swallowed her dental bridge during a coughing episode. At upper endoscopy the dental bridge was snared in the stomach but removed with a pair of Kelly clamps through the feeding gastrostomy orifice. The removal technique ad a discussion of our management alternatives are presented.