Pictorial case study: alopecia areata

The case
Diana was 28 and seriously worried about her hair loss. Six months earlier she had first noticed a small bald patch on her scalp, but in recent weeks a large patch had suddenly appeared, as well as some loss behind the ears.

No obvious cause could be found, although she mentioned some recent stresses at work. Her mother had a similar problem in the past and there was a history of diabetes and other autoimmune disease in the family. On examination, the skin over the affected areas was entirely normal but 'bald', except for a few white hairs.

What is the diagnosis, management and differential diagnosis?

Diagnosis and management
The diagnosis of alopecia areata seemed clear in Diana's case so no skin biopsy was necessary. Although Diana was aware that, as in her mother's case, the problem may resolve spontaneously and that the white hairs might herald a recovery, she was alarmed by the recent dramatic changes and requested some medical intervention. She was reminded that the possible treatments could have side-effects and were unpredictable in their results.

Diana was prescribed prednisolone for the next month, which led to some improvement followed by further recovery. In the meantime she wore a wig.

Possible different diagnoses

  • Trichotillomania.
  • Tinea capitis.
  • Androgenic alopecia.
  • Telogen effluvium.
  • Scarring alopecia, for example discoid lupus erythematosus, lichen planus, pemphigoid.

Differential diagnosis

Trichotillomania

  • Anxiety disorder in which patients pull out their own hair.
  • Average age of onset is 13.
  • Most commonly affects the scalp.
  • Punch biopsy should confirm the diagnosis if necessary.

Dr Jean Watkins, a GP locum in Hampshire

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