Sir,

Alopecia areata (AA) is a common dermatological condition. It may manifest with one or more well-defined areas of alopecia and either diffuse or complete hair loss. Its course is unpredictable [1–3].

In diffuse alopecia areata (DAA), diffuse hair thinning is observed, which develops quite rapidly and is associated with increased hair loss.

In DAA, dystrophic hair, broken hair, black dots, and hollow yellow dots are found. Currently, there are few studies describing DAA in a standardized manner.

Consequently, this clinical variant of AA is often not recognized.

Herein, we describe a case of non-uniform AA and DAA that appeared one month after the first AA spots appeared.

A woman and her child (girl aged 14) with severely thinning hair reported to the facility.

The mother recounted the entire story. Several months previously, two small coin-shaped areas of hairlessness appeared on the scalp (no documentation in the form of photographs). The dermatologist that they were seen by diagnosed AA. Then, after around a month, the hair gradually began to fall out all over the head, leading to severe thinning (Fig. 1) Prior to the incident, there was severe dandruff, and the attending physician decided to introduce steroid preparations. An interview was conducted, which revealed that the girl had Down syndrome, diagnosed hypothyroidism, and Hashimoto’s. She had been Eutyrox. The diet was based on good quality products, yet there were a lot of simple carbohydrates (sweets, sweet rolls). The tests that the mother had with her on the day of the visit indicated that failure to change her eating habits could contribute to glucose and insulin disorders over time (insulin 12.3 mU/L (3.00–17.00)), and of concern was elevated iron 146 μg/dL (40.0–145.0), which could indicate inflammation. The rest of the results did not deviate from the laboratory norm. It is known that Hashimoto’s may be associated with AA. Trichoscopy revealed features indicative of DAA at the site of AA hair loss (Figs. 2a – 2c) [3,4]. DAA is considered to manifest itself to a greater extent in the parietal and frontoparietal areas (prominent trichoscopic features), which was consistent with our observation. The presence of Hashimoto’s disease in the subject, which is also an autoimmune disease, and the presence of inflammation may be associated with the occurrence of AA.

	Figure 1: Scalp before the beginning of therapy (first visit).
	Figure 2: (a) Trichoscopic image (50×; polarized light): regrowing pigtail hair (blue arrows). (b) Trichoscopic image (50×; polarized light): regrowing pigtail hair (blue arrows), broken hair (red arrows). (c) Trichoscopic image (50×; polarized light): broken hairs (red arrows).

The prescribed therapy was based on independent work at home (due to the distance from the patient’s residence to the office). Its main theme was light skin cleansing—performing a trichological scrub one time every seven days applied to the scalp for about ten minutes. Using a gentler shampoo and introducing thorough two-step and more frequent washing, which had not been done before (inaccurate washing may have contributed to or exacerbated the skin condition). In addition, a hair growth-stimulating trichological serum was recommended, which was applied to the scalp after washing without rinsing. Such measures resulted in significant improvement (Figs. 3a – 3d).

Figure 3: (a) Scalp at follow-up visit (hair regrowth). (b-d) Trichoscopic image (50×; polarized light) from follow-up visit (hair regrowth).

The case of DAA in a fourteen-year-old girl may be a continuation of the appearance of non-uniform AA. To our knowledge, the literature has not described a case of such an overlap.

Recommendations for home care of the scalp were implemented, and the patient’s mother was educated on how to properly scrub and wash the scalp, which resulted in a significant improvement.

Also, the implementation of a serum for thermal scalp care to stimulate hair growth is key. It may be concluded that the proper selection of care treatments for the patient at home contributes significantly to satisfying therapeutic results.

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