Our Dermatol Online. 2012; 3(1e): e1
Date of submission: 19.11.2012 / acceptance: 12.12.2012
Conflicts of interest: None

Alopecia areata difficult case

Anca Chiriac1, Doina Mihaila2, Anca E Chiriac3, Liliana Foia3, Florina Filip3, Paloma Manea3

1Nicolina Medical center, Dept Dermatology, Iasi-Romania
2Sf Maria Children Hospital, Dept of Pathology, Iasi-Romania
3Gr T Popa, University of Medicine Iasi-Romania


Case report
A young lady born on 1985, came to our Department with a long history of disease, very anxious, overtreated and searching for an answer concerning her disorders.
Clinical history of the case:
· at the age of 1 year and 6 months she was diagnosed, by the pediatrician , with asymptomatic localised hair loss on the scalp (patch alopecia areata).
Figure 1. Patch alopecia areata at the age of 2 years old
At that time, she was investigated for imunological and neurological problems, thyroid disturbances, metabolic anomalies , but all the tests were within normal range. A systemic corticotherapy (Prednisone) in daily administration was continously recommended for 3 years, with partial regrowth of the hair. The withdrawal of glucocorticoids, however, allowed a relapse of the disease within the following years.
Figure 2. The clinical aspect at the age of 7 years old
Figure 3. Regrowth of the hair at the age of 9 years old
· at the age of 10 years old, after a stressful personal event, she was hospitalised at the Dermatology Unit with alopecia totalis. A biopsy was taken and supported the clinical diagnosis.
All the lab parameters and clinical examination were within normal ranges.
For the following 10 years she underwent many treatments including vitamins, intralesional steroids, highly potent topical corticosteroid under occlusion, contact sensitizer (Cignolin, Diphencyprone), Minoxidil (monotherapy and associated with topical antrhalin), homeopathy, all with no results.
· at the age of 25 she was hospitalised for suicide attempt at the Psychiatric Hospital and severe depression caused by alopecia universalis.
Figure 4. Detail (close image) Total loss of scalp hair
Figure 5. Detail (close image) Total loss of scalp hair
Figure 6. The absence of the hair in the axillae
· In 2012 Rheumatology Department asked for an opinion on the same patient with a ophiasis alopecia, arthralgias (diffuse, with no radiological signs nor any modifications of the inflammatory parameters), depression (upon medication with Xanax).
Figure 7. The aspect at the age of 27 years old
Histopatological examination:
Figure 8. HE x40: overview for hairless follicles and inflammatory infiltrate around Annexes
Figure 9. HE x100: no hair follicles and lymphocytes in the periphery
Figure 10. HE x 100: Fig.9.- cross section
Figure 11. Szekely x100: fibrosis and inflammation
Figure 12. Szekely x100: fibrosis and inflammation

Laboratory parameters:
DNAss = 420U/ml (normal range: 0-99U/ml); DNAds=56U/ml (normal range: 0- 40u/ml); Sm= 24U/ml ( normal range: 0-89U/ml); RNP/Sm= 5U/ml (normal range: 0- 83U/ml); SSA/La= 1U/ml (normal range: 0-73U/ml); Chromatin=775U/ml (normal range: 0-99U/ml); Scl-70=1U/ml (normal range: 0-32U/ml); Centhromere =3U/ml (normal range :0-100U/ml); Anti-tireoglobubine=301U/ml (normal range:0-115U/ml); Anti-TPO=218U/ml (normal range: 0-34U/ml);TSH=2,5U/ml (normal range : 0,4-6U/ml); 17OH-progesterone=0,6U/ml( normal range: 0,2-1,3U/ml); DHEAS=5,3U/ml ( normal range: 0,9-3,6U/ml); Testosteron=1,3U/ml ( normal range: 0,32-2,3U/ml). Serum vitamin B12, folate, ferritin, and iron levels were within normal range.
The rheumatologist raised the question of an association between alopecia areata and systemic lupus, although not all the criteria were accepted.
Endocrinological examination concluded autoimmune thyroiditis with no treatment, just control two times per year. A family history of hair loss or connective tissue diseases was absent. Clinical exam of the heart revealed a third sound, which could be sugestive as an early sign of myocarditis. Even the electrocardiogram and echocardiography were normal, a cardiac magnetic resonance was indicated.
In the view of the cardiologist the firm diagnosis had finally to consider systemic erithematous lupus associated to alopecia areata.
· Is, in this case, alopecia areata associated with lupus erythematous and autoimmune thyroiditis?
· What would be the proper recommended therapy in this case?



Prof. Sundaramoorthy Srinivasan and Dr. Riswana Jasmine – Chennai, India
Cutaneous presentations of lupus in patients with known autoimmune thyroiditis is a rare presentation but reported. Awareness of this association is important for dermatologists since, in a setting of autoimmune thyroiditis, cutaneous manifestations may be the first clue to the development of SLE for other systemic manifestations may be mistaken to be due to the thyroid disorder per se.The manifestations of lupus respond to therapy with steroids and chloroquine. However, therapy of the lupus may have to be continued for a long time, since discontinuation of therapy has been reported to precipitate thyrotoxic crisis.Although thyroid involvement is not presently included in the classification criteria of SLE, the lookout for the association of thyroiditis and cutaneous lupus may prompt the inclusion of thyroiditis within the broader spectrum of SLE. our final diagnosis is autoimmune thyroiditis masquerading the impending SLE.
Dr. Harjeet Singh – Qatar
Autoimmune Thyroiditis has been seen commonly as associated finding with various dermatological diseases like alopecia areata,vitiligo,pernicious anaemia but association with rarely suspected. This patient. was on continued systemic corticosteroid therapy as treatment of alopecia areata,which may have induced suicidal tendency& depression in this patient. This patient not have clinical features suggestive of S.L.E. except there are investigational changes which shows Latent phase of S.L.E.
More similar cases studies are required to establish the association of Alopecia Areata & S.L.E. Depression is common in patients of Alopecia Areata & alopecia Universalis. So final diagnosis in this case will be Alopecia Areata progressed to Alopecia Universalis with associatd Autoimmune Arthritis.



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