Discrete Patches of Hair Loss on the Scalp

TELEDERMATOLOGY VIEWPOINT DiscretePatchesofHairLosson the Scalp Caroline Perez, Gayle Boghosian, Sharon E. Jacob

ABSTRACT: Teledermatology is a term to describe the pro- TELEDERMATOLOGY IMAGING READER REPORT1 vision of dermatologic medical services through telecom- There is one image provided with this consult. The image munication technology. This is a teledermatology case of shows two large, ovoid patches of alopecia on the parietal acute onset hair loss in ovoid patches on the scalp. scalp, left of midline (see Figure 1). Key words: Alopecia Areata, Exclamation Point Hair, Hair Loss, Poliosis, Teledermatology INTERPRETATION OF IMAGES Lesion A n the store and forward teledermatology modality, there is a transfer of patient medical information Findings electronically (including history and visual data) ob- The morphology of the lesions, distribution, and history Itained in one location to a provider who is in another are characteristic for alopecia areata (AA). location (Roman & Jacob, 2015). The construct of the RECOMMENDATIONS TeleDermViewPoint column is such that cases are pres- ented in a standardized teledermatology reader format Skin Care Recommendations reflective of an actual teledermatology report. Triamcinolone 0.1% ointment should be applied twice daily to affected areas on the scalp for up to 6 weeks. TELEDERMATOLOGY READER REPORT1 History Medication Recommendations Chief complaint: presenting for diagnosis and therapeutic None at this time. options. Other Treatment Recommendations It is prudent to assess for underlying systemic disease, as History of Present Illness correction of underlying condition is needed, if present. A 31-year-old woman presents with acute onset hair loss Check thyroid function tests, complete blood count (CBC), in discrete patches on her scalp, which she says developed and anti-nuclear antibody (ANA) titer, if symptoms dictate. over the last 10 weeks. Prior treatment for skin condition: none. Her primary symptom: none. Prior biopsy: none. RECOMMENDED FOLLOW-UP IMAGE QUALITY ASSESSMENT Type of Visit Fully satisfactory. Return to primary care for follow-up after 4Y6 weeks. Refer to dermatology if no improvement in 6 weeks. Caroline Perez, MD, Department of Dermatology, University of Missouri Y Columbia, Columbia, MO. CLINICAL PEARL Gayle Boghosian, GB, RN, Section of Dermatology, Loma Linda AA is considered to be a T-cell-mediated autoimmune Veterans Hospital, Loma Linda CA condition that generally occurs in persons with genetic Sharon E. Jacob, MD, Department of Dermatology, Loma Linda predisposition (Islam, Leung, Huntley, & Gershwin, 2015). University, Loma Linda, CA. There is thought to be a preferential autoimmune target The authors declare no conflicts of interest. of follicular melanocytes in the hair bulb (Gilhar et al., Correspondence concerning this article should be addressed to Sharon E. Jacob, MD, Department of Dermatology, Loma Linda University, 11370 Anderson Street, Suite 2600, Loma Linda, CA 92354. 1The standardized teledermatology reader report format is available for E-mail: [email protected] authors in Table 1 and on the submissions Web T1 site online at http:// Copyright B 2017 by the Dermatology Nurses’ Association. journals.lww.com/jdnaonline/Documents/Teledermatology%20Column DOI: 10.1097/JDN.0000000000000346 %20Template.pdf.

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tapers as it extends proximally. This tapering is due to miniaturization of the hair follicle from inflammation. It is also important to note that patients with AA may lose hair in a pattern known as poliosis, wherein gray (nonpigmented) hair is preserved. Of note, nail abnormalities may also be present in AA, with pitting being the most common (Sperling, Sinclair, & El Shabrawi-Caelen, 2012). For localized AA, it is reasonable for the primary care physician to prescribe a midpotency topical corticosteroid to be applied twice daily to affected areas on the scalp for up to 6 weeks. If there is no improvement, referral to dermatology for intralesional corticosteroids is warranted. In extensive AA, more intense, systemic therapy may be re- quired, so timely referral to a dermatologist is also recommended in this case (Finner, 2011; Sperling et al., 2012).

NURSING PERSPECTIVE AA can lead to disturbed body image, which can be emo- tionally traumatic and can have long-term effects on self- esteem. As nurses, we need to be aware of the frustrating characteristics of this disease. Opportunities to offer encour- agement, education, and connection to resources should be emphasized during the course of treatment. Patients can be directed to appropriate resources and support groups, such as the National Alopecia Areata Foundation (https://www.naaf.org).

FIGURE 1. On the parietal scalp, slightly left of midline, there REFERENCES are two discrete, large ovoid patches of alopecia. Finner, A. M. (2011). Alopecia areata: Clinical presentation, diagnosis, and unusual cases. Dermatologic Therapy, 24(3), 348Y354. 2001). Because this is a nonscarring process, with proper Gilhar, A., Landau, M., Assy, B., Shalaginov, R., Serafimovich, S., & Kalish, R. S. (2001). Melanocyte-associated T cell epitopes can treatment and a tincture of time, most patients will grow function as autoantigens for transfer of alopecia areata to human their hair back. scalp explants on Prkdc(scid) mice. Journal of Investigative Dermatol- ogy, 117(6), 1357Y1362. The disease affects about 3% of the population in the Islam, N., Leung, P. S., Huntley, A. C., & Gershwin, M. E. (2015). The United States. The most common clinical presentation is autoimmune basis of alopecia areata: A comprehensive review. Y hair loss in an ovoid or circular patch pattern on the scalp. Autoimmunity Reviews, 14(2), 81 89. Roman, M., & Jacob, S. E. (2015). Teledermatology: Virtual access to The disease may also present with alopecia totalis, which quality dermatology care and beyond. Journal of the Dermatology is total loss of scalp hair, or alopecia universalis, defined Nurses Association 6(6), 285Y287. Sperling, L. C., Sinclair, R. D., & El Shabrawi-Caelen, L. (2012). Alopecias. as loss of all scalp and body hair. Exclamation point hairs In J. L. Bolognia, J. L. Jorizzo, & J. V. Schaffer (Eds.), Dermatology (3rd may be visible, where the hair shaft is normal distally but ed., pp. 1100Y1101). Atlanta, GA: Elsevier.

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