Cases Of Alopecia Areata Research Articles

"Turban PUVAsol:" A Simple, Novel, Effective, and Safe Treatment Option for Advanced and Refractory Cases of Alopecia Areata.

Background:Alopecia areata (AA) is an autoimmune characterized by nonscarring loss of scalp and/or body hairs. Topical PUVA has been reported to have good effect in AA. The modification of topical PUVA which we call, “Turban PUVA-sol,” is a method of localized immunotherapy using psoralen solution followed by sun exposure.Aims:We aim to study the therapeutic role and side effect profile of turban PUVA in the treatment of advanced and refractory AA.Methodology:Fifteen consecutive patients of alopecia subtotalis (at least 70% of scalp hair loss), totalis, and universalis, attending the dermatology outpatient department of a tertiary care hospital in eastern India were subjected to “Turban PUVA-sol” after duly signed consent. Alternate day therapy was given.Results:At the end of 10 months of study, 2 (13%) out of fifteen patients were lost to follow-up for some unknown reasons. The severity of alopecia tool scores showed a significant (P = 0.0002) decrease posttreatment. Correlation between the severity of alopecia and grade of improvement showed a rho value of −0.453. In the remaining thirteen patients, using physician global assessment (PGA), 4 (26%) showed good response, 4 (26%) showed moderate response, 3 showed mild (20%) response, and 2 patients (13%) showed negligible response. Three out of four patients who showed good improvement in PGA showed more than 80% of new hair growth. Side effects are minimal with some patients complaining of mild irritation and scaling.Conclusion:We found topical Turban PUVAsol to be a very cost-effective and safe treatment option for AA.

Mesalazine in the Treatment of Extensive Alopecia Areata: A New Therapeutic Option?

Background:Alopecia areata (AA) is a T-lymphocyte-mediated disease that results in alopecia plaques or diffuses alopecia on the scalp and body. Etiologic factors include genetic and autoimmune susceptibility. Treatment modalities are usually considered according to the extent of hair loss and the patient's age. Since there is no approved treatment by the US Food and Drug Administration, treatment options and combinations available are off-label. Patients with extensive AA (including totalis and universalis) have a low rate of spontaneous remission and poor treatment response. Extensive AA is usually associated with severe emotional distress, social discomfort, bullying, and other psychological problems for the child and family. In this context, the need for new therapeutic schemes is clear.Materials and Methods:We retrospectively analyzed five patients (aged 2–17 years) with extensive and refractory AA who were treated with mesalazine associated or not with oral prednisolone and topical betamethasone/minoxidil.Results:We observed complete growth of terminal hair in all patients. No patient had abnormal laboratory results or manifested drug side effects.Conclusions:In extensive and refractory AA cases, the topical treatment combined with mesalazine may provide excellent results, reducing the need for extended oral corticosteroids courses. Besides that, mesalazine seems to minimize relapses on discontinuation of oral steroids. Controlled studies are needed to confirm the effectiveness of this combination.

Race and Alopecia Areata amongst USWomen.

Few studies have examined the clinical epidemiology of alopecia areata (AA) in regard to patient race, and therefore, any disparities in incidence or prevalence of disease are largely unexplored. We sought to investigate potential racial disparities amongst two large cohorts of women. We conducted a cross-sectional analysis from the Nurses' Health Study (NHS) and Nurses' Health Study II (NHSII), wherein participants self-reported a diagnosis of AA. We determined odds ratios for AA by race in a multivariate analysis. Among 63,960 women from NHS and 88,368 women from NHSII with information on race and diagnosis of AA, we identified 418 and 738 cases of AA, respectively. In NHS, the multivariate-adjusted odds ratio for AA was 2.72 (95% confidence interval 1.61-4.61) amongst black women as compared with white women. In NHSII, the multivariate-adjusted odds ratio was 5.48 (95% confidence interval 4.10-7.32) amongst black as compared with white women. In a secondary analysis designating participants by Hispanic ethnicity, in NHSII the multivariate odds ratio was 1.94 (95% CI 1.24-3.02) in Hispanic compared with non-Hispanic white women. In this study, we found increased odds of AA based on self-reported race in black and Hispanic women as compared with white women. Further studies are needed to explore the mechanism of this racial disparity related to AA.

The Changing Landscape of Alopecia Areata: An Introduction.

Alopecia areata is an extremely common autoimmune condition affecting hair. Severe forms of alopecia areata exist, with existing treatments consisting of systemic immunosuppressants with numerous side effects. Recently, breakthroughs have been made in both understanding the pathogenesis of alopecia areata and the treatment thereof, which hold the promise of being able to target severe cases of alopecia areata with more efficacy and better tolerability. This article serves as an introduction to review papers from two of the leading researchers in the field of alopecia areata.

Dermoscopy of alopecia areata-a retrospective analysis.

BackgroundDermoscopy devices can overcome the refractive properties of stratum corneum by interface medium or cross polarization such that the lesion can be easily seen.AimTo examine the dermoscopic feature in alopecia areata and correlate the severity of disease with dermoscopic features.Materials and methodsRetrospective analysis of 72 patients suffering from alopecia areata (AA), irrespective of age and sex, who visited the dermatology outpatient department of a tertiary care center in Eastern India was carried out. The most recently developed cases of AA were examined dermoscopically. Variables included yellow dots (YDs), black dots (BDs), broken hair (BH), short vellus hair (SVH), and exclamation mark hair (EMH) on the basis of available literature and expertise.ResultsYellow dots was the most common finding seen in 57 cases (79.16%), black dots in 51 cases (70.8%). Short vellus hair was seen in 32 cases (44.44%), broken hair was seen in 31 cases (43.05%), and exclamation mark hair in 23 cases (31.9%). YDs per field of vision was considered as the most common finding with increased severity of AA.ConclusionYDS, in increased number per field of vision, is the most consistent finding seen in severe cases of AA, as they are in progressive AA and alopecia universalis. An increased number of SVH and terminal hairs were seen in patients who were being treated.

Incident alopecia areata and vitiligo in adult women with atopic dermatitis: Nurses’ Health Study 2

We aimed to determine the risk of alopecia areata (AA) and vitiligo associated with atopic dermatitis (AD) in a large cohort of US women, the Nurses' Health Study 2. We used logistic regression to calculate age- and multivariate-adjusted odds ratios to determine the risk of incident AA and vitiligo associated with AD diagnosed in or before 2009. A total of 87 406 and 87 447 participants were included in the AA and vitiligo analyses, respectively. A history of AD in 2009 was reported in 11% of participants. There were 147 incident cases of AA and 98 incident cases of vitiligo over 2 years of follow-up. AD was associated with increased risk of developing AA (OR 1.80, 95% CI 1.18-2.76) and vitiligo (OR 2.14, 95% CI 1.29-3.54) in multivariate models. In this study of US women, AD was associated with increased risk of incident vitiligo and AA in adulthood.

Detection of Tumor Necrosis Factor-alpha in Nonlesional Tissues of Alopecia Areata Patients: A Prove for a Systemic Disease.

Introduction:The pathogenesis of alopecia areata (AA) remains incompletely understood. Different cytokines may play a role in AA. Tumor necrosis factor-alpha (TNF-α) has been shown to be inhibitory to hair follicle growth in in vitro studies suggesting that it may play an important role in AA. This study was conducted to assess the presence of TNF-α in lesional and nonlesional skin of AA, to review its possible role in AA, and to show whether AA is a systemic or localized disease by comparing the level of TNF-α between lesional and nonlesional skin biopsies of the patients.Materials and Methods:Thirty patients with AA and thirty age- and sex-matched healthy controls were included in the study. A 4 mm punch skin biopsy was taken from lesional and nonlesional skin of every patient, as well as from the normal skin of each individual in the control group for immunohistochemical analysis of TNF-α.Results:The level of TNF-α in lesional skin biopsies was significantly higher than in nonlesional skin biopsies of patients as well as controls' biopsies. Furthermore, TNF-α level in nonlesional biopsies of patients was significantly higher than the level in controls' biopsies.Conclusions:We concluded that skin of AA has a high level of TNF-α (a normal inhibitor of hair follicle growth in vitro). This high level may point to the important role of TNF-α in AA. Further studies should be conducted to detect the level of TNF-α in long-standing AA and the more severe cases of AA.

Vitamin D Level in Alopecia Areata.

Background:Alopecia areata (AA) is an immune-mediated disease in which autoantigens play an important part in activating T-lymphocytes. Vitamin D has been associated with various autoimmune diseases, and Vitamin D receptors are strongly expressed in hair follicles and their expression in keratinocytes is necessary for the maintenance of the normal hair cycle.Aim:The aim of this study was to find the association between Vitamin D level and AA.Materials and Methods:This was a hospital-based cross-sectional study in which 50 patients with clinically and trichoscopically diagnosed AA cases, and 35 healthy age- and sex-matched controls were studied in summer months. Blood samples were taken from both cases as well as controls and samples were immediately processed by centrifugation (4000 rpm) at room temperature. Plasma 25-hydroxyvitamin D (25(OH)D) was analyzed by chemiluminescence method. A deficiency in Vitamin D was defined as serum 25(OH)D concentrations <30 ng/ml.Results:The mean body mass index in cases was 20.96 ± 1.91, whereas in controls, it was 21.37 ± 1.70 (P = 0.31). The mean serum 25(OH)D levels of AA patients was 16.6 ± 5.9 ng/ml, whereas in control group, the mean level was 40.5 ± 5.7, the difference being statistically significant (P < 0.001). A significant negative correlation was found between severity of alopecia tool score and Vitamin D level (P < 0.001; r = −0.730) and also between the number of patches and Vitamin D level (P < 0.001, r = −0.670).Conclusion:In our study, we found that the levels of 25(OH)D were low in AA patients when compared to healthy controls. Furthermore, there was a significant negative correlation between the levels of serum Vitamin D and severity of AA. Thus, the study suggests the role of Vitamin D in pathogenesis of AA and hence a possible role of Vitamin D supplementation in treatment of same.Limitations:Our study was limited by the lesser number of patients and lack of therapeutic trial of Vitamin D for these patients.

Plasmacytoid dendritic cells as a key player in the initiation phase of alopecia areata-induced C3H/HeJ mouse

Recently, the pathomechanism of alopecia areata (AA) has been thought to be a tissue-specific autoimmune disease. So far, interferon (IFN)-γ has been regarded as the most important key cytokine that may induce the collapse of HF immune privilege, apotosis and the upregulation of CXCL 10 in C3H/HeJ AA mouse. In this study, we focus on the role of type I IFN, IFN-α, in the initiation of AA. We previously reported seven cases of AA, including both new onset and recurrent AA, following swine flu viral infection. In this study, we generate AA-induced C3H/HeJ mouse by intra-dermal injection of activated lymphonode cells with IL-2, IL-7 and IL-15. Immunohistochemical staining revealed that IFN-α producing plasmacytoid dendritic cells (pDCs) densely distributed around HFs in not only lesion skin but also non-lesional skin obtained from AA induced-C3H/HeJ mice. Flowcytometric analysis showed the increased frequency of pDCs in skin-infiltrated cells of non-lesional skin from C3H/HeJ mice with AA. Real-time PCR also showed higher expression of IFN-α2, IFN-α4 and chemerin mRNA in C3H/HeJ mouse with AA. In vitro study, IFN-α inhibited the hair elongation of cultured murine vibrissae in Willium's E medium by Philpott's model. In addition, H-2k and CXCL10 expression were upregulated in cultured murine vibrissae by IFN-α. Imiquimod (IMQ) is the potent inducer of IFN-α via TLR7/9 on pDCs. IMQ applied C3H/HeJ mouse showed retardation of hair cycle stage compared to control mouse with infiltration of SiglecH + pDCs with IFN-α expression by immunohistochemical staining. Finally, we succeeded the induction of AA only by intra-dermal injection of pDCs in C3H/HeJ mouse. In conclusion, pDCs may play an important role for the initiation of AA by over expression of IFN-α via pDCs.

Estimated serum vitamin D status, vitamin D intake, and risk of incident alopecia areata among US women.

Studies have identified increased prevalence of vitamin D deficiency in patients with alopecia areata (AA), an autoimmune disease characterized by hair loss, but none have prospectively examined vitamin D status and incident AA. In 55,929 women in the Nurses' Health Study (NHS), we prospectively evaluated the association between estimated vitamin D status, derived from a prediction model incorporating lifestyle determinants of serum vitamin D, and self-reported incident AA. We evaluated dietary, supplemental, and total vitamin D intake as additional exposures. Using Cox proportional hazards models, we calculated age-adjusted and multivariate hazard ratios (HR) to evaluate risk of AA. We identified 133 cases of AA over a follow-up of 12years. The age-adjusted HR between top vs. bottom quartiles for serum vitamin D score was 0.94 (95% CI 0.60-1.48) and the corresponding multivariate HR was 1.08 (95% CI 0.68-1.73). There was no significant association between dietary, supplemental, or total vitamin D intake and incident AA. This study does not support a preventive role for vitamin D in the risk of developing AA.

Alopecia Areata in Down Syndrome: Treatment With Systemic Steroid

Down syndrome is the most common congenital abnormality affecting numerous organs including skin and is associated with an increased incidence of alopecia areata. Down syndrome is an extensively researched condition but alopecia areata seldom received appropriate attention. Alopecia areata in Down syndrome is very refractory to treatment and there are only few relevant published data are available in medical literature. Two cases of alopecia areata associated with Down syndrome are presented here. These patients were treated with a short course of prednisolone; a good result was observed in one case but that was unsatisfactory in another case. The disease relapses in both cases within few months of treatment.&#x0D; CBMJ 2016 July: Vol. 05 No. 02 P: 43-46

Cardiovascular risk in patients with alopecia areata (AA): A propensity-matched retrospective analysis

The cardiovascular risk of patients with alopecia areata (AA) is not well characterized, with limited studies evaluating the risk of acute myocardial infarction (AMI) and ischemic stroke. We sought to determine the risk for patients with AA to develop subsequent stroke and AMI. We conducted propensity-matched retrospective analysis between January 1, 2000, and January 1, 2010, from Brigham and Women's Hospital and Massachusetts General Hospital in Boston, MA. A comprehensive research patient data repository search was done for International Classification of Diseases, Ninth Revision code 704.01 and cases were verified using a natural language processing program. Propensity score matching was used to identify controls for AA cases based on age, race, gender, smoking status, and history of hypertension, diabetes, and hyperlipidemia. We identified 1377 cases of AA matched with 4131 controls. Patients with AA had decreased odds for developing stroke (odds ratio 0.39, 95% CI 0.18-0.87) and a trend toward decreased risk of AMI (odds ratio 0.91, 95% CI 0.59-1.39). This was a retrospective study using a clinical database. Patients with AA had decreased risk for stroke and AMI, although not statistically significant. Further studies are needed to confirm these findings in other AA cohorts and to elucidate a potential mechanism.

Distinguishing diffuse alopecia areata (AA) from pattern hair loss (PHL) using CD3+ T cells

Distinguishing between diffuse subacute alopecia areata (AA), in which the peribulbar infiltrate is absent, and pattern hair loss is challenging, particularly in cases that lack marked follicular miniaturization and a marked catagen/telogen shift. We sought to distinguish diffuse AA from pattern hair loss using CD3(+) T lymphocytes. A total of 28 cases of subacute AA and 31 cases of pattern hair loss were selected and a 4-mm punch biopsy was performed. All the specimens were processed using the "HoVert" (horizontal and vertical) technique. In all cases, hematoxylin-eosin and immunohistochemical stains for CD3, CD4, CD8, and CD20 were performed. The presence of CD3(+) lymphocytes within empty follicular fibrous tracts (stela), even without a concomitant peribulbar infiltrate, is a reliable histopathological clue in supporting a diagnosis of AA (sensitivity 0.964, specificity 1, P ≤ .001). Limited tissue for analysis remained in the clinical sample tissue blocks. The presence of CD3(+) T-cells within empty follicular fibrous tracts (stela) supports a diagnosis of AA.

Serum Vitamin D in patients with alopecia areata.

Background:Alopecia areata (AA) is a common, recurrent, autoimmune hair disorder. It has been found that vitamin D deficiency is associated with many autoimmune diseases.Aims:The current study aimed to estimate serum levels of 25-hydroxy vitamin D in patients with AA.Materials and Methods:This case–control study included 60 patients with AA and 60 age, gender, skin phototype, and body mass index-matched healthy subjects as a control group. Levels of serum 25-hydroxy vitamin D were estimated using ELISA technique.Results:Serum 25-hydroxy vitamin D levels were significantly lower in AA cases when compared with healthy controls (P < 0.001). The least values were significantly associated with alopecia totalis/universalis compared with patchy AA (P < 0.001) and ophiasis (P = 0.04). Severe AA showed significantly the lowest vitamin D levels compared with cases with mild (P = 0.002) and moderate disease (P = 0.03). A significant inverse correlation was found between 25-hydroxy vitamin D levels and age of the patients (r = −0.38; P = 0.03). There was no significant association between serum 25-hydroxy vitamin D levels and gender, disease duration, disease recurrence, nail affection, duration of sun exposure/day, or positive family history of AA.Conclusion:AA patients have lower levels of 25-hydroxy vitamin D than healthy subjects. More studies are required to assess the value of vitamin D supplementation in the treatment of that disease.

English

BACKGROUND AND OBJECTIVES: Alopecia Areata refers to a common usually reversible condition in which patchy loss of hair occurs characterized by presence of mononuclear cell infiltrates developing in and around anagen hair follicles and causing circumscript hair loss. Alopecia Areata has an auto immune pathogenesis mediated by helper T-cells. Since tacrolimus suppresses helper T-cell activity its effect on alopecia areata was studied. METHODS: The study was conducted in the dermatology OPD department in Fr. Muller Medical College Hospital, Mangalore. A total of 50 cases of alopecia areata were taken up for the study. The period of study was from October 2004 - April 2006, the study included 33 males and 17 females. An informed consent was obtained from all the patients. Hair root examination, VDRL, haemogram, Liver Function Test (LFT), Renal Function Test (RFT) and other relevant investigations were done. Focal sepsis was ruled out in all patients. Tacrolimus 0.03% cream was applied once daily and reviewed once in two weeks for twelve weeks. Qualitative data wise score analysis was done by using Friedman's test, Mean, Standard Deviation, Chi-Square test and 'p' value (test of significant) was noted. Response was graded as failure, poor, good and excellent objectively. RESULTS: 6 (12%) patients with scalp involvement had poor response. 20 (40%) patients of alopecia areata on scalp, 5 (10%) patients on face and 2 (4%) patients each on eyebrow and moustache showed good response. 2 (4%) patients with ophiasis pattern also showed good response. 8 (16%) with scalp and 5 (10%) on face had excellent response. None of the patients had any cutaneous or systemic side effects to 0.03% tacrolimus cream during the study period. INTERPRETATION AND CONCLUSION: 10 (20%) patients had associated personal history of atopy and 8 (16%) patients showed exclamatory mark hair. 6 (12%) patients who poorly responded to 0.03% tacrolimus cream had nail pitting. Topical tacrolimus is effective and could be the other modality in treating alopecia areata, however higher strength (0.1%) may give a better result. Being non-irritant topical therapy it could be a treatment modality of choice in children. Absence of cutaneous side effects makes it suitable for use on the face.

Plasmacytoid dendritic cells in alopecia areata: missing link?

Type I interferon (IFN) signature has been implicated in alopecia areata (AA). However, type I IFN source has never been documented. Plasmacytoid dendritic cells (PDCs) are generally known to be the main source and most potent producers of local type I IFNs. Their role in AA pathogenesis has never been investigated. Investigate PDC role in AA. Nineteen AA cases were retrieved from our database and were immunohistochemically tested for PDC occurrence and activity using anti-BDCA-2 and anti-MxA antibodies respectively. Comparison to 10 trichotillomania and 7 androgenetic alopecia (AGA) cases was also done. Plasmacytoid dendritic cells were present in all AA cases in a peri-bulbar location and, as indirectly assessed by MxA expression, were in an active state producing type I IFNs. All trichotillomania cases showed the presence of PDCs, though significantly less abundant and in a different distribution (mainly superficial perivascular) than that in AA. PDC presence and MxA expression were absent in AGA. Plasmacytoid dendritic cells constitute a central component of the peribulbar infiltrate in AA suggesting a significant role in AA pathogenesis. Additionally, PDC distribution could help in microscopically differentiating AA from trichotillomania or AGA.

Detailed clinicopathological characterization of progressive alopecia areata patients treated with i.v. corticosteroid pulse therapy toward optimization of inclusion criteria.

The management of progressive alopecia areata (AA) is often challenging. Recently, i.v. corticosteroid pulse therapy has been reported to be effective for acute and severe AA, however, inclusion criteria have not been sufficiently precise, leaving a chance that its efficacy could be further improved by optimizing therapeutic indications. In our attempts to delineate the factors that correlate with favorable outcomes, we minutely evaluated the clinicopathological findings and the prognoses of single-round steroid pulse-treated progressive AA cases with full sets of image and pathology records during the course. Almost complete hair regrowth has been achieved and maintained up to 2 years in five out of seven AA patients with varying degrees of clinical severity. Interestingly, the worst clinical presentation observed during the course correlated with the size of the area where hairs with dystrophic roots were pulled rather than the extent of visible hair loss on the first visit. Dermoscopy detected disease spread but contributed little in assessing prognoses. Dense perifollicular cell infiltration was detected in all cases treated within 4 weeks of onset and those treated later but with excellent response. Importantly, the cases with poor or incomplete hair regrowth were treated 6-8 weeks of onset and showed moderate inflammatory change with high telogen conversion rate. These findings mandate global dermoscopy and hair pull test for judging the treatment indication and suggest that early administration of high-dose corticosteroid, ideally within 4 weeks of onset, enable efficient suppression of active inflammation and maximize the effectiveness of the remedy.

Diagnostic usefulness of a peribulbar eosinophilic infiltrate in alopecia areata.

The histopathologic diagnosis of alopecia areata (AA) may be difficult in the chronic stage in which the presence of a peribulbar lymphocytic infiltrate is not definite. An eosinophilic infiltrate has been reported as a relatively common histopathologic finding and a helpful diagnostic feature in AA. To investigate the frequency and diagnostic usefulness of an eosinophilic infiltrate around the hair bulbs or within the fibrous tracts during the chronic stage of AA. A retrospective review was conducted at Chungbuk National University Hospital. A total of 162 scalp biopsy specimens of AA were analyzed. The frequency of a peribulbar eosinophilic infiltrate in AA. In 30 of 162 specimens (18.5%) of AA in all stages, eosinophils were found around the hair bulbs with variable density but were not identified in the fibrous tracts of any specimen. Eosinophils around the hair bulbs were detected in 24 of 78 specimens (30.8%) of the acute stage of AA in which a peribulbar lymphocytic infiltrate was present, and eosinophils were densely infiltrated in 6 of these specimens (7.7%). In contrast, in the chronic stage of AA in which a peribulbar lymphocytic infiltrate was sparse or absent, eosinophils around the hair bulbs were found in only 6 of 84 specimens (7.1%); furthermore, eosinophils were sparsely present in all specimens. Pigmentary incontinence around the hair follicles was found in 58 of 84 specimens (69.0%), follicular miniaturization in 52 (61.9%), and shift to the catagen or telogen phase in 46 (54.8%). An eosinophilic infiltrate around the hair bulbs or within the fibrous tracts is not a common finding in the histopathologic characteristics of AA, especially in the chronic stage of the disease. Thus, the diagnostic usefulness of the eosinophilic infiltrate is limited to few cases of AA in the chronic stage. Other histopathologic findings, such as pigmentary incontinence around the hair follicles, follicular miniaturization, and shift to the catagen or telogen phase, are more useful diagnostic features in the cases of AA not showing a definite peribulbar lymphocytic infiltrate.

English

BACKGROUND: Alopecia areata (AA) is an immunologically mediated disorder characterized by focal to diffuse hair loss. It accounts for roughly 2% of new dermatological outpatients. The incidence is higher in children with slightly higher incidence among female children. Onset peaks between 6 and 10 years of age. It has serious implication on a growing child’s psychological well-being at a critical time of development. AIMS: To study the epidemiology of AA, its clinical presentation, association with history of atopy, family history, and rate of recurrence among children below the age of sixteen years. MATERIAL AND METHODS: Fifty consecutively clinically diagnosed cases of AA in children less than sixteen years were enrolled in the study. A detailed clinical examination and history pertained to the aim of the study was recorded. Later the data was entered to MS Excel Spread-sheet and analyzed using SSPS software. RESULTS: Female to male sex ratio was 1.17:1, while the overall incidence in pediatric population was little over 1%. The most common presenting age group was 7-10 years. It was also noted that large majority of patients reported acute loss of hair over the patches. AA appeared earlier among the atopics than in non atopics but the patches were smaller among atopics compared to non-atopics. Almost 1 in 10 patients had significant family history. Nail changes and recurrence were positive in more than 10% of patients. CONCLUSION: Though AA is not a life threatening illness, the cosmetic disfigurement can be bear enormous amount of psychological impact on children of school going age. Most of the therapies only hasten what ultimately would be a spontaneous remission. Treatment may not be successful in many cases; here children will have to be tactfully managed with counseling.

Pigmented Casts

Pigmented casts have been reported with variable frequency in scalp biopsies from alopecia areata, trichotillomania, chemotherapy-induced alopecia and postoperative (pressure induced) alopecia. Their presence and morphology in other scalp disorders has not been described. The authors assessed for the presence and morphology of pigmented casts in 308 transversely bisected scalp biopsies from nonscarring and scarring alopecia, referred to the Department of Dermatology, University of Miami within a year. The pigmented casts were present in 21 of 29 cases of alopecia areata (72%), 7 of 7 cases of trichotillomania (100%), 1 case of friction alopecia, 4 of 28 cases of central centrifugal cicatricial alopecia (14%), and 4 of 4 cases of dissecting cellulitis (100%). They did not show any distinguishing features except for the morphology in trichotillomania, which included twisted, linear (zip), and "button"-like pigment aggregation. The linear arrangement was found also in friction alopecia and dissecting cellulitis. Pigmented casts in the hair canals of miniaturized/vellus hairs was a clue to alopecia areata. Pigmented casts can be observed in biopsies of different hair disorders, but they are not specific for the diagnosis. Horizontal sections allow to better assess their morphology and the follicular level of presence of pigmented casts, which in the context of the other follicular findings may be a clue to the diagnosis.