Snapshot A 35-year old woman with a past medical history of atopic dermatitis comes to the dermatologist for multiple, round patches of balding on her scalp. She has had more and more of these bald spots for about 2 months. She cannot recall any instigating events and denies pulling out her hair intentionally. Physical exam reveals no inflammation or erythema in the affected areas. A punch biopsy reveals lymphocytic infiltration. She has a family history of rheumatoid arthritis and Grave’s disease. Introduction Chronic, autoimmune non-scarring hair loss disorder as opposed to scarring cicatricial alopecic disorders such as discoid lupus or lichen planopilaris that lead to destruction of hair follicle Epidemiology: rare (1.7% lifetime risk of developing disease) affects males and females equally affects children and adults equally Associated conditions: other autoimmune diseases, especially thyroid and atopic disorders Presentation Symptoms: smooth, discrete, circular patches of hair loss that are typically without pain or itchiness can spontaneously regrow hair or spontaneously progress to alopecia totalis/universalis no erythema, inflammation, or scarring nail abnormalities are common, including pitting of nail plate Evaluation Clinical evaluation of hair loss sites “exclamation point hairs” at margins of patches short, broken hairs that narrow at the base extracted easily low sensitivity Punch biopsy peribulbar lymphocytic inflammatory infiltrates surrounding follicles Laboratory studies normal Differential Diagnosis Tinea capitis Trichotillomania (nervous hair pulling) Androgenetic alopecia Cicatricial alopecia Telogen effluvium Traction alopecia secondary to hair tension that is prolonged or repetitive Treatment Watchful waiting for mild cases, as hair may regrow spontaneously Limited therapies available; all with limited efficacy intralesional corticosteroids (triamcinolone) topical steroids pulsed prednisone topical immunotherapy Currently under investigation: targeted immunotherapies janus kinase inhibitors tofacitinib, ruxolitinib Prognosis, Prevention, and Complications Variable, unpredictable pattern of regrowth, patchy hair loss, and progression to alopecia totalis or universalis
QUESTIONS 1 of 2 1 2 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + (M1.MK.48) A 22-year-old female presents to a dermatologist concerned about the formation of several bald spots on her scalp that have developed over the last 6 weeks. She denies any past medical history; however, she reports a family history of a similar hair loss pattern in her maternal uncle. Physical examination reveals the patient's scalp as shown in Figure A. The patient asks her physician about the prognosis of this disease. Which of the following statements is true about this patient's presenting condition? Review Topic QID: 102989 FIGURES: A 1 Treatment strategies are ineffective at inducing hair regrowth 2% (1/61) 2 Hair loss often recurs after successful treatment or spontaneous resolution 62% (38/61) 3 Topical immunotherapy is the first-line treatment option and is effective for all patients with the disease 3% (2/61) 4 Treatment with minoxidil is likely to be curative, with permanent resolution of hair loss 16% (10/61) 5 Spontaneous resolution rarely occurs 15% (9/61) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M1.MK.46) A 19-year-old male presents to a dermatologist with a concern of patchy hair loss resulting in several areas of baldness on his scalp (Figure A). These bald spots have manifested over the last 2 months. There is no notable scaling, inflammation, or scarring associated with these patches. Which of the following conditions is associated with this patient's presentation? Review Topic QID: 102987 FIGURES: A 1 Non-insulin dependent diabetes 5% (5/102) 2 Migraine headaches 1% (1/102) 3 Scoliosis 9% (9/102) 4 Gonococcal arthritis 7% (7/102) 5 Autoimmune thyroiditis 76% (78/102) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 5