Case for Diagnosis DOI: 10.1111/ddg.12369

Patches of hair loss on the occipital scalp

Yuval Ramot1, Yael Renert-Yuval1, ­Alexander Maly2, Abraham Zlotogorski1 (1) Department of Dermatology, Hadassah – ­Hebrew University Medical Center, Jerusalem, Israel (2) Department of Pathology, Hadassah – ­ Hebrew University Medical Center, Jerusalem, Israel

History An 18-year-old man presented with multiple trauma following a motor vehicle accident, including intraventricular and parenchymal brain hemorrhage, lung contusion, pneumothorax and hemothorax and pelvic fracture. He was admitted to the intensive care unit for a one-month-period, during which he was anesthetized and ventilated. After stabilization, he was transferred to the surgical department. During this time he developed patches of hair loss on his occipital scalp, and two months following his initial admission he was referred to dermatology consultation. Detailed history taking revealed

Figure 1  Several scattered patches of hair loss on the occipital scalp.


that his mother suffered from alopecia areata, which was still active and involved mainly the eyebrows.

Physical examination Multiple patches of hair-loss, ranging in size from 0.5 to 4 cm, were evident on the occipital scalp (Figure 1). Some of the patches had an oval appearance. There was no hair loss in other places of the scalp or body. Dermatoscopy evaluation revealed hair of varying length, short vellus hairs, black dots, coiled hairs, fraying and split ends (trichoptilosis), empty follicular ostia and yellow dots which occasionally contained black dots (Figure 2). There was no evidence for peripheral exclamation hairs, pseudomonilethrix hairs, white telogen hairs, flame hairs, v-sign hairs or tulip hairs.

Figure 2  Dermatoscopy of a hairless patch demonstrating hair of varying length, short vellus hairs, black dots, coiled hairs, trichoptilosis, empty follicular ostia and yellow dots which sometimes contain black dots.

© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1210

Case for Diagnosis

Histology Skin biopsy demonstrated miniaturization of follicles, with increased telogen to anagen ratio (Figure 3). There was ­epithelial distortion and atrophy of some of the follicles. No fibrosis or inflammation were evident.

Figure 3  Increased telogen to anagen ratio, along with ­epithelial distortion and atrophy of some of the follicles.

Your diagnosis?

© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1210


Diagnosis: Pressure alopecia

Discussion Pressure alopecia is a form of non-scarring alopecia, which is thought to result from chronic external pressure on the skin, usually in immobilized patients or patients undergoing lengthy operations. It usually manifests as a discrete area of alopecia in the occipital scalp, and is sometimes preceded by tenderness or swelling. Although the exact pathogenesis is not entirely clear, pressure alopecia is thought to be the result of ischemic changes of the scalp, which can be further aggravated by external adjuncts [1]. While this condition is considered to be non-scarring in essence, prolonged ischemia may result in tissue necrosis and follicular loss, leading to scarring alopecia [2]. Therefore, it is essential to recognize this condition early to prevent scarring, and awareness of this disorder is crucial. Alopecia areata is a common autoimmune condition leading to non-scarring hair loss. It usually appears as multiple patches of hair loss, which often affect the occipital scalp in young adults, and might be connected to stress at times [3]. This case demonstrates the challenge in differentiating alopecia areata from pressure alopecia, especially when the presentation is not typical, involving multiple regions of hair loss. It is on this base that there seems to be some confusion in the medical literature regarding the correct terminology for this condition, which has sometimes been called postoperative alopecia areata [4] or pressure-potential alopecia areata [5]. Another diagnosis to be considered when encountered with multiple patches of hair loss is trichotillomania [6]. In the present case dermatoscopy was utilized in an effort to distinguish between these conditions, and to our knowledge this is the first report on the use of dermatoscopy in this disorder. Dermatoscopic examination revealed many of the features also seen in trichotillomania. However, there was no evidence for flame or tulip hairs or the v-sign [7]. Some of the features observed in pressure alopecia can also be seen in alopecia areata, such as black and/or yellow dots and short vellus hair [8]. However, the lack of exclamation hairs, pseudomonilethrix or white telogen hairs may help distinguish this condition from alopecia areata. In pressure alopecia there is no conclusive histopathological appearance [1], and findings probably vary according to the disease stage [9]. In the current case, increased telogen to anagen ratio and the lack of inflammation were a major histological feature. In alopecia areata, on the other hand, inflammation is a prominent feature, especially in the acute phase, which gradually wanes in the chronic phase [3].


­ herefore, histological examination was advocated to diffeT rentiate pressure alopecia from alopecia areata [10]. The early diagnosis of pressure alopecia is crucial for preventing scarring alopecia, and positional or padding devices should be utilized promptly in such cases. While in most cases the diagnosis of pressure alopecia doesn't pose a special challenge, in some situations the clinical appearance can be misleading. Here we demonstrate that dermatoscopy can be a very useful tool for diagnosing pressure alopecia, and help differentiate it from similar-appearing conditions. Therefore, it is possible to avoid a possibly traumatic procedure such as skin biopsy, especially in children, and avoiding delay in diagnosis. Conflict of interest None. Correspondence to Abraham Zlotogorski Department of Dermatology Hadassah – Hebrew University Medical Center Jerusalem 9112001 Israel E-mail: [email protected]

References 1

Davies KE, Yesudian P. Pressure alopecia. Int J Trichology 2012; 4: 64–8. 2 Gormley TP, Sokoll MD. Permanent alopecia from pressure of a head strap. JAMA 1967; 199: 747–8. 3 Alkhalifah A, Alsantali A, Wang E et al. Alopecia areata update: part I. Clinical picture, histopathology, and pathogenesis. J Am Acad Dermatol 2010; 62: 177–88, quiz 89–90. 4 Khalaf H, Negmi H, Hassan G, Al-Sebayel M. Postoperative alopecia areata: is pressure-induced ischemia the only cause to blame? Transplant Proc 2004; 36: 2158–9. 5 Zuehlke RL, Bishara S, Price V. Pressure-potential alopecia areata. Am J Orthod 1981; 79: 437–8. 6 Duke DC, Keeley ML, Geffken GR, Storch EA. Trichotillomania: A current review. Clin Psychol Rev 2010; 30: 181–93. 7 Rakowska A, Slowinska M, Olszewska M, Rudnicka L. New trichoscopy findings in trichotillomania: flame hairs, V-sign, hook hairs, hair powder, tulip hairs. Acta Derm Venereol 2013; Oct 3. doi:10.2340/00015555–1674. [Epub ahead of print]. 8 Mane M, Nath AK, Thappa DM. Utility of dermoscopy in alopecia areata. Indian J Dermatol 2011; 56: 407–11. 9 Mirza RA, Spillane EL, Thomas B. What is your diagnosis? Pressure alopecia. Cutis 2012; 90: 224, 32. 10 Leonardi R, Lombardo C, Loreto C, Caltabiano R. Pressure alopecia from orthodontic headgear. Am J Orthod Dentofacial Orthop 2008; 134: 456–8.

© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1210

Patches of hair loss on the occipital scalp.

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