Sunday, February 26, 2006

Alopecia with peculiar regrowth pattern

The patient is a 35 year old healthy man who presented with alopecia of the scalp of 1 year duration. Many topical therapies were tried with no response. On examination, there was classical alopecia areata. I gave him IM triamcinolone 40mg injection every 2 weeks with topical Dermovate oinment for 2 months. He came back with hair growth in a wavy pattern in the form of concentric circles (see Figure).. I do not have an explanation. I would appreciate any helpful comments.




Presented by Professor Khalifa Sharquie
University of Baghdad, Iraq

4 comments:

  1. Interestingly, there is a reference to this phenomenon in the Archives of Dermatology.
    I will send the title and citation under separate cover
    DJ Elpern


    Here is the comment:
    In 1988, Orecchia and Rabbiosi2 wrote a letter in which they presented 2 figures of a patient with alopecia areata showing hair regrowth in a concentric pattern. The authors suggested that this pattern could be related to the theory proposed by Eckert et al3 in 1968 to explain the pathogenesis of alopecia areata. Eckert and colleagues have proposed that alopecia areata occurs as an "earthquake," beginning in an epicenter and extending peripherally in a wavelike manner. They supported this conclusion with a trichogenic study, collecting plucked hairs from different areas with 2 paper disks with alternate 1-cm empty bands. According to these authors, a telogen wave enlarges from a core marginally extending the alopecia. During hair regrowth, an anagen hair wave may also develop, with the patient achieving complete hair recovery.

    Tan and Delaney4 also described a series of 8 patients with alopecia areata who showed a marginal ring of growing hair during hair recovery. These authors proposed that this pattern was the result of the centrifugal accumulation of corticosteroid cream after a vigorous massage. Nevertheless, they also hypothesized that this peculiar arrangement could be related to the pathogenesis of alopecia areata itself.

    Eckert et al3 did not find a clinical basis for their conclusions and they assessed, finally, that no sequence of events in any single lesion had confirmed their findings. The dermatologic literature has overlooked this study, including the exceptions I have mentioned.2, 4 In my opinion, this pattern of hair regrowth may not be as rare as one might think. After I observed the present case, annular, concentric, or targetoid patterns of hair regrowth were seen in 7 of 19 consecutive patients with alopecia areata treated with either topical or intramuscular corticosteroids. Two of these patients also presented with a targetoid pattern of alopecia areata prior to the treatment. These findings provide additional support for the experimental trichogramic study performed by Eckert et al3 during hair shedding.

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  2. Here is the reference for the above comment:

    Targetoid Hair Regrowth in Alopecia Areata:
    The Wave Theory
    Emilio del Río
    Arch Dermatol. 1998;134:1042-1043.

    DJE

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  3. Fascinating case! I see that the patient was given IM injections of triamcinolone q2weeks X 2 months--a steroid pulse every 14 days for a total of 4 or 5 doses--and I count 4 concentric rings on the scalp, like ripples from a stone tossed into a pool. Coincidence perhaps? Or pure poetry, the magic in medicine.

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  4. Hi Brian,
    Poetry in Medicine! I love that.
    May I add to David and Henry.All patches of alopecia areata show regrowth at the centre and periphery - a phenomenon of reversal from the rapid telogenization pathogenesis. In a large patch as this one described, the regrowth is in the same pattern, following the direction of the application of the topical steroid.
    Intralesional steroid administration is like whipping awake a sleeping horse, which is bound to run amuk. But addition of the topical streoid is like drawing a track for the horse to follow - Brian, literature in Medicine!!
    Your comments please.

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