Nonscarring Alopecia and Hypopigmented Lesions May Be Unusual Signs of Secondary Syphilis

Nonscarring Alopecia and Hypopigmented Lesions May Be Unusual Signs of Secondary SyphilisNovel Insights from Clinical Practice
Skin Appendage Disord 2021;7:203–205
Nonscarring Alopecia and Hypopigmented Lesions May Be Unusual Signs of Secondary Syphilis
Magdalena Ciupiska
aMaria Sklodowska-Curie Medical Academy in Warsaw, Warsaw, Poland; bDepartment of Dermatology, Medical University of Warsaw, Warsaw, Poland
Received: June 13, 2020 Accepted: September 9, 2020 Published online: February 17, 2021
Lidia Rudnicka Department of Dermatology, Medical University of Warsaw Koszykowa 82A PL–02-008 Warsaw (Poland) dermatologia @ wum.edu.pl
© 2021 S. Karger AG, [email protected] www.karger.com/sad
Established Facts
• 3–8% of patients with alopecia areata have concomitant vitiligo. • 3–8% of patients with alopecia areata have concomitant vitiligo. • Secondary lues may manifest as both syphilitic alopecia and syphilitic vitiligo. • 3–8% of patients with alopecia areata have concomitant vitiligo. • Secondary lues may manifest as both syphilitic alopecia and syphilitic vitiligo. • Similar clinical presentation of these entities may be a reason for misdiagnosis unless syphilis screen-
ing is performed.
• Coexistence of noncicatricial patchy alopecia and focal areas of cutaneous hypopigmentation should prompt screening for syphilis.
• Coexistence of noncicatricial patchy alopecia and focal areas of cutaneous hypopigmentation should prompt screening for syphilis.Trichoscopy may help to differentiate between syphilitic alopecia and alopecia areata due to the lack of features typical for the latter (e.g., exclamation mark hairs).
DOI: 10.1159/000511577
Keywords Alopecia · Alopecia areata · Clinical dermatology · Syphilis · Trichoscopy
Abstract Noncicatricial patchy alopecia of the scalp and focal areas of skin hypopigmentation imply a diagnosis of alopecia areata and vitiligo. We present a case of a 22-year-old pa-
tient in whom these symptoms were associated with posi- tive spirochete reactions, which allowed making a diagno- sis of syphilitic alopecia coexisting with leukoderma syphi- liticum. Skin lesions and hair loss resolved after the treatment with benzathine benzylpenicillin. Trichoscopy in syphilitic alopecia is nonspecific, but the absence of features typical for alopecia areata such as exclamation mark hairs may be important on an early stage of the clinical workup.
© 2021 S. Karger AG, Basel
Ciupiska/Skibiska/Sikora/Blicharz/ Kotowska/Rudnicka
Introduction
Alopecia areata and vitiligo, both of which are autoim- mune conditions, are the most common causes of hair loss with concomitant skin depigmentation. However, secondary lues manifesting by syphilitic alopecia and leu- koderma syphiliticum may imitate these entities. We present a case of a patient with secondary lues imitating alopecia areata and vitiligo.
Case Presentation
A 22-year-old man presented with noncicatricial patchy alope- cia of the scalp coexisting with hypopigmented macules localized on the neck (shown in Fig. 1, 2, respectively). Based on the clinical symptoms, the primary diagnosis of alopecia areata coexisting with vitiligo was established. However, the patient tested positive for syphilis (unheated serum reagin [USR] +++, venereal disease research laboratory [VDRL] 1/64, and fluorescent treponemal an- tibody absorption [FTA-ABS] 1/16,000). There were no other clin- ical findings characteristic of secondary lues within the skin and the mucous membranes. Wood’s lamp examination of the lesions located on the neck revealed well-demarcated areas of the skin ex- hibiting blue fluorescence. Based on the clinical picture and addi- tional testing, the diagnosis of syphilitic alopecia coexisting with leukoderma syphiliticum was established. The patient received a single intramuscular injection of benzathine benzylpenicillin (2.4 million units). The treatment resulted in resolution of skin lesions and hair regrowth.
Discussion/Conclusion
The prevalence of vitiligo in patients with alopecia areata is estimated at 3–8% [1]. Both of these conditions result from an autoimmune reaction mediated by CD8+ cytotoxic T cells and interferon γ. The target organs are hair bulbs and melanocytes in alopecia areata and vitiligo, respectively [1]. Antigens associated with melanogenesis have been discussed as potential triggers of autoimmu- nity in alopecia areata [2]. In both diseases, the peak age of onset is approximately 20–40 years [3, 4]. Both alopecia areata and vitiligo have a patchy distribution and are usu- ally asymptomatic [3, 5]. The lesions of vitiligo are most often located on exposed body sites (such as the face, neck, forearms, feet, dorsal hands, fingers, and scalp) [6]. Alopecia areata is associated with roundish foci of hair loss, which are usually located on the scalp. Occasionally, the disease causes a complete loss of scalp hair (alopecia totalis). Other body sites are affected less commonly, but in severe cases, alopecia areata may result in a complete loss of all body hair (alopecia universalis) [1].
On the other hand, the syphilitic alopecia and syphilitic vitiligo may both be present in the course of secondary lues. Syphilis can resemble a wide range of conditions, which is why it is called a great mimicker in dermatology. Scalp in- volvement in syphilitic alopecia most commonly presents as disseminated patches of nonscarring alopecia, with a
Fig. 1. Alopecia areata-like patches in the patient with syphilis.
Fig. 2. Hypopigmented patches on the skin of the patient with syphilis.
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Alopecia Areata-Like Syphilitic Alopecia 205Skin Appendage Disord 2021;7:203–205 DOI: 10.1159/000511577
“moth-eaten” appearance [7, 8]. Syphilitic alopecia is seen in 2.9–7% of patients with secondary syphilis [9]. Isolated alopecia is very rare in secondary syphilis and appears as a noncicatricial hair loss which can occasionally affect areas other than the scalp and mimic the course of alopecia area- ta [10, 11]. Leukoderma syphiliticum, also known as syph- ilitic vitiligo, manifests by hypopigmented patches usually localized on the neck, face, and extremities [12].
The pathogenesis of both leukoderma syphilitcum and syphilitic alopecia is based on the immune response to Treponema pallidum. As a result, loss of terminal hairs, stoppage of the hair cycle, and hair bending with resulting empty hair follicles and broken hairs are seen in syphi- litic alopecia, while the loss of melanin in the epidermis
takes place in leukoderma syphiliticum [12, 13]. Trichos- copy in syphilitic alopecia shows no typical features of alopecia areata such as exclamation mark hairs (shown in Fig. 3) [12, 14]. In the case of noncicatricial alopecia co- existing with vitiligo, it is very important to remember that the serological tests are pivotal for making the correct final diagnosis and to choose the most effective method of treatment.
Statement of Ethics
The authors state that the patient has given his written in- formed consent to publish photos and details of the case.
Conflict of Interest Statement
Funding Sources
Author Contributions
All authors made substantial contributions to the design of the work, acquisition, analysis, or interpretation of data for the work. M.C., J.S., and M.S. were responsible for drafting the manuscript. L.R., L.B., and M.K. revised the work critically for important intel- lectual content. All authors have approved the final version of the manuscript to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accu- racy or integrity of any part of the work are appropriately investi- gated and resolved.
Fig. 3. Syphilitic alopecia may mimic alopecia areata. Trichoscopy reveals predominant loss of hair and presence of yellow dots (as- terisk). However, typical trichoscopic features of alopecia areata are absent. A few black dots can be present in the course of disease (red arrows). A single flame hair (green arrow) represents a non- specific finding, probably due to the pulling of hair to cover the patches of hair loss.
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