Interesting Patchy Alopecia.

Patchy alopecias of the scalp are frequently seen in clinical practice. We report a young man who presented with progressive patchy alopecia of the scalp, which was finally diagnosed to be due to tuberculoid leprosy. Progression of alopecia was stopped after anti-leprosy treatment was instituted. Despite high prevalence of leprosy in our country, scalp affection due to leprosy is extremely rare but important to recognize.

INTRODUCTION

Patchy alopecia is a common patient presentation in clinical practice. Primary cicatricial alopecia includes common entities such as lichen planopilaris, discoid lupus erythematosus, acne keloidalis, and uncommon causes of central centrifugal cicatricial alopecia, Brocq alopecia, folliculitis decalvans, dissecting cellulitis of the scalp. While common secondary cicatricial alopecia include immunobullous disorders, radiation, epidermal nevi, alopecia neoplastica, and sarcoidosis.[1] Careful clinical examination and appropriate evaluation help to establish the accurate diagnosis and treatment. We report an interesting presentation of patchy alopecia due to tuberculoid leprosy.

CASE REPORT

A 22-year-old male patient presented with asymptomatic progressive patchy hair loss on the scalp since 6 months. It started on the occipital area and gradually involved temporoparietal area on both sides. Shaving of the scalp revealed multiple irregular patches of circumscribed hair loss with different configurations such as linear on the occipital area and circinate, arcuate, and irregular patterns on temporoparietal areas. Interestingly, erythematous to hypopigmented, nontender plaques with tumescent edges were seen at the sites of hair loss. The affected areas were an admixture of cicatricial and noncicatricial alopecia. There were no exclamation mark hairs. Frontal areas were not involved [Figures 1 and 2]. He also had on his beard a large, irregular patch of alopecia along with erythematous to hypopigmented conglomerated plaques associated with hypoesthesia to a pinprick. Peripheral nerves were normal. His rest of cutaneous and mucosal examination was normal. Investigations including complete blood counts, blood sugar levels, venereal disease research laboratory test, HIV antibodies, and KOH preparation were all normal. Slit skin smears and special stain were negative for acid-fast bacilli. Skin biopsy revealed minimally atrophic epidermis and multiple focal collections of epithelioid cells and dense infiltration of lymphocytes forming granulomas in the dermis. There was lymphocytic infiltration around the blood vessel and adnexa and also around the nerve fibers [Figure 3]. With a diagnosis of borderline tuberculoid leprosy on histopathological examination. A course of antileprosy treatment consisting of dapsone 100 mg daily and rifampicin 600 mg, once a month was started with a diagnosis of tuberculoid leprosy. After 4 months, the plaques were flattened, erythema was much reduced and surprisingly, hair re-growth was observed at some of the alopecic patches [Figure 4]. Unfortunately, he was lost to further follow-up.

Figure 1

Linear patchy alopecia with a tumescent plaque affecting occipital area of the scalp with hypoesthesia

Figure 2

Circinate, arcuate, and linear erythematous plaques corresponding to alopecia, affecting right temporal area

Figure 3

Scalp biopsy, multiple focal tuberculoid granulomas in the upper dermis. In the center, a distorted follicular structure is seen in its upper half with infiltration of granuloma cells around the hair follicle. The granuloma cells consist of epithelioid cells, lymphocytes, and a few Langhan's giant cells. An inset shows close view of granuloma that is seen in upper right part of picture

Figure 4

Follow-up at 4 months following anti-leprosy treatment. Plaque resolved with hair re-growth at some places

DISCUSSION

Scalp involvement in leprosy is quite infrequently reported. This may be due to relatively high local temperature. Scalp is included as one of the relatively immune zones of leprosy.[2]

Leprosy affecting bald scalp has been described earlier. It is said that leprosy affecting hairy scalp is exceedingly rare.[3] Mitsuda demonstrated alopecia in Japanese patients suffering from lepromatous leprosy patient.[4] The most common area affected in the scalp is temporal region. Interestingly, an area overlying the temporal artery was said to be spared.[34]

Oteig and Pinegro[5] classified leprotic alopecia as:

Diffuse alopecia

Regional alopecia localized to temple

Circumscribed alopecia

Mitsuda's type

Wig-type.

Till date, a very few reports in the Indian literature are published from the Indian workers describing alopecia in leprosy. To our best knowledge, Parikh et al. described first reports of scalp involvement in leprosy.[67] Ghorpade et al. described two cases with a tuberculoid lesion on the hairy occipital area of the scalp.[89] Malaviya et al.[10] reported plaques and nodules over the scalp in lepromatous leprosy. Abraham et al. reported diffuse alopecia in lepromatous leprosy.[11] In our patient, a hairy area of scalp and beard were the only areas involved. He did not have nerve involvement. This is an extremely rare presentation of leprosy. Appropriate evaluation and early anti-leprosy treatment in our patient lead not only to rapid resolution of plaques but also initiated regrowth of hair at some of the places. Thus, early diagnosis and treatment of leprotic alopecia may be vital in preventing progression to cicatricial alopecia.

A possibility of leprosy must be kept in mind when unexplained progressive alopecia occurs in hairy scalp accompanied by underlying tumescent erythematous plaques.