Patchy Traction Alopecia Mimicking Areata.

Acute traction alopecia is a diagnostic challenge when the external factor is not suspected or admitted. We report two female patients with non-scarring patchy alopecia resulting from traction of video-electroencephalogram electrodes in which the clinical diagnosis of alopecia areata was suspected. Associated diffuse hair disorders might be implicated in these cases. The correct diagnosis of traction alopecia is important in order to avoid unnecessary treatments.

INTRODUCTION

Traction alopecia (TA) is a form of trauma-induced alopecia and results from continuous excessive pulling of hair shafts. Hairstyling is the most common cause of longstanding traction and usually results in alopecia of scalp margins.[1] When tension forces are not applied over the margin, for example, due to hair clips or wefts,[23] an atypical pattern may result and the diagnosis can be challenging.

We present two cases of patchy TA due to video- electroencephalogram (VEEG) test. Differential diagnosis with alopecia areata (AA) and trichotillomania (TTM) are discussed.

CASE REPORTS

Case 1

A 40-year-old epileptic woman complained of hair loss few days after a 12-day-long VEEG test. Lamotrigine had been started couple months before and was withdrawn after hair loss onset. The patient presented several irregularly shaped alopecic patches [Figure 1a] with black dots, yellow dots, and vellus hairs on dermoscopy [Figure 1b]. No exclamation mark hairs were observed. The rest of the scalp showed normal hair density with diffusely positive pull test. The clinical hypothesis of AA, TTM, or TA associated with telogen effluvium was made. Scalp biopsies showed increased telogen germinative units [Figure 1c] and pigment casts [Figure 1d]. No peribulbar infiltrate or miniaturized follicles were observed and AA was excluded. Spontaneous complete regrowth was observed after 6 months of follow-up [Figure 1e and f].

Figure 1

Case 1 (a): Clinical aspect; (b): Dermoscopy - yellow dots, black dots, few vellus hairs (videodermoscopy, ×32); (c): Biopsy - no peribulbar infiltrate (H and E, ×40); (d): Vertical section - pigment cast (H and E, ×100); (e): Six-month follow-up - complete hair regrowth clinically and (f): On dermoscopy

Case 2

A 44-year-old epileptic woman presented with hair loss few days after a 7-day-long VEEG test. Scalp examination revealed several irregular alopecic patches associated with diffuse thinning over the crown [Figure 2a]. Dermoscopy showed black dots, yellow dots, vellus hairs and increased shaft diameter variability on the patch border [Figure 2b]. Female pattern hair loss (FPHL) associated with patches of AA, TTM, or TA was considered as a clinical hypothesis. Histology showed increased catagen count and pigment clumps with no signs of AA. After 6 months, full recovery of the alopecic patches was observed and topical minoxidil 5% was initiated for FPHL diagnosis [Figure 2c and d].

Figure 2

Case 2 (a): Clinical aspect - patches of alopecia (electrodes REF and F2), diffuse hair thinning; (b): Dermoscopy - black dots, yellow dots, vellus hairs. Notice hair variability (videodermoscopy, ×32); (c): Six-month follow-up - hair regrowth; (d): Dermoscopy; (e): Model - loosely braided hair, electrodes positions

DISCUSSION

TA is usually due to traumatic hair care practices[4] and presents as bandlike hair loss of the frontal-temporal margin of the scalp, with the typical fringe sign.[1] Patchy TA due to hair pins, clips or wefts is not marginal, and presents as localized areas of noncicatricial alopecia, mimicking AA or TTM.[23]

Dermoscopy of recent-onset TA differs from longstanding TA[45] and shows mainly black dots and broken hairs.[67] Vellus hairs and yellow dots might also be seen,[7] but exclamation mark hairs are absent.[8] Histology of recent-onset TA closely resembles TTM with increased catagen-telogen count and pigment casts within the hair canal.[9] The absence of peribulbar lymphocytic infiltrate or miniaturized hair follicles help differentiate from AA [Table 1].[10]

Table 1

Comparative findings between longstanging traction alopecia, recent-onset traction alopecia, acute patchy alopecia areata and trichotillomania

VEEG test is indicated in epileptic patients with infrequent convulsive episodes and includes the application of several electrodes to the scalp surface [Figure 2e]. To our knowledge, these are the first reported cases of TA due to VEEG electrodes. We hypothesize associated hair cycle disorders, such as telogen effluvium and FPHL, might have facilitated plucking in cases 1 and 2, respectively.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest