Alopecia Areata Sisaipho: Clinical and Therapeutic Approach in 13 Patients in Spain.

Sir,

Alopecia areata (AA) sisaipho (ophiasis spelled backward) is an uncommon variant of AA, first described by Muñoz and Camacho in 1996.[1] It consists of scalp hair loss sparing the temporal and occipital areas, just the opposite than ophiasis.[1] Some authors prefer the term ophiasis inversus[2] and even “anti-ophiasis;” however, this could have negative connotations.

AA sisaipho has been scarcely described in literature. The objective of our study was to analyze the clinical profile and therapeutic approach in a series of patients diagnosed with AA sisaipho.

A multicenter, cross-sectional, retrospective study was designed. Patients diagnosed clinically with AA sisaipho between 1988 and 2015 were included. Epidemiological, clinical, therapeutic, and evolutive variables were recorded. The therapeutic response was assessed as complete response (>75% regrowth), partial response (<75% regrowth), and no response (absence of regrowth).

A total of 13 patients (11 females and 2 males) with a mean age of 33.4 years (range 9–58 years) were included. The mean follow-up time was 10.7 years. The sisaipho pattern [Figure 1a] was the initial clinical presentation of AA in five patients (38%). In the remainder eight patients (62%), it developed during the regrowth of alopecia universalis. The most frequent comorbidities were atopic dermatitis in 11 patients (84%), thyroid disorders in 7 patients (54%), and celiac disease and vitiligo in 2 patients (15% each). Nail involvement with trachyonychia was observed in ten patients (77%). Relating to disease management, all patients received active therapy with potent topical corticosteroids. Other concomitant therapies used were intralesional corticosteroids in ten patients (77%), pulse corticosteroid therapy in nine patients (69%), topical immunotherapy in two patients (15%), and oral azathioprine in one patient (8%). Overall complete response was achieved in 12 patients (92%), partial response in 1 patient (8%), without any nonresponder. Clinical relapse after withdrawal of therapy was observed in 6 patients (46%) after a mean follow-up time of 3.5 months. Both patients with a sisaipho debut as with a pattern of regrowth responded similarly. Adverse effects were detected in 8 patients (62%), including dermal atrophy and striae (four patients), hyperglycemia (one patient), and weight gain (one patient).

Figure 1

Alopecia areata sisaipho: temporal and occipital scalp hair clearance usually involving vertex and avoiding ophiasic areas: (a) Initial pattern of hair loss; (b) evolution after 9 months of treatment: complete response after combination of intralesional corticosteroids and oral pulses of dexamethasone (4–10 mg biweekly)

AA sisaipho is considered a rare variant of AA in which lateral scalp is unscathed.[13] It may be the initial form of presentation or a latter evolution of AA, described to be more common,[4] in concordance with our series. Its etiology is not well determined; a centrifugal wave-like pattern of propagation of AA has been proposed.[34] This promotes an opposite pattern of scalp involvement, contrary to ophiasis, with infrequent eyebrow involvement. Based on our data, sisaipho type is associated more frequently to previous or concomitant disorders such as atopy, vitiligo, or thyroid disease than other AA variants. AA sisaipho patients also tend to have more onychopathy,[4] mainly trachyonychia, which is a predictor of poor prognosis in some studies.[5] Interestingly, sisaipho type seems to have a more benign behavior than its inverse counterpart[45] with apparent higher response rates [Figure 1b] even if it may cause severe esthetic impairment.

The limitations of the present study include the retrospective design, short sample size, and lack of equivalent nonsisaipho control group to compare.

In conclusion, AA sisaipho is an infrequent subtype of AA that, contrary to ophiasis, seems to have a good therapeutic response.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.