Alopecic and Aseptic Nodules of the Scalp with a Chronic Relapsing Course.

Alopecic and aseptic nodules of the scalp (AANS) is a relatively new and little-known entity, and thus may possibly be underdiagnosed. This condition was first described in Japan by Iwata et al., in 1992. This disease occurs mainly in young males and is characterized by the presence of aseptic nodular scalp lesions associated with nonscarring alopecia that may resolve within 3 months. Here, we are reporting a case of AANS with a chronic relapsing course. To the best of our knowledge, this is the first case of this rare entity that has been reported in Iraq. We are urged to report this case due to the following factors: a paucity of reports in the literature (to date, fewer than 90 cases have been reported worldwide), an uncanny resemblance to other entities - especially, dissecting cellulitis of the scalp and alopecia areata - and the unusual chronic relapsing course of the disease. Copyright:

INTRODUCTION

Alopecic and aseptic nodules of the scalp (AANS) is a possibly underdiagnosed condition occurs mainly in young males and is characterized by the presence of aseptic nodular scalp lesions associated with nonscarring alopecia.[12] The etiology of this condition is presently unknown; however, the prognosis is good.[34] Here, we are reporting a case of AANS with a chronic relapsing course.

CASE REPORT

A 27-year-old Iraqi man presented to our outpatient clinic at Al-Sadr Teaching Hospital with a 2-week history of a nodular scalp lesion on the occiput associated with a circumscribed area of hair loss. In the past 6 years, the patient had recurrent episodes of the same lesion, usually appearing as single or multiple, firm, tender nodules, enlarging in size to reach 2.5–3 cm in diameter, and then becoming less tender and fluctuating, accompanied by alopecia on the surface, all within a span of 3–4 weeks. Alopecia is nonscarring, and regrowth often occurs within 2–3 months after resolution of the nodule.

Examination of the patient's scalp showed a single, firm, tender, skin-colored, and dome-shaped nodule of 2 cm in diameter on the upper part of the occipital area. There was also an alopecic area of 2 cm in diameter, resulting from a resolved nodule 2 months earlier [Figure 1]. The surrounding scalp was normal.

Figure 1

Posterior view of the patient's scalp showed an alopecic patch with some regrowth of hair 2 months after resolution of the fluctuating nodule at the same site

Trichoscopic examination was performed [Figure 2], and a biopsy from the firm nodule showed mixed inflammatory infiltrate in the deep dermis, including neutrophils, lymphocytes, and numerous plasma cells [Figure 3a and b]. Cultures of the punctured material were negative. Serological tests for syphilis (venereal disease research laboratory and treponema pallidum hemagglutination) were performed and the results were negative.

Figure 2

Trichoscopy of the alopecic patch revealed numerous yellow dots, a few black dots, fine vellus hairs, and broken hair shafts

Figure 3

(a) Histopathology showed mixed inflammatory cell infiltrate in the deep dermis (H and E; vertical section; ×10). (b) Histopathology showed mixed inflammatory cell infiltrate, including a combination of neutrophils, lymphocytes, and numerous plasma cells.(H and E, ×40)

DISCUSSION

In 1992, Iwata et al. described in Japan a new entity characterized by the presence of a solitary alopecic nodule that showed a pseudocystic cavity in the histopathology.[1] At that time, they named this new entity “pseudocysts of the scalp (PCS);” but later on, in 2009, the term alopecic and aseptic nodules of the scalp (AANS) was coined by Abdennader and Reygagne, as they did not find the pseudocysts in all cases, while they noticed that all the nodules are alopecic with a sterile punctured material.[12345] Currently, some authors consider PCS and AANS to be the same entity, while Lee et al. believed them to be two different entities.[256] Overall, the prognosis of the condition is good, and it can even resolve spontaneously.[78] Based on previous studies, chronic cases are rarely reported, and the mean disease duration ranged from 6.4 to 27 months.[4789] Here, we report on a 27-year-old Iraqi man with clinical, trichoscopic, and histopathologic features consistent with AANS. However, the course of the disease differs from the previously reported cases, insofar as it lasted for more than 6 years, with periods of remission that varying from 3 weeks to 2 months. Furthermore, after a close observation of the recurrent episodes, three clinical stages of the scalp lesion could be identified:

Stage I: firm, tender nodule lasting 1–3 weeks, which may be associated with tenderness and cervical lymphadenopathy. Puncture is usually negative or hemorrhagic, but sterile

Stage II: alopecic fluctuating nodule. The nodule becomes less tender, fluctuating, and accompanied by alopecia on the surface. Puncture usually results in a sterile, citrine-yellowish material. This stage often lasts 3–7 days

Stage III: alopecic patch. The fluctuating nodule is flattened spontaneously or after puncture, leaving an area of alopecia surrounded by the normal scalp. This stage lasts for 2–3 months until hair regrowth occurs. At this stage, the condition may be misdiagnosed as alopecia areata.

It is important to know the different stages of the disease as this may be helpful in differentiation of AANS from other diseases, such as alopecia areata, dissecting cellulitis of the scalp, bacterial folliculitis, ruptured trichilemmal cysts, and folliculitis decalvans, which are the main differential diagnoses of this condition.[710]

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.