Hairband Alopecia in a Covid Carer

May 8, 2020

Dr. Z. is a 30 year-old ophthalmology resident called to duty on the Covid ward of a large East Coast metropolitan hospital where over a 1000 Covid patients had been treated to date.  In this age of telemedicine, she wrote me the following:

“Our community was hit hard by this pandemic, and we continue to help out on the Covid floors. It’s been a scary and yet rewarding experience!

I want to ask your opinion regarding a dermatology question! Last night I noticed a small patch of hair missing. I think it was in the area where I was wearing a tight hairband while in the hospital about 3 weeks ago. I had the hair band on for four days. It was so tight that the area would hurt when I took it off at night after a long shift. I just didn’t want any hair in front of face on Covid ward. I was wondering if there is anything I need to do about it? Or just wait for it to grow out. The scalp area looks a little red, here are two photos.”

While this appears to “pressure alopecia,” I offered to run Dr. Z.’s anamnesis by a colleague with a special interests in disorders of hair.  How we practice now is different from a few months back.  We will be seeing new variations on a theme such as perhaps, Hairband Pressure Alopecia.

References:

1. Sano DT, et. al. Headband pressure alopecia: clinical, dermoscopy, and histopathology findings in four patients. Int J Dermatol. 2018. Feb;57(2):237-239

2. Iwai T, et. al. Temporary alopecia caused by pressure from a headband used to secure a reference frame to the head during navigational surgery. Br J Oral Maxillofac Surg. 2009 Oct;47(7):573-4. 

We consulted with a dermatologist nationally recognized specialist interest hair disorders.  She responded “I do not have much experience with pressure induced alopecia, likely because the etiology is apparent and it regrows in most cases. The photos do suggest pressure alopecia, although there is a differential for patchy alopecia including alopecia areata and tinea capitis. As you know, the current theory is that it is ischemic in nature. I wonder how tight the headband was! Her area of loss is small and it looks rather non-inflammatory, so one would think prognosis for regrowth would be good. It can take a couple of months to see new sprouting hair shafts. Scarring can occur if the insult is severe or prolonged – this can sometimes result in ulceration which is not present."

 

Congenital Triangular Alopecia

The patient is an 11 y.o boy seen for an unrelated problem.  His mother noted an alopecic area in her newborn and attributed it to something the obstetrician did,

O/E:  There is a 1.5 xm area of alopecia on the left fronto-temporal area.

Diagnosis: Temporal (Congenital) Triangular Alopecia

We have presented two similar cases in the past.

Here is a free full text article from the Indian Journal of Dermatology

Scalp Burn Post-Beauty Parlor Visit

Abstract: 54 yo woman with localized hair loss after a visit to the beauty parlor

HPI: The patient is a 54-year-old woman who was seen for evaluation of a localized hair loss and dermatitis of the scalp since she had her hair roots bleached 4 – 5 weeks ago.

She notes that the roots of her hair were left exposed to the chemical for about 4 hours after application.  On a next morning, her scalp was sore and burning, and somewhat swollen throughout the day. She was seen at ER  for evaluation that night and told that her scalp was probably burnt by the hair product; and was advised to wash her hair with cool water and was given a topical medication to apply, the name of which she cannot recall today. She has been using icepack and the medication that was given from ER, which helped. She has noticed that her hair was falling out in the mid parietal area since a few days after the insult.. She was reevaluated by her primary care physician two weeks ago for dryness and pruritus of the scalp and was prescribed another topical medication but does not remember the name.

Past medical history reveals bariatric surgery in  four years ago and had an episode of transient hair loss thereafter. She has been using hair products from the same store, JCP salon, since the episode, and has not had any problems until this recent hair dye/bleach treatment. She washes her hair once weekly, and takes multiple vitamins (including biotin) for her health in general.

The patient is quite upset, angry and tearful about the situation. Currently, she is seeing a therapist for the stress. She fears that the condition will be permanent.

O/E: The skin exam shows a healthy but distraught woman with a well-defined 9.5 x 1.3 cm alopecic patch with many scattered black short broken hairs on the mid parietal scalp to vertex region. There is mild erythema on the involved scalp without evidence of atrophy or cicatrix. Her roots of the surrounding hair are dark brown to blackish about 1 cm from the root.

Clinical Photos:

Impression: Irritant dermatitis with alopecia secondary to her recent hair dye/bleach process

Plan: We had a lengthy discussion of her recent hair damage. This is likely irritant dermatitis most likely secondary to the hair dye/bleach. There is no evidence of scarring today, and her hair will likely grow back although it will take some time. We reassured the patient that we will support her while she is recovering from the recent trauma. 

Follow-up Photo: Around 7 months after chemical burn.

Marked improvement, but patient still feels traumatized.

References:

1. Hair highlights and severe acute irritant dermatitis ("burn") of the scalp. Chan HP, Maibach HI. Cutan Ocul Toxicol. 2010 Dec;29(4):229-33. PubMed

2. Chemical burns to the scalp from hair bleach and dye.  Jensen CD, Sosted H.  Acta Derm Venereol. 2006;86(5):461-2.  Free Full Text

3. The hair color-highlighting burn: a unique burn injury.

Peters W. J Burn Care Rehabil. 2000 Mar-Apr;21(2):96-8.

Abstract: A unique, preventable, 2.8 x 3.7-cm, full-thickness scalp burn resulted after a woman underwent a professional color-highlighting procedure at a hair salon. The burn appeared to result from scalp contact with aluminum foil that had been overheated by a hair dryer during the procedure. The wound required debridement and skin grafting and 3 subsequent serial excisions to eliminate the resulting area of burn scar alopecia. The preventive aspects of this injury are discussed.

4.  Curling iron-related injuries presenting to U.S. emergency departments.

Qazi K et. al. Acad Emerg Med. 2001 Apr;8(4):395-7. PubMed.

FTM Transgender Alopecia?

This is the history of a ftm transgendered man with relatively early androgenetic alopecia.  In spite of his exogenous testosterone, the frontal hairline is preserved.  Most of the alopecia is in parietal and vertex areas.  There is only one PubMed reference that is pertinent, and that is not available full text.(1)

I am a ftm Transman. I started my transition December 2013 and have been on testosterone for about 1 year and  4 months. My resources are limited. I have been a queer female all my life, and as a result of this, economically marginal. I am very serious about my transition to male,. I realize that gender is a fluid spectrum and that I am not yet sure how I will finally present as male.

I have just turned 60 years old, though I look about 20 years younger. I have been very athletic and have always eaten healthfully and have taken care of myself.  Perhaps this is because, subconsciously, I knew that I would have to venture into gender transition at some point, and thus prepared myself.

I am a musician and performer with disabling social anxieties and gender dysphoria. This has severely hampered my ability to perform. My appearance, as an artist, and someone who must go before the public, is a critical issue for me. My biggest problem with transition at present is that I am beginning to bald on the vertex of my head. If this continues unabated, I will wind up with the typical horseshoe pate of male pattern balding.

None of the men in my family, on either side, have this type of balding. Yes they have receding hairlines on my father's side. Thus, I do think my particular balding (and its rapidity) is impacted greatly by the effect of the testosterone. This is a very disturbing and unwanted consequence of testosterone injections. In general, I want to use testosterone for my transition,  but I do not want to be used by testosterone. I don't accept the assessment, “well at your age, men bald.” That does not fly with me. I want to know what my options are proactively.  I have done extensive research on the Internet in regards to balding. I have spent a lot of money trying a number of natural DHT blockers. The problem with this, as with Propecia, is that they work by consequence of increasing female hormones, which is unwanted in ftm transition, and also, block facial hair, a secondary sexual characteristic very important for most trans guys. Secondly, it is not even clear that they work to prevent balding.

Presently, I have started to use Rogaine 5% foam (just this week, so the jury is out).  Currently, I am switching my health care to a clinic that specializes in transgenders individuals. That way, I can also evaluate my balding in terms of testosterone levels. The endocrinologist I see presently is not skilled enough in this regard.

I am extremely interested in any research or techniques that can be offered to me to prevent my balding and turn it around. I am doing all I can on my own at present, but feel there are other options and knowledge out there to which I haven't access.

I am not out to my family yet regarding my transition to male. My appearance, and the quality of my appearance is very personally important to my journey as a man and to my profession as a public performer. I need to continue to be healthy, and to look good.  I want to cure my gender dysphoria so that I can have a life. I do not want to create more obstacles blocking my success in life.

It has been a difficult journey! And, I am willing to do all I can. Unfortunately, I am not in an economic position to do all I could otherwise. I do not want this to be a limitation to my successful transition.  Thus, I am seeking all the support and help I can possibly get in relation to a truly successful transition, unlimited by my financial circumstances. I cannot adequately express my gratitude for any help on this challenging crossing.  Any benefit I receive in these ways are not only for myself, but will be knowledge freely disseminated, for the use of all transmen now and in the future.

Reference:
1) Short- and long-term clinical skin effects of testosterone treatment in trans men. Wierckx K, et al.  J Sex Med. 2014 Jan;11(1):222-9.

Testosterone (T) treatment increased facial and body hair in a time-dependent manner. The prevalence and severity of acne in the majority of trans men peaked 6 months after beginning T therapy. Severe skin problems were absent after short- and long-term T treatment. PubMed.

Central Centrifugal Cicatricial Alopecia (CCCA)

Abstract: 46 year old Ghanaian woman with scarring alopecia

HPI: The patient is a 46 yo woman from Ghana with 3 - 4 mo history of progressive alopecia. She has lived in the U.S. for ten years, takes no medications p.o. and has used hot combs only infrequently in the past.

The Examination shows patchy areas of complete hair loss on frontal, parietal and vertex areas of the scalp.
Clinical Photos:


Pathology: (Photomicrographs courtesy of Marjan Mirzabeigi, M.D. Department of Dermatopathology, Boston University School of Medicine.)









These show: Marked decrease in the number of follicular units which have been replaced with extensive fibrosis.

Diagnosis: Central Centrifugal Cicatricial Alopecia (CCCA)

Discussion: Dr. Lynn Goldberg, Boston University Department of Dermatology: "The patchy alopecia in the vertex is consistent with CCCA. If the frontal loss is contiguous it could be CCCA, although these patients often have coexistent traction. My first line of therapy is a topical steroid. Most patients will experience stabilization. I reserve ILK and doxycycline for those patients with persistent symptoms and loss, or for those patients who also have pustules, which, in my experience, is infrequent. Some physicians will start with 6 months of topical and intralesional steroids and doxy. There are no controlled trials!

Reference:
Gathers RC, Lim HW. Central centrifugal cicatricial alopecia: past, present, and future. J Am Acad Dermatol. 2009 Apr;60(4):660-8.
Abstract: Clinical scarring alopecia in African American women has been recognized for years. The classification of this unique form of alopecia dates back to Lopresti, who first described the entity called "hot comb alopecia." More recently, the term "central centrifugal cicatricial alopecia" has been adopted to describe a progressive vertex-centered alopecia most common in women of African descent. While this form of hair loss is widely recognized, and may even be on the rise, the causes of central centrifugal cicatricial alopecia are a constant source of debate and remain to be elucidated. This review outlines the descriptive evolution of central centrifugal cicatricial alopecia and the historical controversies ascribed to its pathoetiology; it also examines African hair structure and discusses how hair structure along with common physical and chemical implements utilized by individuals with African hair type may play a causal role in the development of central centrifugal cicatricial alopecia.

Alopecia Universalis

HPI: The patient is a 77-year-old woman who was seen for alopecia, which has been present for about eight months now. This followed chemotherapy for nonhodgkin’s lymphoma. She has a history of alopecia areata decades ago which resolved on its own.

O/E: The examination shows that this patient has alopecia universalis. She has a few eyelashes but no eyebrows, no body hair, no scalp hair.

DX: Alopecia universalis following chemotherapy. This is unusual. There is one report of alopecia universalis following treatment for hepatitis C with ribavirin and interferon.

PLAN: I am going to get a list from her of the medications she was treated with for NHL and see if there are any reports on this. I will also run this be some colleagues.

Question: Has anyone seen a similar patient?

References:

Traction Alopecia

Abstract: 15 yo girl with one year history of alopecia
HPI: This 15 yo African-American girl has noted progressive alopecia for the past year or so. Earlier in her life her hair was in corn-rows for one to two years. She has used "relaxers" for many years but stopped ~ a year ago. Her hair was pulled back for many years. Her mother has been applying "fish oil" to the area which they think may be helping.
O/E: There is marked thinning of the hair at the temporal and occipital areas. Much less involvement on frontal and parietal areas. No inflammation, scaling or scarring is appreciated.
Photos:







Diagnosis: This is most likely " Marginal Traction Alopecia"
Questions: What would you offer this young woman as for treatment. I told her to leave her hair natural, avoid relaxers or any tension on hair.
References:
1. eMedicine.com has a good chapter on Traction Alopecia: Here is an excerpt: "Traction alopecia is a common cause of hair loss due to pulling forces exerted on the scalp hair. This excessive tension leads to breakage in the outermost hairs. This condition is seen in children and adults, but it most commonly affects African American women. The 2 types of traction alopecia are marginal and nonmarginal. Unlike trichotillomania, a psychiatric disorder of compulsive hair pulling that leads to patchy hair loss, traction alopecia is unintentionally induced by various hairstyling practices (eg, use of braids, hair rollers, weaves, twists, locks, or "cornrows"). In the initial stages, this hair loss is reversible. With prolonged traction, alopecia can be permanent. Physicians, especially dermatologists, must recognize this condition early to prevent irreversible hair loss."

2. I would recommend renting Chris Rock's documentary "Good Hair" when it is available.

Alopecia in a Child

This 11 yo boy has had this alopecic area since infancy. He has been with adoptive parents since he was a baby and his mother says this has been here since coming to live with her. At first, I thought this was a nevus sebaceous, but the scalp looks normal here with none of the raised "pebbly" surface seen in this disorders in older children.



My working diagnosis here is "Congenital Triangular Alopecia."

References: (supplied by Brian Maurer)
1. Elmer KB, George RM. Congenital triangular alopecia: a case report and review. Cutis. 2002 Apr;69(4):255-6.
Congenital triangular alopecia is a nonscarring loss of hair mass on the scalp's temporal regions. The area of hair diminution commonly is described as triangular or lancet shaped. Although previously considered congenital, this condition usually is noticed after 2 years of age and, more recently, is thought to be acquired. We propose that this entity be renamed triangular alopecia. Because this condition involves normal rather than inflamed skin, it does not respond to topical or intralesional steroids. It is important to make the correct diagnosis to avoid unnecessary and potentially harmful interventions. We present the case of a 10-year-old boy with triangular alopecia.

2. Congenital Triangular Alopecia occurring in sisters. Full Text. Original in Portugese

3. García-Hernández MJ, Rodríguez-Pichardo A, Camacho F. Congenital triangular alopecia (Brauer nevus). Pediatr Dermatol. 1995 Dec;12(4):301-3.Department of Medical-Surgical Dermatology and Venereology, Virgen Macarena University Hospital, Seville, Spain.
Abstract: Congenital triangular alopecia is manifested at 3 to 5 years of age by unilateral or, less frequently, bilateral patches of alopecia in the frontotemporal region. At this age the differential diagnosis is important, particularly as regards alopecia areata. Only about 47 cases have been reported, probably because the lesion is benign and nonprogressive. In 6200 patients seen in index visits, we found 7 with triangular alopecia, a frequency of 0.11%. We believe that males do not require treatment because of the later development of androgenic alopecia, but in women, surgical treatment is successful.2. Tosti A. Congenital triangular alopecia. Report of fourteen cases.

4. Tosti A. Congenital triangular alopecia. Report of fourteen cases. J Am Acad Dermatol. 1987 May;16(5 Pt 1):991-3.
Abstract: Fourteen patients affected by congenital triangular alopecia are presented. The clinical and histologic features of this condition are discussed. I suggest that the condition is considerably more common than hitherto has been thought.