Dermatoscopic findings of syphilitic alopecia,

AnBrasDermatol.2020;95(4):518---520

Anais

Brasileiros

de

Dermatologia

IMAGES

IN

DERMATOLOGY

Dermatoscopic

findings

of

syphilitic

alopecia

夽,夽夽

Izabella

Cristina

Cardozo

Bomfim

_,

_Mayra

_Ianhez

_,

_Hélio

_Amante

_Miot

a_{DepartmentofDermatology,HospitaldeDoenc¸asTropicaisDr.AnuarAuad,Goiânia,GO,Brazil}

b_{DepartmentofTropicalMedicineandDermatology,HospitaldasClínicas,UniversidadeFederaldeGoiás,Goiânia,GO,Brazil} c_{SectorofPsoriasisandPediatricDermatology,HospitaldeDoenc¸asTropicaisDr.AnuarAuad,Goiânia,GO,Brazil}

d_{DepartmentofDermatologyandRadiotherapy,FaculdadedeMedicinadeBotucatu,UniversidadeEstadualPaulista,SãoPaulo,} SP,Brazil

Received19March2019;accepted19January2020

Availableonline11May2020

KEYWORDS

Alopecia; Dermoscopy; Syphilis

Abstract Syphilisisaninfectiousdiseasethathasafflictedmankindforcenturies,butarecent

increaseinworldwideincidencehasbeenevidenced.Theauthorsdescribeapatientwithtypical

lesionsofsecondarysyphilisandmoth-eatenalopecia,whosedermoscopicexamination

demon-stratedemptyhairfollicles,vellushair,follicularhyperkeratosis,peripheralblackdots,dilated

and tortuousvessels, reddishbrown background, andhypopigmentation ofthe hair shafts.

Furthermore,thiscasepresentedanerythematousbackgroundmoreevidentthanpreviously

describedcases.

©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan

openaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

Introduction

Syphilisisaninfectious diseasethathasafflictedmankind for centuries. Epidemiological data show that the inci-dence has increased over the last years throughout the world.1,2 _{It is primarily a sexually transmitteddisease. In}

addition, pregnant women can transmit the infection to theirunborn child,characterizing congenitalsyphilis. The

夽 _{How to cite this article: Bomfim ICC, Ianhez M, Miot HA.} Dermatoscopicfindings of syphilitic alopecia. AnBrasDermatol. 2020;95:518---20.

夽夽_{StudyconductedattheHospitaldeDoenc¸asTropicaisDr.Anuar} Auad,Goiânia,GO,Brazil.

∗_{Correspondingauthor.}

E-mail:izabellabomfim@hotmail.com(I.C.Bomfim).

diseasetypicallyfollowsaprogressionthroughstages: pri-mary syphilis (sore onor aroundthe genitals), secondary syphilis(rash mayappearasrough,red,or reddish brown spotsbothonthepalmsandsoles,amongotherlesscommon sites), and tertiary syphilis (affecting multiple organ sys-tems,includingthebrain,nerves,heart,andbloodvessels, among others).1,3 _{The secondary stage may be}

accompa-niedby syphiliticalopecia(SA),whose prevalencemaybe underestimated due to its subtle presentation and diffi-cultdiagnosis.Dermoscopyisausefultooltodifferentiate various hair diseases.4---6 _{The present report describes a}

patientwithtypicallesionsofsecondarystageandSA,whose dermoscopicdiagnosis was compatiblewithother findings in the literature, but with the peculiarity of showing an erythematousbackgroundmoreevidentthanthecases pre-viouslydescribed.

https://doi.org/10.1016/j.abd.2020.01.007

0365-0596/©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BYlicense(http://creativecommons.org/licenses/by/4.0/).

Dermatoscopicfindingsofsyphiliticalopecia 519

Figure1 Areasofnon-scarringalopeciaonthescalp.

Figure2 Dermoscopyoftheareasofnon-cicatricialsyphilitic

alopecia.*Dermatoscope:DermLitemodelDL3,×10

magnifi-cation.

Case

report

A29-year-oldman,infectedbyHIVfiveyearsago,hadbeen using antiretroviraltherapy witha history of poor adher-ence.HislastCD4demonstrated674cells andaviralload of417copies.Hepresentederythematous-brown,infiltrated plaques ontheface,trunk, andarms,aswell asareasof multiplenon-healingalopecia,withpoorlydefinedborders, presentintheoccipitalregionofthescalp(Fig.1).Abiopsy ofthecutaneouslesionwasperformed.The anatomopatho-logicalexaminationdescribedanintactepidermis,adermis withsuperficialanddeepperivascularneuralinflammatory lymphohistiocyticinfiltrate, presence offociof inflamma-tory aggression to nervous filaments, and formation of epithelioid granulomas, without Langhans giant cells. He hadbeendiagnosedwithsyphilis,withVenenearalDisease Research Laboratory test (VDRL)=1/512. The dermoscopy (Figs.2and3)ofthescalplesionsrevealedemptyhair fol-licles (3A),vellushair (3B), follicular hyperkeratosis(3C), peripheralblackdots(3D),dilatedandtortuousvessels(3E), reddish-brownbackground(3F),anddepigmented capillar-ies(3G).Hewastreatedwithbenzathinepenicillin,evolving withpromptregrowthintheareasofalopecia.

Discussion

SA is an uncommon manifestation of syphilis infection. In 1940, McCarthydescribed two clinical types of SA, symp-tomaticand essential,the latter beingdivided intothree

Figure3 Dermoscopyoftheareasofnon-cicatricialsyphilitic

alopecia.A,Emptyhairfollicles;B,VellushairC,

Perifollicu-larhyperkeratosis;D,Blackpointontheperiphery;E,Dilated

andtortuousvessels;F,Erythematous-brownishbackground;G,

Hypopigmentationofthehairshafts.

patterns:moth-eatenorpatchyalopecia,diffusealopecia, and mixed-pattern alopecia. This classification continues to be used, practically unchanged. Although the clinical aspectsof SAarewelldescribed,thetrichoscopicfindings have been demonstrated in scant publications in recent years,detailedintable1.4---7

SymptomaticSAisthemostraremanifestation,inwhich thereis an association of skin and scalp lesions, simulta-neously.TheessentialSAischaracterizedbycapillaryloss, withnoothervisiblesyphiliticlesions.Moth-eatenalopecia isthemostcommon,presentedbymultipleplaquesof non-cicatricialalopecia,intheabsenceoflocalinflammationor scaling.Theyoccurmainlyin theparieto-occipital region, butmayalsoariseinotherareassuchasbeard,eyelashes, armpits, pubis, trunk, and legs. The diffuse SA is caused bycapillaryloss,liketelogeneffluvium.Themixedformis characterizedbysmallirregularplaquesthatdevelopalong withdiffusealopecia.5,8,9

SA has several differential diagnoses, such as alope-ciaareata (the main differential diagnosis of the patient in question), lupus, trichotillomania, tinea capitis, lichen planuspilaris,andtelogeneffluvium.5,8_{Clinicalfindingsof}

cutaneouslesionsassociatedwithalopeciafacilitate diag-nosis,butcaseswithisolatedalopeciamayoccur,makingit difficulttodiagnoseSA.

RecentmolecularstudieshaveidentifiedTreponema

pal-lidumin theaffected follicles,supporting thetheory ofa

specificimmunereactiontotreponemalantigens. Immuno-histochemistry can show the presence of spirochetes, generallyintheperibulbarandperifollicularregions, indi-catingthatthismicroorganismhasadirectpathogenicrole inalopecia.10

Thepatientinthereportedcasehaspresentedtherarest formofalopecia,calledsymptomatic,duetothepresence of skin and scalp lesions simultaneously. At dermoscopy, the typical signsdescribed in the literature, such as vel-lus hairs, empty hair follicles, follicular hyperkeratosis, peripheral black spots, hypopigmented hairs, and dilated andtortuous vesselswere visualizedon an erythematous-brownbackground.However,themoststrikingfeaturewas

520 BomfimICCetal.

Table1 Dermoscopicfindingsofsyphiliticalopeciadescribedintheliterature.

Author(year) Numberofpatients Dermoscopicfindings

Tognettietal.(2017) 1 Emptyostiaandyellowdotsarevisibleinthecenterofthe

alopecicpatchesoveranerythematousbackground.Tapered

benthairsarepresentattheperipheryofthealopecic

patches.Vellushairsarevisibleattheperiphery.Scales

appeartobethinandwhitish;perifollicularhyperkeratosisis

focallyvisible.

Docheetal.(2017) 3 Reductionofthenumberofhairs,yellowdots,brokenand

zigzaghair.

Piraccinietal.(2015) 4 Reductioninthenumberofterminalhairsandthepresenceof

emptyhairfollicles,vellushairs,red-brownbackground,and

irregularlydilatedcapillarieswithslightbloodextravasationin

fourpatients.

Yeetal.(2014) 1 Blackdots,focalatrichia,hypopigmentationofhairshaftsand

yellowdots,andthescalpshowednoobvioussignsof

inflammationordesquamation.

Reviewofallreported

results

9 Yellowdotsandblackdots.

Vellushairs;curved,tapered,broken,orzigzaghairs.

Hypopigmentationofthehairshaft.

Emptyhairfollicles,reductionofterminalhairs.

Dilatedandtortuousvessels,slightextravasationofblood.

Erythematousorerythematous-brownishbackground

Perifollicularhyperkeratosis

erythema more intense than the others reported, which may correspond to a symptomatic lesion of secondary syphilis. Trichoscopy can facilitate the diagnosis of SA in a patient with capillary loss of unknown origin.5,6,8 _The

clinicalpresentation,theserologicalscreeningforsyphilis, and the histopathology of the scalp should be taken into accountforthefinaldiagnosis.

Financial

support

Nonedeclared.

Authors’

contributions

Izabella Cristina Cardozo Bomfim: Approval of the final version of the manuscript; conception and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of the data; crit-ical review of the literature; critical review of the manuscript.

Mayra Ianhez: Approval of the final version of the manuscript; conception and planning of the study; participation in the propaedeutic and/or therapeutic conduct of the cases studied; critical review of the manuscript.

HélioAmanteMiot:Approvalof thefinalversionofthe manuscript;conception andplanningofthestudy; critical reviewofthemanuscript.

Conflicts

of

interest

Nonedeclared.

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