Alopecia areata incognita: True or false?

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To the Editor: We read with great interest the article by Tosti et al¹ in the July 2008 issue of the Journal about alopecia areata incognita. The basis for Tosti et al's conclusions was the assumption that yellow dots in scalp videodermoscopy are highly specific for alopecia areata. We disagree with this statement. We performed trichoscopy (videodermatoscopy of hair and scalp) in 332 female patients with different types of alopecia (68 with alopecia areata, 123 with female androgenic alopecia [FAGA], 76 with telogen effluvium, 26 with cicatricial alopecia, 15 with congenital hair abnormalities, and 74 healthy controls).

Statistical analysis, performed by the classification and regression tree method, showed that the presence of yellow dots in the “androgen-dependent” frontal area is the strongest criterion for FAGA.² In alopecia areata, yellow dots were less frequent, and usually visible in long-lasting, not active alopecia, accompanied by cadaverized, dystrophic, or exclamation mark hairs. Yellow dots were also observed in discoid lupus erythematosus, Marie–Unna hypotrichosis, perifolliculitis capitis abscedens et suffodiens, and other diseases.

We do not share the opinion of Tosti et al¹ that yellow dots are indicative of alopecia areata. Therefore, we do not agree that the disease observed by Tosti et al¹ is in the spectrum of alopecia areata.

We do agree, however, that there is a disease that does not fit current hair loss classification. In our observation of 332 female patients, it was not possible to establish a diagnosis in 24 women with rapid effluvium and diffuse hair thinning.

At least 20 of these patients shared some features of FAGA and acute telogen effluvium and might have fit the description of Tosti et al.¹ Yellow dots were seen over the entire scalp, predominantly in the frontal area, starting a few weeks after onset of the disease (Fig 1, A). Short, thin pigmented hair shafts were extensively present between thick terminal hairs (Fig 1, A and B) regardless of therapy. In patients with this “acute hair miniaturization,” histopathologic findings were not indicative of alopecia areata. Peribulbar lymphocytic infiltrates were sparse (Fig 2) and not present in all patients despite active disease. Histology showed also more or less pronounced hair follicle miniaturization and follicular ostia with keratinous material, which may correspond to “yellow dots” in dermatoscopy. The disease was most prominent in the frontal area.

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• Fig 1. 

  Trichoscopy in patients with “acute hair miniaturization.” A, Yellow dots, marked by blue stars, and thin, pigmented hairs between thick terminal hairs, marked by red arrows. B, The regrowth phase with tadpole-like hairs, marked by green arrows. (Original magnification: ×70.)

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• Fig 2. 

  Histopathology of frontal area of the scalp in patients with “acute hair miniaturization,” vertical section. A, Miniaturized hair with follicular stellae in the subcutaneous fat. Keratinous material in the follicular ostium may correspond to the “yellow dot” on dermoscopy. B, Sparse lymphocytic infiltrate at the base of the vellous hair. (Hematoxylin–eosin stain; original magnification: A, ×40; B, ×100.)

In our opinion, effluvium that is more pronounced in the frontal area of the scalp is still highly indicative of FAGA (or female pattern hair loss in general), not of alopecia areata. In particular, coexistence of FAGA and telogen effluvium will give the clinical picture of diffuse alopecia with accentuation in the frontal and midscalp areas, because of the primarily diminished hair density in these scalp regions.

In conclusion, we share the opinion of Tosti et al¹ that there a is a new disease that does not fit current hair loss classification, but we do not agree that this is a disease in the spectrum of alopecia areata. We suggest the term “acute hair miniutarization” or “Tosti alopecia” until more research data are available to confirm the pathomechanism of this disease.

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References 

1. Tosti A, Whiting D, Iorizzo M, Pazzaglia M, Misciali C, Vincenzi C, et al. The role of scalp dermoscopy in the diagnosis of alopecia areata incognita. J Am Acad Dermatol. 2008;59:64–67
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2. Rakowska A, Slowinska M, Kowalska-Oledzka E, Olszewska M, Rudnicka L. Trichoscopy criteria for diagnosing female androgenic alopecia. Nature Precedings. 2008;Available at: http://hdl.handle.net/10101/npre.2008.1913.1Accessed May, 2008
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