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Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 136-138

Linear alopecia areata versus trichotillomania: The game of time

Department of Dermatology, Cutis Academy of Cutaneous Sciences, Bengaluru, Karnataka, India

Date of Web Publication26-Mar-2018

Correspondence Address:
Samipa Samir Mukherjee
Department of Dermatology, Cutis academy of Cutaneous Sciences, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpd.IJPD_126_16

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Linear variant of alopecia areata (AA) is a rare entity posing as a diagnostic challenge owing to the ability to mimic multiple conditions ranging from trichotillomania, dermatitis artefacta to linear lupus erythematosus profundus. Awareness regarding this entity optimized with dermoscopy and histopathology examination is essential for an effective diagnosis and treatment. Herein, we describe a case of a 7-year-old female with linear AA simulating trichotillomania which we believe is the first reported case in pediatric age group in India.

Keywords: Alopecia areata, linear, trichotillomania

How to cite this article:
Mukherjee SS, Chandrashekar B S. Linear alopecia areata versus trichotillomania: The game of time. Indian J Paediatr Dermatol 2018;19:136-8

How to cite this URL:
Mukherjee SS, Chandrashekar B S. Linear alopecia areata versus trichotillomania: The game of time. Indian J Paediatr Dermatol [serial online] 2018 [cited 2020 Nov 28];19:136-8. Available from: https://www.ijpd.in/text.asp?2018/19/2/136/211803

  Introduction Top

Alopecia and trichotillomania are both common disorders of childhood. Unusual presentations of either of the conditions pose a diagnostic challenge to the physician. Diagnosis of the individual entities is important as they have an impact on the psychosocial, treatment, and prognostic aspect. Herein, we describe an unusual case of linear alopecia areata (AA) which to the best of our knowledge is the first reported case in pediatric age group simulating trichotillomania.

  Case Report Top

A 7-year-old girl child, born to nonconsanguineous marriage, presented with complaints of asymptomatic, patchy hair loss over the scalp of 3 weeks duration. Hair loss was initially noted over the left temporal area which further spread to involve the right temporal and vertex area. There was no history of applications of any home remedies, topical medications, hair pulling, or trauma before the onset of lesions. Medical history was not contributory with insignificant family history.

General examination was within normal limits. Local examination of the scalp revealed three linear patches of hair loss with smooth underlying skin and occasional excoriation marks located almost symmetrically over bitemporal areas and over the vertex area. Hair of varying length was noted over the vertex patch along with the presence of black dots [Figure 1]a. The dermoscopic evaluation revealed broken hair (yellow circle), black dots, flame hair (green circle), and V-hair (red circle) on the patches [Figure 1]b. Based on clinical evaluation and dermoscopic evaluation, a diagnosis of trichotillomania was made, and the child was managed with minoxidil 2% gel twice daily application along with 1200 mg of N-acetyl cysteine and a neutral Ph shampoo. Parents were counseled regarding the importance of behavior modification.
Figure 1: (a) Linear patches of hair loss with excoriation and varying length of hair. (b) Dermoscopy showing broken hair, hair dust, flame hair, and V-hair

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A week later, the child revisited with complaints of extension of patch and on evaluation, superficial erosions, and excoriations were noted on the patch which further clinched the diagnosis of trichotillomania [Figure 2]a. The patch although had extended retained its linear pattern. A possibility of dermatitis artefacta was also considered, and a thorough evaluation of a pediatrician was called for which was within normal limits. In the following week, the child came with complaints of hair loss over bilateral eyebrows of sudden onset [Figure 2]b. Dermoscopic evaluation of the eyebrows revealed classic picture of AA with yellow dots, broken hair, and exclamation hair [Figure 3]. Further to this finding, a biopsy was done from the patches on the scalp which revealed features of AA.
Figure 2: (a) Superficial erosions and excoriations with varying length of hair and extension of patch (b) involvement of eyebrows

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Figure 3: Dermoscopy showing broken hair and exclamation mark hair

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Thus, based on clinical course, dermoscopic evaluation, and histopathological evaluation, the diagnosis was revised to linear AA. The child was managed with topical minoxidil 2% application with mometasone ointment application at night.

  Discussion Top

AA is the most common form of nonscarring alopecias, with about twenty percent of cases being children, and 60% of AA patients had their first patch before 20 years of age.[1] It has varied presentation ranging from a single patch, multifocal, sisaphio pattern, ophiasis pattern, reticular, diffuse, totalis and universalis, perinevoid and very rarely linear pattern.[2] In the literature, there are very few cases of linear AA that has been mentioned. Most of the cases mentioned in literature were that of linear lupus erythematosus profundus (LEP) which clinically simulated AA; however, histopathology proved the diagnosis of LEP.[3],[4],[5]

In our case, the suspicion of AA was missed in the first few visits owing to the other circumstantial evidence such as excoriations, hair of varying length on the patch, sudden onset and dermoscopic findings of broken hair, perifollicular hemorrhage and black dots masquerading the picture and clinching the diagnosis of trichotillomania. In a recent report by Brzezinski et al., coexistence of both disorders is possible adding to the confusion in diagnosis where trichoscopy may provide a clue.[6] However, in our case, trichoscopy pointed only toward trichotillomania, and AA was picked up only in the later visits, which highlights the importance of periodic follow-up, an open mind, and a thorough clinical examination.

Histopathology still remains the gold standard of diagnosis in dubious cases despite trichoscopy being an invaluable non invasive tool. In our case, histopathology revealed the classical “swarm of bees” appearance thus proving the diagnosis of AA. Psychiatric evaluation of the child did not reveal any abnormality; however, on repeated asking, the child revealed that she became self-concerned and would scratch the area of hair loss leading to secondary changes visible clinically as excoriation and broken hair and dermoscopically revealing perifollicular hemorrhages. Although asymptomatic, but some patients (14%) experience a burning sensation or pruritus in the affected area, which on further manipulation may lead to secondary changes masking the primary cutaneous picture.

  Conclusion Top

This case highlights that although both trichotillomania and AA are common in children knowledge regarding its coexistence, rare presentations of the conditions, thorough and repeated clinical examination, watchful observation during the clinical course of the disease and an open-minded approach, guided through diagnostic tools such as dermoscopy and biopsy helps in arriving at a diagnosis.

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Wasserman D, Guzman-Sanchez DA, Scott K, McMichael A. Alopecia areata. Int J Dermatol 2007;46:121-31.  Back to cited text no. 1
Seetharam KA. Alopecia areata: An update. Indian J Dermatol Venereol Leprol 2013;79:563-75.  Back to cited text no. 2
[PUBMED]  [Full text]  
Nagai Y, Ishikawa O, Hattori T, Ogawa T. Linear lupus erythematosus profundus on the scalp following the lines of Blaschko. Eur J Dermatol 2003;13:294-6.  Back to cited text no. 3
Shin MK, Cho TH, Lew BL, Sim WY. A case of linear lupus erythematosus profundus on the scalp presenting as alopecia. Korean J Dermatol 2007;45:1280-3.  Back to cited text no. 4
Rhee CH, Kim SM, Kim MH, Cinn YW, Ihm CW. Two cases of linear alopecia on the occipital scalp. Ann Dermatol 2009;21:159-63.  Back to cited text no. 5
Brzezinski P, Cywinska E, Chiriac A. Report of a rare case of alopecia areata coexisting with trichotillomania. Int J Trichology 2016;8:32-4.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3]


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