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Diagnosing Alopecia Areata: Two Cases

Dr. Stephen M Schleicher is a director of the DermDx Centers for Dermatology of Northeastern Pensylvania, as well as a cclinical instructor of dermatology at Graduate Hospital's City Line Campus in Philadelphia, Kings College in Wilkes-Barre, and Beaver College in Glenside, Pennsylvania. These are two of his cases, originally printed in Emergency Medicine magazine.


sudden hair lossA 26-year-old man seeks treatment for "bald spots" in his beard area, which he first noted several months earlier. He has been in good general health and claims no history of thyroid disease. The facial condition was initially diagnosed as ringworm, but several weeks of topical antifungal therapy produced no improvement.

On examination, three dime-sized annular areas devoid of hair are noted on the patient's jaw line and neck. In addition, he has a fairly large area of hair loss on his abdomen. Both inflammation and scales are absent from all sites.

What is your diagnosis?

Alopecia areata is a localized form of hair loss that affects more than 1% of the population. The condition usually manifests on the scalp, but it may occur anywhere that hair grows-including the beard and trunk. The disorder is considered an autoimmune disease; although no sign of clinical inflammation will be evident, biopsy of an affected site will reveal an infiltrate of T lymphocytes. Some cases occur in association with vitiligo and thyroid disease. Spontaneous hair regrowth is the rule, although recurrences are common.


A 41-year-old woman requests treatment for a growth on her finger. The lesion, which she first noted several months before, has slowly increased in size. Although the growth is usually asymptomatic, it has often been traumatized, because of its location. The patient gives no history of arthritis or other systemic disease.

Examination reveals a semitranslucent, flesh-colored papule that is located on the distal phalangeal joint and measures 0.5 cm in diameter. Palpation does not elicit tenderness. Puncture of the lesion with a no. 11 blade produces extravasation of a jellylike fluid.

What is your diagnosis?

The patient has a mucinous, or synovial, cyst. Such lesions are found predominantly on the terminal digits of the fingers, sometimes in association with osteoarthritis. They present as bluish to flesh-colored nodules that generally do not exceed 1.0 cm in diameter. Although asymptomatic, they are prone to trauma. Pressure on the nail plate may lead to distortion of the adjacent nail. The cysts are filled with the viscous fluid mucin, which is thought to be extravasated from the underlying joint space. Therapy is difficult, and the cysts frequently recur even after surgical excision.

By Dr. Stephen M Schleicher, Emergency Medicine, 10-01-2001


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