Dermatology Games

Approach to Alopecia areata

History taking

• Onset, course and duration.
• Family and past history of alopecia areata.
• Ask about any other autoimmune diseases e.g. thyroid disease
• Ask about vitiligo, thyroid manifestations, atopic dermatitis, inflammatory bowel disease and psoriasis.
• Ask about manifestations of hyperthyroidism which may include:
  • weight loss.
  • Increased appetite.
  • Heat intolerance.
  • Excessive sweating.
  • Anxiety.
  • Insomnia
  • Tachycardia.
  • Menstrual changes.
  • Bowel habits changes.
  • Palpitations.
  • Eye changes.

• Ask about manifestations of hypothyroidism
  • Fatigue
  • Weight gain.
  • Cold intolerance.
  • Dry skin.
  • Hoarseness of voice.
  • Constipation.

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Clinical examination

Dermatological examination

Confirm the diagnosis and assess the severity according to the following

• Mild cases : three or less alopecia patches with the widest diameter is 3 cm or less.
• Moderate cases : more than 3 patches or a single patch with diameter of more than 3 cm.
• Severe cases: Alopecia totalis or alopecia universalis.
• Ophiasis pattern.
• Ophiasis inversus pattern.

Nail examination

• Pitting.
• Trachyonychia.
• Longitudinal ridging.
• Beau’s lines.
• Onycholysis.
• Punctate leukonychia.
• Red spotted lunulae.

Eye examination

• Exophthalmos.
• Lid lag.
• External ocular movements.

Thyroid examination

• Size changes.
• Pulsation.
• Consistency.

Dermoscopic examination

• Black dots.
• Short vellus hairs.
• Broken hair.
• Exclamation mark hairs.
• Coudability signs.

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Lab investigations( to exclude associated autoimmune diseases- no standard list)

• TSH.
• Free T3.
• Free T4.
• Thyroglobulin antibodies.
• Thyroid peroxidase antibodies.
• Antinuclear antibodies (ANA)
• Fasting blood sugar.

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Differential diagnosis

Although the diagnosis of alopecia areata is straightforward, The following conditions should be considered

• Tinea capitis.
• Trichotillomania.
• Traction alopecia.
• Secondary syphilis.
• Loose anagen syndrome.
• Temporal triangular alopecia.

Treatment options

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