Alopecia areata incognito responsive to azathioprine presenting in a patient with uncontrolled iatrogenic hypothyroidism

Authors: Felix Paolo J,. Lizarondo, MD, Claudine Yap-Silva, MD, FPDS

Abstract

Introduction: Alopecia areata incognito is a rare variant of alopecia areata presenting as diffuse hair thinning, hence its other name diffuse alopecia areata. It usually mimics acute telogen effluvium but has the characteristic trichoscopic findings of alopecia areata.

Case Summary: A 22 year old female who underwent radioidine thyroid ablation as a child due to to hyperthyroidism presented with a 1 month history of increased hair fall. At this time, patient’s iatrogenic hypothyroidism was uncontrolled due to noncompliance with levothyroxine. Decreased hair density diffusely affecting the vertex, parietal area with some extension into the frontal and occipital area was seen; hair pull was positive on all affected areas. Trichoscopy revealed exclamation point hairs, broken off hairs, black dots and yellow dots on affected areas. Patient was diagnosed to have alopecia areata incognito. Oral steroids was started at 0.5-1mg/kg/day with markedly decreased hair pull count. Normalization of TSH levels was achieved with an Endocrinologist. Tapering of the steroids was initiated but there was further extension of the hair loss and increased hair pull count. Due to the persistent activity of the disease, azathioprine was started at 100mg/day for 4 weeks at which steroid tapering was managed. Regrowth of hair was achieved and no recurrence was noted for 2 months.

Conclusion: This case demonstrates that alopecia areata should always be in the differential diagnosis of patients presenting with acute diffuse hair fall to properly address its autoimmune process. This case also demonstrates that azathioprine is a viable alternative to systemic steroids.

 

Citation

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Keywords

alopecia areata incognito, diffuse alopecia areata, hypothyroidism, azathioprine

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