Nonscarring Alopecia and Hypopigmented Lesions May Be Unusual Signs of Secondary Syphilis

Abstract

Noncicatricial patchy alopecia of the scalp and focal areas of skin hypopigmentation imply a diagnosis of alopecia areata and vitiligo. We present a case of a 22-year-old patient in whom these symptoms were associated with positive spirochete reactions, which allowed making a diagnosis of syphilitic alopecia coexisting with leukoderma syphiliticum. Skin lesions and hair loss resolved after the treatment with benzathine benzylpenicillin. Trichoscopy in syphilitic alopecia is nonspecific, but the absence of features typical for alopecia areata such as exclamation mark hairs may be important on an early stage of the clinical workup.

Established Facts

• 3–8% of patients with alopecia areata have concomitant vitiligo.

• 3–8% of patients with alopecia areata have concomitant vitiligo.

• Secondary lues may manifest as both syphilitic alopecia and syphilitic vitiligo.

• 3–8% of patients with alopecia areata have concomitant vitiligo.

• Secondary lues may manifest as both syphilitic alopecia and syphilitic vitiligo.

• Similar clinical presentation of these entities may be a reason for misdiagnosis unless syphilis screening is performed.

Novel Insights

• Coexistence of noncicatricial patchy alopecia and focal areas of cutaneous hypopigmentation should prompt screening for syphilis.

• Coexistence of noncicatricial patchy alopecia and focal areas of cutaneous hypopigmentation should prompt screening for syphilis. Trichoscopy may help to differentiate between syphilitic alopecia and alopecia areata due to the lack of features typical for the latter (e.g., exclamation mark hairs).

Introduction

Alopecia areata and vitiligo, both of which are autoimmune conditions, are the most common causes of hair loss with concomitant skin depigmentation. However, secondary lues manifesting by syphilitic alopecia and leukoderma syphiliticum may imitate these entities. We present a case of a patient with secondary lues imitating alopecia areata and vitiligo.

Case Presentation

A 22-year-old man presented with noncicatricial patchy alopecia of the scalp coexisting with hypopigmented macules localized on the neck (shown in Fig. 1, 2, respectively). Based on the clinical symptoms, the primary diagnosis of alopecia areata coexisting with vitiligo was established. However, the patient tested positive for syphilis (unheated serum reagin [USR] +++, venereal disease research laboratory [VDRL] 1/64, and fluorescent treponemal antibody absorption [FTA-ABS] 1/16,000). There were no other clinical findings characteristic of secondary lues within the skin and the mucous membranes. Wood's lamp examination of the lesions located on the neck revealed well-demarcated areas of the skin exhibiting blue fluorescence. Based on the clinical picture and additional testing, the diagnosis of syphilitic alopecia coexisting with leukoderma syphiliticum was established. The patient received a single intramuscular injection of benzathine benzylpenicillin (2.4 million units). The treatment resulted in resolution of skin lesions and hair regrowth.

Fig. 1.

Alopecia areata-like patches in the patient with syphilis.

Fig. 2.

Hypopigmented patches on the skin of the patient with syphilis.

Discussion/Conclusion

The prevalence of vitiligo in patients with alopecia areata is estimated at 3–8% [1]. Both of these conditions result from an autoimmune reaction mediated by CD8+ cytotoxic T cells and interferon γ. The target organs are hair bulbs and melanocytes in alopecia areata and vitiligo, respectively [1]. Antigens associated with melanogenesis have been discussed as potential triggers of autoimmunity in alopecia areata [2]. In both diseases, the peak age of onset is approximately 20–40 years [3, 4]. Both alopecia areata and vitiligo have a patchy distribution and are usually asymptomatic [3, 5]. The lesions of vitiligo are most often located on exposed body sites (such as the face, neck, forearms, feet, dorsal hands, fingers, and scalp) [6]. Alopecia areata is associated with roundish foci of hair loss, which are usually located on the scalp. Occasionally, the disease causes a complete loss of scalp hair (alopecia totalis). Other body sites are affected less commonly, but in severe cases, alopecia areata may result in a complete loss of all body hair (alopecia universalis) [1].

On the other hand, the syphilitic alopecia and syphilitic vitiligo may both be present in the course of secondary lues. Syphilis can resemble a wide range of conditions, which is why it is called a great mimicker in dermatology. Scalp involvement in syphilitic alopecia most commonly presents as disseminated patches of nonscarring alopecia, with a “moth-eaten” appearance [7, 8]. Syphilitic alopecia is seen in 2.9–7% of patients with secondary syphilis [9]. Isolated alopecia is very rare in secondary syphilis and appears as a noncicatricial hair loss which can occasionally affect areas other than the scalp and mimic the course of alopecia areata [10, 11]. Leukoderma syphiliticum, also known as syphilitic vitiligo, manifests by hypopigmented patches usually localized on the neck, face, and extremities [12].

The pathogenesis of both leukoderma syphilitcum and syphilitic alopecia is based on the immune response to Treponema pallidum. As a result, loss of terminal hairs, stoppage of the hair cycle, and hair bending with resulting empty hair follicles and broken hairs are seen in syphilitic alopecia, while the loss of melanin in the epidermis takes place in leukoderma syphiliticum [12, 13]. Trichoscopy in syphilitic alopecia shows no typical features of alopecia areata such as exclamation mark hairs (shown in Fig. 3) [12, 14]. In the case of noncicatricial alopecia coexisting with vitiligo, it is very important to remember that the serological tests are pivotal for making the correct final diagnosis and to choose the most effective method of treatment.

Fig. 3.

Syphilitic alopecia may mimic alopecia areata. Trichoscopy reveals predominant loss of hair and presence of yellow dots (asterisk). However, typical trichoscopic features of alopecia areata are absent. A few black dots can be present in the course of disease (red arrows). A single flame hair (green arrow) represents a nonspecific finding, probably due to the pulling of hair to cover the patches of hair loss.

Statement of Ethics

The authors state that the patient has given his written informed consent to publish photos and details of the case.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

The authors did not receive any funding.

Author Contributions

All authors made substantial contributions to the design of the work, acquisition, analysis, or interpretation of data for the work. M.C., J.S., and M.S. were responsible for drafting the manuscript. L.R., L.B., and M.K. revised the work critically for important intellectual content. All authors have approved the final version of the manuscript to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.