(Alopecia circumscripta; Tinea decalvans; Prurigo decalvans; Area Celsi).
Definition. A condition of the hairy surface, characterized by one or more circumscribed, rounded areas of complete baldness without any apparent change in the skin.
Symptoms. There usually appears without local sensation, although occasionally moderate itching or other manifestations may be present, one or more, small, round, smooth, white spots entirely denuded of hair. The skin is apparently sound and the lesions are irregularly distributed but commonly located on the scalp, especially in the occipito-parietal regions, although other parts of the body may be attacked at the same time. The male beard or the eyebrow, axillae, pubes or even the downy surfaces in either sex may be subsequently involved. Occasionally the patches remain stationary but usually they increase by peripheral extension. This method of growth is characteristic of true alopecia areata and, although the lesions usually keep the rounded or perhaps oval shape, they may form irregular areas by union with other patches. Rarely the condition is more pronounced at one or more sections of the periphery, forming single or multiple zigzag extensions in several directions. The patches involved appear polished, thin, softened and somewhat depressed. Sensitiveness to irritants is diminished to a marked degree. Short hairs which can be removed by the slightest traction are noted at the border of the spreading patch and occasionally some of the longer hairs come out easily. Exceptionally, a few of the short hairs may be seen on the central part of the area.
When the lesion becomes stationary, the short hairs no longer appear, the longer hairs are not so easily pulled out and recovery ensues. This may be demonstrated as the spots become smaller from peripheral hair growth, but in most favorable cases the hair appears all over the patch at once. The new hair is fine, of lighter color, sometimes even white, and frequently falls out to remain absent for a variable period before its renewal, when it appears to be nearer the normal shade. This performance of shedding may be repeated a number of times before the hair becomes permanent. The return of pigment may be observed if the successive growths are carefully watched. Occasionally as the hair is restored, other areas of baldness appear as recurrences or rather reactivities are quite common and the same spots may be affected a second time.
Among the atypical forms may be mentioned that in which the alopecia spreads in a band-like girdle around the head just within the hair line. Another form is represented in pea- to bean-sized patches which remain white and resemble scar tissue. When these are distinctly depressed, some what anesthetic and run a persistent and unfavorable course, they constitute the alopecia circumscripta seu orbicularis of Neumann. Other atrophic forms of alopecia result from injuries to a nerve, neuralgia or neuritis and present linear or irregular shapes unlike the true primary patches of alopecia areata. Certain neurotic conditions such as vitiligo, morphea and thyroid disease have been noted as coexisting with irregular alopecia and a number of examples of white, spotty, granular nail changes have been reported.
Etiology and Pathology. Both sexes at any age may be affected but the disease is more prevalent between the ages of ten and thirty. It probably does not number more than 1 per cent. of all cases in this country but is much more common in Europe. There are two etiological theories; one regards alopecia areata as parasitic and contagious and the other as trophoneurotic and non- contagious, and there are no doubt many plain examples of each. From my own experience I should say that the contagious variety is the more common, although it is less prevalent in the United States than in England, Germany and France. Numerous cases demonstrating contagion have been reported, such as several children in the same family, ten patrons of one barber, instances where two or more people intimately associated have contracted the disease, and outbreaks occurring in schools. The nature of the parasite is not definitely decided, many of the European authorities believing that true alopecia areata is related to ringworm. Others describe fungi or micrococci which have been occasionally found. Hutchinson claims that ringworm of the scalp in childhood may result in adult alopecia areata, and Crocker held the view that adult alopecia areata is equivalent to ringworm in childhood. Most of the evidence to bear out these theories is inferential; an example of which is the well-known fact that in the countries where alopecia areata is most common, so also is ringworm. Sabouraud believes that this disease is due to the microbacillus that he found in acne, seborrhea and comedo, and considers it an acute form of seborrhea oleosa. No doubt the majority of cases are contagious, but only slightly so, owing to unknown favoring circumstances.
In private practice a large bulk of the cases are neurotic and no doubt this fact has led many American observers to hold strictly to the trophoneurotic theory. In any case, the nerve disturbance may be largely predisposing, even in the parasitic type, and absolutely essential in the neurotic forms. The generalized or universal form of alopecia is undoubtedly neurotic. All authorities have seen cases that gave a history of previous nervous shock, accident, worry, fright or anxiety, or followed some definite neurosis. Pathological findings, according to Robinson, are due to an inflammation in the corium with round cell infiltration and thickening of the vessel-walls of the affected parts. The resulting interference with the nutrition of the hair results in atrophy of the hair-producing structures.
Diagnosis. Circumscribed baldness caused by such diseases as favus, lupus erythematosus, syphilis, etc., may be diagnosed by the history of the course of the antecedent disease. Circumscribed baldness from injuries to the nervous structures may have the same surface appearance as the common form, but the absence of the characteristic peripheral hairs and the difference in the mode of occurrence and extension should make this type plain. The orbicular variety with its small depressed areas and absence of characteristic border hairs is like- wise distinctive. Ringworm patches show scales and short twisted hairs scattered over the surface and the hairs at the margins are not as easily extracted as those of alopecia. The microscope may be used to distinguish the fungus if suspected.
Prognosis. The older the patient, the larger the involved area and the longer the duration of the disease, the less hopeful is the outlook. When the skin has become atrophic after a duration of one or more years there is little prospect of recovery, though a new growth is always possible. Recurrences are common and no time limit can be set for recovery, even in the most hopeful cases. In those due to nerve disturbance the hair usually grows again but often is abnormal in color, while in the orbicular type a regrowth must not be expected.
Treatment. The methods employed in each case depend entirely upon the underlying factors, hence it is that the neurotic type calls for physiological methods and careful internal medication with a small amount of local stimulation. If the clinical signs of a parasitic disease be present, all of the above methods may be helpful but a penetrating parasiticide is absolutely essential. Local treatment for the ordinary forms consists in the cleansing of the affected area and then of the whole scalp. This may be accomplished with tincture of green soap or some other shampoo which should be thoroughly sponged off and the scalp quickly dried. The loose hairs about the margin of the patch may be removed with forceps and a stimulating lotion or antiparasitic application thoroughly applied to the patch, as well as a quarter of an inch beyond the border. I often employ chloroform or ether to more thoroughly cleanse the area and to facilitate the penetration of the germicide.
Frequently one or more applications of one of the following will be all sufficient; carbolic acid; formalin; lactic acid; trikresol pure or diluted with alcohol or water; chrysarobin as a saturated solution in chloroform; or iodin 5 to 20 per cent. in collodion. After the irritation of the application has passed off, in three to five days, a 2 to 5 per cent. ammoniated mercury, salicylic acid or carbolic acid ointment may be applied continuously. If continued antiparasitic or stimulating treatment is needed, it may be applied in the form of lotions or ointments containing cantharides, capsicum, turpentine, essential oils, carbolic acid, chrysarobin, ammonia, sulphur, iodin, mercury, betanaphthol, etc. Choice may be made of the following:
Rx Hydrarg. bichlorid.
Spr. vini rect.,
M. Sig. Apply twice daily.
Rx Hydrarg. bichlorid.,
Ol. amagdalae dulc.,
M. Sig. Apply twice daily.
Rx Tinct. cantharides,
M. Sig. Apply to patches vigorously once or twice a day.
M. Sig. Rub in thoroughly twice a day.
M. Sig.- Apply night and morning.
M. Sig. Paint over the affected area every second to fourth day, as needed.
Although these local agents often accomplish the purpose desired, I much prefer electrical and physical agents, especially the high-frequency currents applied with a glass electrode or in the form of mild fulguration or the effluve spray. Galvanism and faradicism present no advantages over the currents just mentioned. Cataphoresis, X-raying, especially short exposures with intermittent flashes, radium and phototherapy, which includes the Finsen apparatus. London Hospital lamp or other modifications of actinic light rays, have all been serviceable in stubborn cases. As hyperemia of the affected area is most desirable, the repeated application of Bier’s suction and exhaustion cups is especially valuable. Selection of a remedy for internal use, especially in the neurotic type is most important and can be made from a large number of drugs. Among these I may mention Calcarea phos., Fluoric acid., Phosphorus, and Vinca minor.