Alopecia developed in a transitional case from pemphigus foliaceus to pemphigus vulgaris

[A Case of Pemphigus Vulgaris Showing a Local Nose Erosion as the First Clinical Manifestation]

A 73-year-old male noticed a localized nose erosion that we thought was possibly an exacerbation of skin erosion due to the direct influence of friction from wearing a mask. Blood examination revealed a remarkable increase in serum anti-desmoglein-1 and anti-desmoglein-3 antibodies. A skin biopsy showed acantholysis in the epidermal granular layer. Based on the clinical manifestation and laboratory examination, we diagnosed his eruption as anti-desmoglein-1 and anti-desmoglein-3 antibody - positive pemphigus vulgaris. His skin eruption responded well to oral prednisolone and azathioprine and gradually improved. Pemphigus was a candidate as a differential diagnosis in this case, in which the direct mechanical friction from wearing a mask was thought to be an exacerbating factor of skin eruption.

Alopecia as a systemic disease

Alopecia is a skin condition of great social and psychologic impact. Primary alopecia originates from the hair follicles and usually does not have systemic manifestations; however, secondary alopecia can affect the hair follicles in the setting of systemic diseases, medications, and external trauma. Connective tissue diseases, granulomatous diseases, bullous diseases, infections, and tumors are some of the systemic diseases that will be covered in this review. Trichoscopy is a useful noninvasive tool that can help with the diagnosis in the office and can guide the selection of the optimal site for the scalp biopsy. Histopathology is the ultimate tool for the diagnosis in most cases of secondary alopecia and can be performed on vertical and horizontal sections. In most cases, treating the underlying condition is the single most important strategy, but topical treatments for the alopecia are also applied.

Alopecia in Autoimmune Blistering Diseases: A Systematic Review of Pathogenesis and Clinical Features of Disease

Background

Autoimmune blistering diseases (AIBD) are characterised by the body's production of autoantibodies against structural proteins in the epidermis and/or the basement membrane on cutaneous and mucosal surfaces. Alopecia is a complication of AIBD that has generally been overlooked in patients with severe blistering diseases because it is regarded as a cosmetic issue. Yet recent research into quality of life tools has found that stigmatisation by appearance plays a significant role in blistering diseases.

Aim

To review the current literature detailing the pathogenesis and clinical presentations of alopecia in AIBD patients.

Method

We searched Medline, PubMed and EMBASE electronic databases up to September 2018, for empirical human and animal studies.

Results

Only 36 human studies including 223 patients (190 pemphigus, 25 pemphigoid, 5 epidermolysis bullosa acquisita, 2 dermatitis herpetiformis and 1 linear IgA disease) detailed demographic and clinical manifestations of alopecia. A range of hair evaluation methods was demonstrated to reach alopecia diagnosis. Furthermore, with no universal validated scoring system for alopecia severity, alopecia patterns have been summarised.

Conclusion

Previous randomised trials have not highlighted alopecia as an important outcome of AIBD, so epidemiological evaluation of the available literature has been helpful in summarising trends between existing studies and demonstrating inconsistencies.

The Significance of Scalp Involvement in Pemphigus: A Literature Review

Scalp is a unique location for pemphigus because of the abundance of desmogleins localized in hair follicles. Scalp involvement is observed in up to 60% of patients in the course of pemphigus. The lesions may occasionally lead to alopecia. Unforced removal of anagen hairs in a pull test is a sign of high disease activity. Direct immunofluorescence of plucked hair bulbs is considered a reliable diagnostic method in patients with pemphigus. Follicular acantholysis is a characteristic histopathological feature of pemphigus lesions localized on the scalp. Trichoscopy may serve as a supplementary method in the diagnosis of pemphigus. This review summarizes the most recent data concerning scalp involvement in pemphigus vulgaris and pemphigus foliaceus. A systematic literature search was conducted in three medical databases: PubMed, Embase, and Web of Science. The analysis included literature data about desmoglein distribution in hair follicles, as well as information about clinical manifestations, histopathology, immunopathology, and trichoscopy of scalp lesions in pemphigus and their response to treatment.