Treatment-resistant alopecias

CASE #1

A 30-year-old black man came to the clinic with a history of scarring alopecia in his scalp and severe acne since puberty. The patient reported that his scalp would, on a regular basis, develop painful flocculent nodules. He did not complain of joint pain. No one else in his family had similar symptoms. He had used oral isotretinoin, dapsone, minocycline, and prednisone (individually and in combination), with some decrease in size and number of nodules but suffered the side effects of increased lipids and blood sugar. A skin biopsy revealed a dense neutrophilic infiltrate, fibrosis, and destruction of the hair follicle.

CASE #2

The patient was a 14-year-old black male with hair loss on his rear scalp. The alopecia was nonscarring, and the hair follicles could be visualized. The area had been treated with intralesional triamcinolone (Kenalog) 5 mg/cc, topical tacrolimus, topical anthralin, topical clobetasol, and topical minoxidil as monotherapy and in combination, without effect. The patient had a history of hay fever or atopic dermatitis. He did not have any nail dystrophy. Two brothers had no scalp pathology; an aunt had Graves’ disease. The patient thought the area, which did not itch, burn, or hurt, was expanding.

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