Case scenario

Michael is 15 years old. At the age of 13 he developed a solitary patch of alopecia areata. Two weeks after intradermal injection of triamcinolone, 5 mg/ml, he developed diffuse generalised hair shedding and within 10 days was totally bald (Figure 43.2). Three months later he began to lose his eyebrows, eyelashes and ultimately every hair on his body was lost. Unable to cope with the teasing at school, he had not attended for the previous 8 weeks. A general assumption by his teachers was that he was away from school receiving chemotherapy.

A reducing course of oral prednisolone (starting dose 0-75 mg/kg) led to complete regrowth within 6 weeks. The prednisolone was ceased after 8 weeks. He remained in remission for 4 months, changed schools and performed well at his work, before a new patch appeared. He refused intralesional corticosteroids, as he related the progression to totalis on the previous occasion to the injection. Topical immunotherapy was commenced with diphencyprone. Within 12 weeks the patch regrew and the therapy was ceased. Eight months later, following a mild upper respiratory tract infection, he relapsed and within 3 weeks had progressed to alopecia totalis/ universalis once again. A second course of prednisolone failed to stimulate any regrowth. Topical immunotherapy over 6 months failed to initiate regrowth. Michael bought a wig, but found it uncomfortable to wear due to the heat in summer. In sympathy a friend at school shaved his head. Michael wore glasses with ordinary glass to disguise the loss of eyebrows and protect his eyes from dust etc. He elected to have intralesional corticosteroids into the eyebrows, which produced patch regrowth, around which he pencilled in his eyebrows. No other treatment was sought.

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