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Case Reports

Abstract

A 56-year-old woman presented with 6-week history of hair loss and scalp sensitivity. She denied constitutional or infectious symptoms. Her last sexual encounter was 1 year ago. Exam was notable for alopecic patches diffusely over the scalp without erythema or scale. Punch biopsy revealed diminished number of hair follicles with >50% in catagen/telogen phase. There was peribulbar inflammation and miniaturized hairs. This was initially read as alopecia areata. The patient was subsequently admitted to the hospital with vision changes and found to have ocular syphilis. This prompted staining of the scalp biopsy for Treponema pallidum, which was positive, consistent with a diagnosis of syphilitic alopecia. RPR screen was positive with a titer of 1:256. The patient was started on IV ceftriaxone due to allergic reaction to penicillin. On chart review, the patient had presented to dermatology clinic 2 months prior with a truncal rash. Punch biopsy from the chest showed superficial perivascular lymphocytic dermatitis. One month later, the patient developed a rash over the forearms, which was diagnosed as vacuolar interface dermatitis. Both biopsies also stained positive for T. pallidum. Overall, syphilitic alopecia and alopecia areata can be indistinguishable clinically and histologically. Syphilitic alopecia is a nonscarring alopecia that can present in a diffuse, moth-eaten, or mixed pattern. Appropriate treatment leads to hair regrowth in weeks to months. Syphilis is on the rise across the country. This case highlights that clinicians must have a high index of suspicion and consider secondary syphilis in patients presenting with new onset patchy alopecia.