Alopecia Areata, Exclamation Point Hair, Hair Loss, Poliosis, Teledermatology



  1. Perez, Caroline
  2. Boghosian, Gayle
  3. Jacob, Sharon E.


ABSTRACT: Teledermatology is a term to describe the provision of dermatologic medical services through telecommunication technology. This is a teledermatology case of acute onset hair loss in ovoid patches on the scalp.


Article Content

In the store and forward teledermatology modality, there is a transfer of patient medical information electronically (including history and visual data) obtained in one location to a provider who is in another location (Roman & Jacob, 2015). The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.




Chief complaint: presenting for diagnosis and therapeutic options.


History of Present Illness

A 31-year-old woman presents with acute onset hair loss in discrete patches on her scalp, which she says developed over the last 10 weeks. Prior treatment for skin condition: none. Her primary symptom: none. Prior biopsy: none.



Fully satisfactory.



There is one image provided with this consult. The image shows two large, ovoid patches of alopecia on the parietal scalp, left of midline (see Figure 1).

Figure 1 - Click to enlarge in new windowFIGURE 1. On the parietal scalp, slightly left of midline, there are two discrete, large ovoid patches of alopecia.


Lesion A


The morphology of the lesions, distribution, and history are characteristic for alopecia areata (AA).



Skin Care Recommendations

Triamcinolone 0.1% ointment should be applied twice daily to affected areas on the scalp for up to 6 weeks.


Medication Recommendations

None at this time.


Other Treatment Recommendations

It is prudent to assess for underlying systemic disease, as correction of underlying condition is needed, if present. Check thyroid function tests, complete blood count (CBC), and anti-nuclear antibody (ANA) titer, if symptoms dictate.



Type of Visit

Return to primary care for follow-up after 4-6 weeks. Refer to dermatology if no improvement in 6 weeks.



AA is considered to be a T-cell-mediated autoimmune condition that generally occurs in persons with genetic predisposition (Islam, Leung, Huntley, & Gershwin, 2015). There is thought to be a preferential autoimmune target of follicular melanocytes in the hair bulb (Gilhar et al., 2001). Because this is a nonscarring process, with proper treatment and a tincture of time, most patients will grow their hair back.


The disease affects about 3% of the population in the United States. The most common clinical presentation is hair loss in an ovoid or circular patch pattern on the scalp. The disease may also present with alopecia totalis, which is total loss of scalp hair, or alopecia universalis, defined as loss of all scalp and body hair. Exclamation point hairs may be visible, where the hair shaft is normal distally but tapers as it extends proximally. This tapering is due to miniaturization of the hair follicle from inflammation. It is also important to note that patients with AA may lose hair in a pattern known as poliosis, wherein gray (nonpigmented) hair is preserved. Of note, nail abnormalities may also be present in AA, with pitting being the most common (Sperling, Sinclair, & El Shabrawi-Caelen, 2012).


For localized AA, it is reasonable for the primary care physician to prescribe a midpotency topical corticosteroid to be applied twice daily to affected areas on the scalp for up to 6 weeks. If there is no improvement, referral to dermatology for intralesional corticosteroids is warranted. In extensive AA, more intense, systemic therapy may be required, so timely referral to a dermatologist is also recommended in this case (Finner, 2011; Sperling et al., 2012).



AA can lead to disturbed body image, which can be emotionally traumatic and can have long-term effects on self-esteem. As nurses, we need to be aware of the frustrating characteristics of this disease. Opportunities to offer encouragement, education, and connection to resources should be emphasized during the course of treatment. Patients can be directed to appropriate resources and support groups, such as the National Alopecia Areata Foundation (




Finner A. M. (2011). Alopecia areata: Clinical presentation, diagnosis, and unusual cases. Dermatologic Therapy, 24(3), 348-354. [Context Link]


Gilhar A., Landau M., Assy B., Shalaginov R., Serafimovich S., Kalish R. S. (2001). Melanocyte-associated T cell epitopes can function as autoantigens for transfer of alopecia areata to human scalp explants on Prkdc(scid) mice. Journal of Investigative Dermatology, 117(6), 1357-1362. [Context Link]


Islam N., Leung P. S., Huntley A. C., Gershwin M. E. (2015). The autoimmune basis of alopecia areata: A comprehensive review. Autoimmunity Reviews, 14(2), 81-89. [Context Link]


Roman M., Jacob S. E. (2015). Teledermatology: Virtual access to quality dermatology care and beyond. Journal of the Dermatology Nurses Association 6(6), 285-287. [Context Link]


Sperling L. C., Sinclair R. D., El Shabrawi-Caelen L. (2012). Alopecias. In Bolognia J. L., Jorizzo J. L., Schaffer J. V. (Eds.), Dermatology (3rd ed., pp. 1100-1101). Atlanta, GA: Elsevier. [Context Link]


1The standardized teledermatology reader report format is available for authors in Table 1 and on the submissions Web T1 site online at [Context Link]