Case and Research Letters
Transitory Rectangular Alopecia After Endovascular Embolization: A Case Report and Description of the Histopathology Findings
Alopecia rectangular transitoria tras embolización endovascular: presentación de un caso y descripción de los hallazgos histopatológicos
C. Bernárdez, I. Alcaraz, A.M. Molina-Ruiz
, L. Requena
Corresponding author
Servicio de Dermatología, Hospital Universitario Fundación Jiménez Díaz, Universidad Autónoma, Madrid, Spain
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A) Se observa ausencia de folículos pilosos en la hipodermis. B) Dermis respetada con folículos pilosos retraídos en ausencia de infiltrado inflamatorio. C) La vaina radicular externa de los folículos pilosos retraídos muestra una morfología ondulada y arrugada, típico de la fase de catagen. D) Característica estela fibrosa de los folículos en catagen.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Bernárdez, I. Alcaraz, A.M. Molina-Ruiz, L. Requena" "autores" => array:4 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Bernárdez" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Alcaraz" ] 2 => array:2 [ "nombre" => "A.M." "apellidos" => "Molina-Ruiz" ] 3 => array:2 [ "nombre" => "L." 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A dark, kerotic pigmented lesion measuring 1.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm can be seen, with the Hutchinson sign, on the ball of the left little toe.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Ivars, P. Redondo" "autores" => array:2 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Ivars" ] 1 => array:2 [ "nombre" => "P." 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Bernárdez, I. Alcaraz, A.M. Molina-Ruiz, L. Requena" "autores" => array:4 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Bernárdez" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Alcaraz" ] 2 => array:4 [ "nombre" => "A.M." "apellidos" => "Molina-Ruiz" "email" => array:1 [ 0 => "amolinar@fjd.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Requena" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Fundación Jiménez Díaz, Universidad Autónoma, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Alopecia rectangular transitoria tras embolización endovascular: presentación de un caso y descripción de los hallazgos histopatológicos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 863 "Ancho" => 975 "Tamanyo" => 128554 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagnostic angiography image prior to the intervention, showing a large arteriovenous malformation in the left occipital region (arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Endovascular embolization is the first-line treatment for intracranial aneurysms and vascular malformations. The possibility of inducing transitory secondary alopecia with this technique is well known by interventional neuroradiologists, but has received little attention in dermatology publications and even less in the dermatopathology literature, in which there are still no published descriptions of the histopathologic findings characteristic of this condition.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report a new case of transitory rectangular alopecia after endovascular embolization and provide the first description of its histopathologic characteristics. The patient was a 32-year-old woman who underwent endovascular embolization to treat an intracranial arteriovenous malformation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). She consulted for hair loss of rapid onset in the left parieto-occipital region 1 month after the procedure. On physical examination, a well-defined rectangular plaque of alopecia with a strongly positive hair pull test was present in the left parieto-occipital region (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). On trichoscopy, dystrophic hair shafts were observed in the follicular orifices, with no exclamation mark hairs. A skin biopsy taken from the plaque of alopecia revealed a high percentage of follicles in catagen, with no signs of damage to the follicular epithelium or radiodermatitis. The hair follicles appeared retracted, with an undulating, corrugated outer root sheath and with the presence of apoptotic cells (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). In addition, the typical fibrous stela of follicles in catagen extended beneath the follicular bulb. It was decided to take a wait-and-see approach, without performing treatment. The plaque of alopecia showed a spontaneous and progressive improvement, with complete repopulation within 2 months.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Alopecia after radiotherapy to the head and neck is extensively documented in the literature; however, few reports have been published on alopecia after diagnostic and therapeutic endovascular procedures and the condition is probably underdiagnosed. Fluoroscopy, a technique that uses the fluorescent properties of x-rays to obtain images in real time, is an important aid when performing endovascular embolization as it allows us to take video images of, for example, the movement of fluids. Taking images over a long interval can give rise to radiation-induced adverse effects, as patients receive high doses of radiation to a single area. Transitory rectangular alopecia after endovascular embolization is considered to be a specific form of acute radiodermatitis caused by the marked sensitivity to radiation of scalp hair follicles in anagen.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> The follicular cycle is interrupted abruptly by an acute lesion of mitotically active cells in the follicular matrix. This produces a premature and synchronic entry of all follicles into catagen phase, and the hair shafts are eliminated from affected follicles. However, the follicular cycle reinitiates when the harmful stimulus ceases, hence the complete repopulation of these lesions within 2 to 4 months after the procedure.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The typical clinical presentation of transitory rectangular alopecia after endovascular embolization is as a plaque of alopecia of artifactual morphology that appears a few weeks after the intervention, in the area of scalp that received the highest dose of radiation. Onset depends mainly on total fluoroscopy time (more than 100<span class="elsevierStyleHsp" style=""></span>minutes) and on the total dose received (definitive cicatricial alopecia will occur at doses over 7<span class="elsevierStyleHsp" style=""></span>Gy and transitory alopecia at doses between 3 and 5<span class="elsevierStyleHsp" style=""></span>Gy).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> However, when calculating the total radiation dose used in the intervention, it is important also to take into account prior diagnostic procedures that the patient has undergone, such as angiography, as the effects of these techniques on the hair follicles are cumulative.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,3</span></a> In addition, certain biological factors such as age, hair density, hormone status, and some genetic factors, can also influence the onset of this type of alopecia, although the underlying mechanisms are still poorly understood.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">It is important to differentiate transitory rectangular alopecia after endovascular embolization from postoperative alopecia and alopecia areata,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> as these are also nonscarring alopecias that are of rapid onset and present a circumscribed morphology. Postoperative alopecia is due to hypoxia caused by pressure on the reclined head during a long general anesthetic. Alopecia areata has a more complex and multifactorial etiology and pathogenesis. In the majority of cases, the diagnosis of transitory rectangular alopecia after endovascular embolization is based on the history of radiation to the area and the artifactual morphology of the lesions (typically rectangular). However, the absence of inflammation and the presence of dystrophic hair shafts can make it difficult to distinguish the condition from alopecia areata.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> In these cases, histopathology of a biopsy from the affected area is useful to differentiate the 2 entities. From a histopathological point of view, transitory rectangular alopecia after endovascular embolization should theoretically show changes compatible with anagen effluvium, associated with a minimal inflammatory infiltrate, although the findings will depend to a large extent on the moment at which the biopsy is performed. In our case, the biopsy showed a minimal inflammatory infiltrate and all the follicles were in catagen after the abrupt cessation of their cycle. We did not observe a honeycomb-like morphology of the infiltrate around the follicular bulb, typical of alopecia areata, or signs of radiodermatitis in the interfollicular epidermis or in the follicular epithelium. The absence of areas of scarring confirmed the transitory nature of the alopecia, as was observed clinically.</p><p id="par0030" class="elsevierStylePara elsevierViewall">With the progressive increase in the number and complexity of endovascular embolization techniques, treating ever more complex lesions and requiring longer fluoroscopy times,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5–7</span></a> it is likely that consultations for transitory rectangular alopecia after endovascular embolization will increase in the near future. It is therefore important that dermatologists are aware of the clinical characteristics and histopathologic features of this condition, so that they can reassure patients and inform them that the clinical course will be favorable.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Bernárdez C, Alcaraz I, Molina-Ruiz AM, Requena L. Transitory Rectangular Alopecia After Endovascular Embolization: A Case Report and Description of the Histopathology Findings. Actas Dermosifiliogr. 2015;106:848–850.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 863 "Ancho" => 975 "Tamanyo" => 128554 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagnostic angiography image prior to the intervention, showing a large arteriovenous malformation in the left occipital region (arrow).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 921 "Ancho" => 975 "Tamanyo" => 152229 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical image of the alopecia lesion. A plaque of alopecia with a rectangular morphology and well-defined borders in the left parieto-occipital region 1 month after the intervention and presented a rectangular morphology with well-defined borders.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1338 "Ancho" => 1800 "Tamanyo" => 620885 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histopathology after staining with hematoxylin and eosin. A, No hair follicles are visible in the hypodermis. B, The dermis is spared and presents retracted hair follicles with no inflammatory infiltrate. C, The outer root sheath of the retracted hair follicles has an undulating, corrugated morphology, typical of catagen phase. D, Characteristic fibrous stela of follicles in catagen.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Temporary hair loss simulating alopecia areata after endovascular surgery of cerebral arteriovenous malformations: A report of 3 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Tosti" 1 => "B.M. Piraccini" 2 => "G. Alagna" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 9 | 13 |
| 2024 October | 78 | 34 | 112 |
| 2024 September | 78 | 18 | 96 |
| 2024 August | 127 | 44 | 171 |
| 2024 July | 91 | 30 | 121 |
| 2024 June | 93 | 34 | 127 |
| 2024 May | 66 | 57 | 123 |
| 2024 April | 70 | 29 | 99 |
| 2024 March | 63 | 26 | 89 |
| 2024 February | 51 | 37 | 88 |
| 2024 January | 55 | 37 | 92 |
| 2023 December | 41 | 22 | 63 |
| 2023 November | 54 | 22 | 76 |
| 2023 October | 105 | 17 | 122 |
| 2023 September | 52 | 28 | 80 |
| 2023 August | 50 | 19 | 69 |
| 2023 July | 57 | 30 | 87 |
| 2023 June | 47 | 25 | 72 |
| 2023 May | 54 | 26 | 80 |
| 2023 April | 60 | 23 | 83 |
| 2023 March | 36 | 21 | 57 |
| 2023 February | 40 | 26 | 66 |
| 2023 January | 42 | 17 | 59 |
| 2022 December | 71 | 37 | 108 |
| 2022 November | 29 | 29 | 58 |
| 2022 October | 39 | 16 | 55 |
| 2022 September | 25 | 34 | 59 |
| 2022 August | 35 | 31 | 66 |
| 2022 July | 23 | 25 | 48 |
| 2022 June | 21 | 35 | 56 |
| 2022 May | 40 | 23 | 63 |
| 2022 April | 38 | 31 | 69 |
| 2022 March | 33 | 40 | 73 |
| 2022 February | 11 | 31 | 42 |
| 2022 January | 39 | 61 | 100 |
| 2021 December | 30 | 37 | 67 |
| 2021 November | 32 | 41 | 73 |
| 2021 October | 45 | 43 | 88 |
| 2021 September | 30 | 42 | 72 |
| 2021 August | 27 | 50 | 77 |
| 2021 July | 38 | 27 | 65 |
| 2021 June | 20 | 18 | 38 |
| 2021 May | 30 | 30 | 60 |
| 2021 April | 84 | 27 | 111 |
| 2021 March | 64 | 23 | 87 |
| 2021 February | 72 | 15 | 87 |
| 2021 January | 40 | 18 | 58 |
| 2020 December | 39 | 11 | 50 |
| 2020 November | 29 | 17 | 46 |
| 2020 October | 25 | 12 | 37 |
| 2020 September | 35 | 10 | 45 |
| 2020 August | 29 | 24 | 53 |
| 2020 July | 27 | 14 | 41 |
| 2020 June | 35 | 27 | 62 |
| 2020 May | 37 | 14 | 51 |
| 2020 April | 47 | 20 | 67 |
| 2020 March | 35 | 20 | 55 |
| 2020 February | 10 | 0 | 10 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 1 | 9 |
| 2019 November | 4 | 0 | 4 |
| 2019 October | 0 | 1 | 1 |
| 2019 September | 8 | 0 | 8 |
| 2019 August | 4 | 6 | 10 |
| 2019 July | 2 | 7 | 9 |
| 2019 June | 5 | 2 | 7 |
| 2019 May | 2 | 1 | 3 |
| 2019 April | 1 | 9 | 10 |
| 2019 March | 2 | 5 | 7 |
| 2019 February | 0 | 3 | 3 |
| 2019 January | 4 | 0 | 4 |
| 2018 December | 0 | 5 | 5 |
| 2018 November | 3 | 0 | 3 |
| 2018 October | 5 | 0 | 5 |
| 2018 September | 6 | 0 | 6 |
| 2018 March | 1 | 0 | 1 |
| 2018 February | 26 | 7 | 33 |
| 2018 January | 30 | 4 | 34 |
| 2017 December | 34 | 10 | 44 |
| 2017 November | 25 | 9 | 34 |
| 2017 October | 27 | 7 | 34 |
| 2017 September | 17 | 6 | 23 |
| 2017 August | 21 | 12 | 33 |
| 2017 July | 24 | 12 | 36 |
| 2017 June | 29 | 32 | 61 |
| 2017 May | 35 | 12 | 47 |
| 2017 April | 27 | 13 | 40 |
| 2017 March | 19 | 30 | 49 |
| 2017 February | 18 | 6 | 24 |
| 2017 January | 9 | 7 | 16 |
| 2016 December | 21 | 20 | 41 |
| 2016 November | 24 | 12 | 36 |
| 2016 October | 24 | 12 | 36 |
| 2016 September | 0 | 5 | 5 |
| 2016 August | 0 | 1 | 1 |
| 2016 July | 2 | 0 | 2 |
| 2016 June | 1 | 1 | 2 |
| 2016 May | 0 | 3 | 3 |
| 2016 April | 0 | 1 | 1 |
| 2016 March | 0 | 5 | 5 |
| 2016 February | 0 | 2 | 2 |
| 2016 January | 0 | 1 | 1 |
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